Medical Magic

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For medicine to match other aspects of modern technology it must be characterised by magic and it is a crucial aspect of magic that the burden of the effort involved in creating an illusion not be borne by the observer.

It is thus with other technologies where underlying mechanisms involved might be highly complex and even messy but the user experience is relatively simple and painless. To be able to drive a car you don’t need to know the intricacies of the internal combustion engine or the gearbox. You just need to know how to operate the controls. To use a computer you don’t need to grapple with the complexities of the operating system or the hardware. You just need to know how to use the interface.

Much of modern technology is the stuff of myth. We have flying machines and the ability to send messages through the air but we don’t have a plethora of magic pills and potions that cure diseases painlessly and instantaneously. What medicine badly needs are silver bullets, which I define as treatments that satisfy the following criteria:

  1. Virtually painless and non-invasive: The treatment should cause minimal discomfort and involve procedures that are non-invasive, ensuring a positive and comfortable experience for the user. For example nothing much worse than an injection.
    Motivation: It is undesirable to use surgery as a means to cure disease.

  2. Fast-acting and of brief duration: The intervention should provide rapid relief or resolution of the condition, with a short duration of treatment, contributing to a swift improvement in the patient's health. For example, no hospital stays, long-term follow-ups and interventions, and no need to take anything permanently.
    Motivation: Treatments should not entail long-lasting dependence on the healthcare system.

  3. Minimal temporary side effects and no long-term side effects: The treatment should not have debilitating side effects and should not adversely affect the patient's life in the long-term. For example, nothing much worse than a spell of mild flu-like symptoms or slight nausea.
    Motivation: Treatments should not compromise quality of life.

The criteria and the motivations behind them emerge from the principle of “first do no harm” and they are somewhat intertwined. For example, invasive treatments can result in long-term side effects and the need for additional interventions whilst any life-long treatment, even if non-invasive and without serious side effects, potentially restricts personal freedom which is inextricably tied to quality of life.

I exclude monetary cost from the criteria because it is not a fundamental aspect of the idea. Many technologies that are now commonplace were once expensive but this did not diminish their transformative potential. Some silver bullets will be inherently cheap whilst others may be expensive to begin with but are likely to become cheaper over time with advances in technology and economies of scale.

Medicine is not without such treatments that broadly satisfy these criteria 1. Here are some examples:

  1. Hydration for cholera: Cholera was once a deadly disease and epidemics were common with high mortality rates but now according to the WHO

    Cholera is an easily treatable disease. The majority of people can be treated successfully through prompt administration of oral rehydration solution (ORS).

    Oral hydration therapy (ORT) involves administering a solution of salts and sugars to the patient, typically through a drink, to restore lost fluids and electrolytes. The straightforward intervention can be remarkably effective, saving lives rapidly without invasive procedures and perfectly satisfies the criteria for a silver bullet.

  2. Penicillin for syphilis: The discovery of penicillin revolutionised the treatment of bacterial infections, including syphilis. Administered through injections, penicillin has the ability to rapidly eliminate the causative bacteria, providing a relatively quick and painless solution to a once life-threatening disease. The consequences of untreated syphilis were severe, often leading to debilitating health issues, neurological disorders, and even death. Prior to the advent of penicillin, the treatment methods for syphilis were often brutal, including the use of toxic substances like mercury but now according to the CDC

    A single injection of long-acting Benzathine penicillin G can cure the early stages of syphilis. This includes primary, secondary, or early latent syphilis.

    This antibiotic 2 therapy has become a classic example of a medical silver bullet, swiftly curing infections with comparatively little discomfort.

  3. Vitamin C for scurvy: In the age of exploration, sailors faced the devastating effects of scurvy due to vitamin C deficiency. The introduction of citrus fruits, rich in vitamin C, as a simple remedy became a remarkable silver bullet 3. Vitamin C continues to be the primary treatment for scurvy.

  4. Dostarlimab for rectal cancer: As employed in the protocol followed in a 2022 study, this immunotherapy approach was given to patients with locally advanced mismatch repair deficient rectal cancer and resulted in 100% clinical complete response without additional interventions. Since the protocol involved administering “single-agent dostarlimab, an anti–PD-1 monoclonal antibody” intravenously every 3 weeks for 6 months, if the criteria above were rigidly applied, this would not qualify as a silver bullet. However, as discussed below, compared to the standard treatment of surgery, chemotherapy and radiation, it can be considered to satisfy them at least in spirit.

    1. Like an injection, IV may be considered to fulfil 1 and is certainly preferable to a resection of the rectum.

    2. The extended duration of the treatment does not strictly fulfil 2. However, it was noticed that a majority of patients had no evidence of viable tumour as early as 6 weeks after the treatment had been initiated. Although, since the study is fairly recent, it can’t be ruled out that the patients may undergo further interventions, given all had remained cancer-free for at least 6 months, this treatment can be considered to be of finite duration and therefore in the spirit of 2. In comparison, chemo-radiation and surgery can have severe and permanent consequences. As the study notes, “resection of the rectum is life-altering and often warrants a permanent diverting colostomy”.

    3. Side effects were observed in several patients but were only of grades 1 (mild) or 2 (moderate). Here is how the National Cancer Institute defines adverse event grades (slightly modified to expand acronym)

      Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated.

      Grade 2: Moderate; minimal, local or non-invasive intervention indicated; limiting age-appropriate instrumental activities of daily living (ADL)

      Whilst moderate events may constitute a gray area relative to what 3 envisages, they are likely to be far less brutal compared to the effects of the standard treatment noted above.

These examples notwithstanding, approaches akin to silver bullets are not at present the dominant paradigm in medicine. Until that happens, it is plausible that people in the future will marvel at our technological advancements but cringe at the supposedly sophisticated medical practices of our era, much as we now reflect on the primitive methods employed in bygone ages even as we celebrate their achievements in other fields 4.

  1. This discussion is centred on curative interventions and excludes preventive methods such as vaccines and public health measures, acknowledged for their significant and widespread benefits. I also exclude life-long treatments such as insulin for diabetes, which go against the spirit of the idea as expounded here. ↩
  2. Due to the controversy around their overuse, I do not include antibiotics as a category here but have chosen to focus on their action against a once-dreaded disease as an instance of their efficacy when responsibly used. ↩
  3. It's worth noting that vitamins, in general, can be considered silver bullets when administered to treat deficiencies, which can be serious if left untreated but are usually easily addressed sometimes through dietary interventions alone. ↩
  4. For instance, the Encyclopédie, the 18th century encyclopedia, which is considered a symbol of the values of the Enlightenment, prominently features the practice of "cutting for the stone". This procedure to remove bladder stones, performed without anaesthesia, unsurprisingly seems barbaric to us today but the Encyclopédistes, despite their relentless pursuit of excellence in so many areas, were not only able accept the gruesomeness of the practice but regarded it as a pinnacle of medicine worth highlighting in their work. (See the illustrations in plates XII to XIV if interested). ↩
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