This was written in June, 1996 as an op-ed piece for Biomaterials Forum, the newsletter of the Society for Biomaterials. I had just returned home from an international congress and was, as one will gather from the text, very depressed at what I had seen and heard (and, more importantly, had neither seen nor heard). After delaying submission for several weeks, I decided not to publish it, as it seemed overly bleak. I subsequently read it aloud as an introduction to a talk entitled "The Way Forward." This was the last public talk of my academic career and was given to a group of graduate students at the annual Southern Biomedical Engineering Conference, in San Antonio, TX on 2/7/98. This is its first appearance in print.
The situation in my former academic field, Biomaterials Science and Engineering, remains pretty much as I saw it in 1996 and shows little signs of positive change. Otherwise well meaning people continue to work on what interests them (a mere human failing) rather than focusing on real, unsolved human problems. My growing discomfort with my academic colleagues was the origin of the "Rwanda Test," described in the 3rd edition of my textbook Biological Performance of Materials: Fundamentals of Biocompatibility (1999):
"Finally, I want to suggest a simple functional test for engineers and scientists in these (or, for that matter, other related) fields of investigation. Even if one can personally resolve the issues which I have raised, as we each must, it is worthwhile considering this question:
Will this work ultimately benefit refugees in Rwanda or in the other parts of the world mired in desperate, apparently chronic, poverty and deprivation?
I have come to call this question the "Rwanda Test." I offer it to readers, experienced professionals and students alike, not with the suggestion that a negative response is a necessary "show stopper" but with the hope that, among all the good and promising questions which you can ask, you will select more and more often those which have the potential to bring the greatest good to the most with the least risk of catastrophe. If we fail to apply such a test to future investigations, we run the risk of losing ourselves and our society."
One positive note: the "biomaterials crisis" came to be seen properly as only a litigation, not a supply, crisis and was resolved positively by passage and signing of the Biomaterials Supply Act (1998). But enough background; here is "No Monarchs":
Monarchs in Trouble on Northern Journey
"...(R)esearchers...report drastic reductions in the numbers of butterflies heading north on their annual spring journey. ...(A) few have been spotted in southern Ontario in the past two weeks." The Globe and Mail, 5/29/96
Monarchs (large orange and black butterflies) will apparently be in short supply this year, in Toronto (Ontario), as well as elsewhere. This sad situation is variously blamed on a hard winter, a late spring, deforestation or whatever. The life of butterflies remains mysterious and unpredictable.
This information greeted delegates as they gathered in Toronto for the 5th World Biomaterials Congress. On the surface, this was a splendid affair, well planned and conducted by our friendly Canadian colleagues. But beneath the glitter and the bustle, there was also an absence: few monarchs (leaders) were sighted in Toronto.
The scientific program included six keynote addresses as well as 992 podium presentations and posters, representing the work of thousands of scientists and engineers from more than two dozen countries. The Transactions volumes weigh 2.7 Kgs (that's ~ six pounds for those living in the US, Burma or other non-metricated holdouts!). The subject (key word) index alone occupies 12 pages.
Indexes are interesting documents. One can weigh and measure the current state of a field of research simply by counting the titles which appear under various key word listings.
What are the current critical problems in Biomaterials? Every worker considers his or her project one of critical importance. Rather than judging which are or are not so, let me simply pick out two areas which have excited public attention within the past several years:
Breast Implant "Disease": No one can not have heard of this situation. Therefore, I need not recount its' history. However, diligent searching through the Transactions index revealed only 12 presentations and posters concerning biological performance of silicones and, of these, only three which I could relate in a reasonably way to efforts to understand the possibly implant related problems of the tens of thousands of patients. There were four implant retrieval studies and two clinical studies, both investigating the presence of silicone and its degradation products in tissues and fluids obtained from patients. There was only one biological response study, based on a simple animal model. There were no studies attempting to relate biomaterials properties to patient symptomatology. What do we tell the patients and their relatives? Where are the monarchs?
Temporomandibular Joint Replacement "Disease": Equally, no one can not have heard of this situation. As far as I could tell there were no presentations or posters on this problem, related to inappropriate use of biomaterials, which has been evolving over the past twenty-five years. What do we tell the patients and their relatives? Where are the monarchs?
Monarchs are apparently in short supply this year, in Toronto (Ontario), as well as elsewhere. This sad situation can variously be blamed on a hard winter, a late spring, deforestation, oversight, self-interest or whatever.
However, we are all also aware of the so-called "Biomaterials Supply Crisis." I suggest that this "situation," an apparently impending shortage of specific biomaterials, is closely related to a continuing shortage of monarchs (leaders in Biomaterials). A positive sign in Toronto was the presence of so many young students. Perhaps some of them will evolve to monarchs. We can only hope. The life of workers in Biomaterials remains mysterious and unpredictable.