History and insulin: what lessons can be learnt?

Presidents blog - 17th February 2013

There is no doubt that the discovery of insulin ninety years ago was a spectacular event for medicine, on many fronts. The summer of 1921 in Toronto resulted in a rapid series of physiological experiments and basic biochemical methodology studies that led to the new preparation of insulin being available for injection into children and adolescents dying from diabetes. From the amazing original results of a limited number of case studies it was rapidly realised that "a wonder drug" had been discovered. Perhaps just as spectacular was the industrial production of insulin over the next 1-2 years leading to the modem era of diabetes treatment.

All this was brought into vivid reality at a recent "Jubileum Symposium -1922-2012, 90 Years of Insulin" hosted by Sanofi at their Type 1 Diabetes Summit in Barcelona. The great and the good gave a detailed historical perspective on the discovery of insulin, by the Toronto Group, leaning heavily on Michael Bliss's book ("Discovery of Insulin" 25th Anniversary, available on Amazon).

Various speakers commented on the personalities involved in the Toronto Research Group (Banting, Best, McCleod and Colip), their difficulties but also successes in working together as a team and the other players such as Minkowski who had a pivotal role in the preceding science leading to the production of insulin. Interestingly, Prof. Zvi Laron (previous President and founding father of ISPAD) presented a deserved "hatchet job" on Nicolae Paulescu, the Romanian clinical physiologist, who was a leading fascist with detestable political views, negating any benefits of his work in the production of insulin by the pancreas.

The subsequent changes in insulin preparation that the occurred over the 70 years were outlined in detail by a host of eminent speakers and the current "state of diabetes" was proposed with reference to exciting opportunities in islet transplantation, stem cell therapy, immunological therapy, new technology for delivering insulin, monitoring and prevention.  

All well meaning and a very enjoyable symposium. However, I was left with a few concerns that self-congratulatory meetings of this type leave me with. Most relate to my own age. As  Shakespeare's seven ages seem to flash by, I personally want to look forward through the vision of the young, rather than looking forward through rose tinted older eyes. I can remember some of the developments and the quoted studies as being relevant to my own career - nice but scary!  Are the elders the right ones to comment on the ideas for the future. I do not think so. You always feel your own work is important and it will leave a legacy and, therefore, I think we link too easily the findings of the past with what will be produced in the future.

For me the major deficiency in this symposium on the history of insulin and Type 1 diabetes was a critique of the historical progress. Could it have been done differently, what charted it's progress, what held it back? There was little comment on what it was like as a patient to have diabetes in its early days. The dramatic response was commented on as "a wonder drug" but in fact for most patients the diabetes therapy was awful and the therapy very hard to comply with. A review of published papers on diabetes treatment with insulin in the decade after its study will point this out. (On reflection has much changed?) This was the main reason that drove the initial changes in insulin structure leading to 50 years of "conventional therapy". To make it easier for patients. It has taken effort to change direction and only in the last 20 years has "intensive therapy" been reaffirmed as the "best" approach to manage T1D. What "blind alleys are we going down at the present time?" Unfortunately, history cannot tell us this and we need to continue to assess rigorously our clinical practice and more importantly the outcome of therapy and service performance, which includes patient views and attitudes to our management strategies.

Perhaps one of the benefits of the current super-regulatory world of the "Research Business" that we now live is that, hopefully, research is being directed towards priorities and certainties based on the desires of patients. However, on the contrary, Banting (who suffered from post-traumatic stress following his experiences in World War One) and Best (a medical student allocated for the summer to the project) would never in the current environment have been allowed to undertake any study involving direct clinical care, and probably would not have been given any funding to do such a basic 'first in human' study. History, if anything, should teach us that we still need people with vision and an enquiring mind.

Stephen Greene

 Stephen Greene is the current President of ISPAD. He is a Professor of Child & Adolescent Health at the University of Dundee, Scotland and has been a member of ISPAD since 1990. He would be delighted for any engagement with his Blog but would ask you respect the normal and accepted rules of civilised debate and criticism. He will try to comment on all aspects of Diabetes in the Young, but cannot engage in specific discussion of clinical care or management.