Editor's Note
The Body as Foe
In autoimmune disease, the enemy is us.
We would all like to think of our bodies as wise or at least very smart. After all, for most of us, the billions of cells and chemical reactions that we call life tick along with amazing regularity and efficiency for years, seemingly regulating themselves without asking us for help. Even if we aren’t at all helpful by eating or drinking too much or otherwise abusing ourselves, our body obediently tries to correct our mistakes, pulling us out of our latest jam, and seeking homeostasis. We expect our body to be on our side, a wise advocate working for our benefit at all times, fighting outside invaders such as bacteria and viruses and scanning for internal foes such as cancer. And that’s why the idea of autoimmune disease, which is at the heart of this month’s focus on rheumatology, seems hard to grasp. When such diseases strike, our sage, trusted partner starts turning against us, using the same antibody and cellular weapons it used for years against foreign enemies. In a strange twist on Pogo’s legendary quip, in autoimmune disease, the enemy is us.
Joints are the most common victims of this attack, but any tissue in the body is a possible target as T cells and an armada of lettered and numbered immune mediators lead the rebellion against self. The battle leaves tracks, markers of disease that are being discovered almost daily, helping us understand the whys and the hows of these diseases (p. 38). Our growing understanding of these markers forms the basis for the new biologics that promise a true shutdown of disease for many rheumatics, if only our cash-strapped health care system can figure out how to pay for them (p. 22).
For years, rheumatology seemed stuck with the same old weapons, veritable blunderbusses of questionable effectiveness. Legions of nonsteroidal anti-inflammatory drugs poured onto the market in the 1980s, trying to distinguish themselves in an increasingly crowded market of aspirin-like compounds. But each seemed to fizzle after brief introductory excitement dissolved into the me-too-drug doldrums. Introduced in the early ’50s as a panacea for almost everything, cortisone still is a treatment for rheumatological diseases, but its long-term side effects prohibit widespread use. And for many with rheumatology’s most common ailment, osteoarthritis, mundane pain relievers such as acetaminophen and ibuprofen are a poor man’s compromise to soothe the pain they have to live with.
So why would anyone want to practice rheumatology if the patients always hurt and the treatments fall far short? Listen to the voice of Gerry Mullin who still speaks glowingly of the rewards of his decades-long practice of rheumatology (p. 12). And listen to the voice of Hollis Krug who predicts a sparkling future for the specialty (p. 26).
Those proteins with funny labels that seem to pop up weekly explaining one more piece of the immunological puzzle will likely be just a prescription away from future rheumatologists who will fight the good fight against pain and that mercurial enemy, autoimmunity. And, if they are wise, they will realize that the body still has its own wisdom that should be enlisted in the battle.
Charles R. Meyer, M.D., editor in chief Dr. Meyer can be reached at cmeyer1@fairview.org