The Erwin Neter Memorial Lecture: looking to the future of medical laboratory immunology, a personal view.

Immunologic techniques have become very useful and important in the diagnosis of disease. Although many people regard immunology as a new science, it can be traced back to antiquity. Egyptian writings from 4,000 years ago describe severe epidemics, and two Greek historians, Thucydides and Procopius, recorded details of devastating plagues (Table 1). These historians noted that survivors of the disease were safe from further attack and could care for the sick. Procopius coined the term immunity, from the latin immunitas, which means exempt from service. The concept of immunity was also known in ancient China, where children were inoculated with fluid from the pustules of smallpox patients to protect them from the disease (4). The next step forward occurred in the late 18th century, when Edward Jenner used nonvirulent organisms for immunization and reduced the risk of the procedure. This is where we are today, designing vaccines to prevent serious infections. Successful immunization does prevent disease and can lead to eradication of the infecting organisms. We are indebted to Louis Pasteur, who postulated and proved the germ theory of disease; to Emil von Behring, who saw that antitoxins could be used to treat existing disease; to Ilya Metchnikoff, who realized the importance of phagocytosis and cellular immunity; and to Paul Ehrlich, who proposed the concepts of cellular receptors and autoimmunity. The discipline of medical laboratory immunology is relatively new. When I began working in this field about 30 years ago, we did not have the reagents and techniques that are taken for granted now; we raised our own antibodies in rabbits, using antigens which we isolated ourselves. Sephadex and column chromatography, sucrose density gradients, and Spinco centrifuges were the workhorses. The detailed study of lymphocytes was in its infancy, and patient immunologic studies were limited to proteins in serum and urine and some skin tests. Decisions on the immune status of a patient were made on the basis of specific antibody titers and crude serum protein electrophoresis patterns. The concept of radial diffusion, developed by Mancini and her colleagues (2, 3) and by Fahey and McKelvey (1), had tremendous impact in the clinical laboratory. Suddenly it was possible to measure the levels of IgG, IgA, IgM, and any antigen in serum by a simple straightforward procedure. This technique quickly became indispensable and was, I believe, the impetus for the establishment of many diagnostic immunology laboratories. It was quickly realized that these were very useful laboratories; the data generated were applicable to many of the traditional specialties, in particular rheumatology, pediatrics, allergy, and hematology-oncology. The new immunology laboratories gradually absorbed other tests, especially those involving autoantibodies, serology, and lymphocyte assays, and the modern diagnostic immunology laboratory was born (Table 2). Medical laboratory immunology is now an accepted subspecialty, with a Board (the American Board of Medical Laboratory Immunology [ABMLI]), an association (the Association of Medical Laboratory Immunologists [AMLI]), and a journal (Clinical and Diagnostic Laboratory Immunology). We owe a big debt to the individuals who have guided us through the past few years, especially Drs. Douglas, Escobar, Folds, Nakamura, Osterland, Penn, Rabin, and Rose. Through their efforts the diagnostic immunology laboratory has become an important component of the clinical laboratory. We are independent units with a reputation for excellence, and until recently the future seemed bright. Now, however, there are clouds on the horizon; changes in health care financing have altered the rules, and we must recognize this. Managed-care programs, which contract to provide a patient’s medical care for a fixed amount of money per year, are forcing hospitals to compete for patients. These patients have to be accepted at a low, fixed price, resulting in serious budget problems, especially at academic centers. Clinical laboratories have traditionally been money earners, but the fee-for-service concept is no longer viable; laboratories are now cost centers and must revise their operations to produce test results for the absolute minimum cost. Some people worry that academic laboratories will be replaced by commercial laboratories. I believe that we can survive, but only if we change. Many academic centers have the traditional setup for an academic institution: separate laboratories for chemistry/hematology, microbiology, immunology, and transfusion medicine, plus independent laboratories in other departments. There are many directors (some M.D.s, some Ph.D.s), managers, and specialized technologists, which is an expensive and wasteful system. A unified laboratory with a single control structure would be more efficient. It would have a minimum of faculty and managers and be staffed with well-trained medical technologists, at a ratio of about one technologist per four to five occupied beds. This would permit condensation of the ancillary services while maintaining excellence and would keep costs to a minimum. How would medical laboratory immunologists fit into this unified laboratory? As I see it, the key to the efficient operation of a laboratory is the knowledge base of the people involved. As immunologists, we have had to learn many different disciplines, so that both faculty and staff have a wide knowledge base and are comfortable with highly complex tests and instruments. I have noticed that immunology attracts people who like to think—who enjoy challenges. Such skills will always be needed, but we must not be complacent, we must become more knowledgeable. All of us, M.D.s, Ph.D.s, and technologists, should learn more skills and not be afraid of new and different * Mailing address: Department of Pathology, Box 168, University of Virginia Health Sciences Center, Charlottesville, VA 22908.