MRC National Institute for Medical Research, London

After such excellent efforts, the participants deserve some comments on the way the essays were written generally and our impression of how the specific essays could have been written.

The overall standard of writing of the finalists was high and once again significantly higher than the previous year; most entrants made great efforts to develop a logical narrative with a clear focus. In adjudicating a competition of this kind, the judges sometimes have to choose between entries with a high quality of information or a particularly attractive style of writing. Entries that were properly referenced clearly gave a good impression, but most authors had managed this very well. As this is all a matter of balance, we hope you will accept our deliberations may be slightly arbitrary. A few unusual initiatives ought to be mentioned:

• Individuals who mentioned personal communications with academics concerned with the topic. Such initiative does them credit and gives originality to the narrative that we liked.
• The idea of using some “reportage” to make a more vivid contribution was another enterprising and potentially very interesting approach used by several entrants.
• The tone of world-weary cynicism affected by many professional journalists was a novel perspective although one that can be difficult to carry off effectively at this level. The example I was thinking of was based on a misconception about the commercial uses of umbilical stem cells. As yet there is little possibility to make significant amounts of money from this as the consent of the mother is required and the beneficiaries are usually family members.

We hope everyone who participated in the Essay Competition thought the effort was worthwhile and learnt from the experience. At university, you may appreciate having jumped an important hurdle and this, we hope will facilitate further developments in your technique.

Three times in the twentieth century devastating influenza epidemics emerged following a genetic reassortment of human and bird flu viruses.

Disappointingly and surprisingly, we didn't have a finalist with this title.

A good essay would have reported the features of flu virus epidemiology (reassortment of RNA species, selection for strains that avoid immune response). They would have also described the steps needed to jump to a new species, (mutations, reassortment of the RNA strands, changes in pathogenicity of strains).

The distinctive feature of avian flu is that infects the gut of birds, whereas human flu normally infects the lungs. At the moment strains lack the ability to attach to upper lung regions (whether we have to fear a gut infection is an issue that the experts do not seem to consider). Key parts of the epidemiology include the events of 1918/1956/1967 and the reports that people in East Asia have picked up avian flu in the past while living cheek by jowl with the birds.

Almost all the entrants had these facts but there was very little explicit discussion about how a new flu might progress in Europe (migrating birds and exotic imports but is that everything?). Ultimately, the entrants for this essay were a little unlucky; the facts were brought together quite well but lacked a conclusion relating to the title.

It has taken many years to engineer a protein medicine based on an antibody that can control one type of cancer.

The winner of the competition wrote on this subject. The essay accurately described what Herceptin is, although it did not quite convey the scale of the achievement. The evolution of the technology for making protein medicines is probably the most spectacular use of biological science in the last 50 years and the development of therapies based on monoclonal antibodies must be the pinnacle. Herceptin is not the first drug that can control a cancer, as other protein medicines (Interferon) are effective against certain cancers.

A relevant issue is that Herceptin was made by industry (Gannett, the leader in gene technology) and that gene technology was the only way this drug could have been made. The triumph lies in the ability to (a) make monoclonal antibodies (mAbs) (b) make the mAbs humanised (c) express them in a cell factory effective enough to make the mAb on a large scale.

The winner had a very good grasp of the stages of making Herceptin and how it will be used and also took a very balanced view of the evidence suggesting when it was successful, and a suitably cautious assessment of its merits in early stage disease. Unfortunately the other entries went astray discussing irrelevant fruits of gene technology without conveying the essence of why gene technology is so valuable.

We can hardly imagine clinical medicine without blood transfusion but the safety of the blood supply has been seriously challenged several times in the last thirty years.

This was the least popular title. Possibly because there is little appreciation that blood transfusion, like many medical interventions could save lives but with a significant (though steadily diminishing) risk. The suggestion that the risk of incompetence by medical staff is the real risk is not based on scientific evidence and is suggestive of coverage in the tabloid press.

Two of the essays had a lot to say about historic efforts at blood transfusion. As this usually ended tragically (in fact, no one benefited from blood transfusion before about 1910) this kind of historical information is not really of interest. The historical approach in essays works much better if it is used to explain the origins of a currently acceptable or useful procedure.

A good essay would have considered possible incompatibilities between blood types and how they can be circumvented and the other major risk, infection. Syphilis was an early anxiety but was entirely eclipsed by severe dangers from hepatitis, AIDS and prions. Behind this are some of the most interesting stories about bold and intelligent adventures in medicine and of course some important disasters. People might look back at the mistakes that were made with horror but nobody (least of all the tabloid press) was wise at the time.

To make blood transfusion really safe, vigilance is everything but sensitive screening methods are needed as each new danger emerges (such as West Nile virus). Almost nothing can be done at present to protect against an unknown virus or prion that suddenly emerges but there is an interesting debate about selection of donors and whether they should be paid or not.

Cord blood contains stem cells that can correct many genetic diseases but how feasible is it to use them?

This topic attracted a lot of entries. The best ones grasped the value and limitations of stem cells. They saw that umbilical stem cells can repopulate a patient much as bone marrow does with less risk of reaction and is a resource that is more abundant than bone marrow donors that is particularly useful for genetic blood diseases in the family.

There was a little confusion about who was promoting them; at the current time they remain the property of either the parents of the child or a hospital bank. There is not much evidence of seriously fake business interests (yet). The future may be different if they can be expanded indefinitely and used without fear of an immunological reaction. One entrant enterprisingly got information directly from scientists in the field, and another mentioned the issue of ‘spare parts babies’ and the ethical implications.

The argument against 'spare part babies' however, is not only from a pro life perspective. There is also the question of whether the donor is being 'wronged' if an individual is conceived as a project to cure an older sibling.

Heart transplants and coronary bypass surgery save lives but a healthy life style could make such expensive interventions less necessary.

This was the most popular topic. Most entrants had a vivid appreciation of the cost to the NHS of heart disease and the lifestyle factors that increase the risk of heart disease. The evidence about smoking is well known and incontrovertible, while the benefits of exercise and the question of obesity are more complex.

Many entrants mentioned the benefit of anti-oxidants; their efforts would have had a sharper edge if they had given a clear idea of their significance. High blood pressure and low birth weight / childhood malnutrition are two risk factors that were barely mentioned. Both are very important and in the latter case has particular relevance to cardiovascular disease amongst South Asians, which many entrants mentioned.

Most people wrote about LDLs and HDLs (Low and high-density lipoproteins) and about the pathology of coronary heart disease, although only a few accounts were done elegantly.

There was very little awareness that the risk of heart disease has changed a lot in the twentieth century and that a few emigrant groups (Japanese) have acquired the prevalence of their new country (USA). Epidemiological stories like this would have added an interesting human dimension to an essay. The bad effects of smoking and obesity are fairly clear but the benefits of “healthy” behaviour are not so easy to evaluate (e.g. eating of fruit). Not all professional opinion is impressed by the Karla study because of quibbles about the statistics.

Perhaps because the risks are so remote, our entrants had little conviction about who was responsible for keeping healthy. Smoking shows how difficult governments find the issue but many individuals can adopt a healthier lifestyle if they choose to. It was interesting to note a few entrants thought exercise involved more time than one really wanted to spend; perhaps the answer is that if you spend the time when you are young you get more at the end!