In recent years, developments in the realm of Parkinson therapies have been somewhat stalling, and clinically relevant successes are rather more based on findings and knowledge of past decades. The pivotal issue here is levodopa. Various medications have been introduced which improve or even optimize the effects of levodopa. But we are still searching for the one new idea, the one new medication which will halt the progression of this degenerative process, or at least can slow it down substantially. That is the correct way forward. And nonetheless we can legitimately ignore for a moment the requirements in our everyday therapeutic work and must use what we consider at the moment as helpful and nonetheless still try to optimize it at the same time. Patients as well as clinicians have little profit merely because we formulate future goals, they need therapies that work. We can pursue hopes for future work without forgetting the needs of our patients today. That has been the way medicine works since the earliest beginnings. We have to live with the facts and still try to get ahead of them tomorrow. We have done that in the past and will do that in the future. We once realized that we have to give a decarboxylase inhibitor and later realized then that we could give a MAO B- inhibitor as well as a COMT-inhibitor. That meant a major advance that shows that we can help our patients better and better. We have also learned to apply dopamine agonists effectively. They are in no way a substitute for levodopa but certainly an appropriate complement to our armamentarium.

With advances in offering differentiated therapies the prognosis for our patients has been clearly improving over the years. Today, however, this might not appear so optimistic from our present standpoint. But all of us who know patients from the 1980s will certainly confirm this prognosis. Of course, this is to be welcomed, but also means that we have to pay special attention to our advanced PD patients, that stage of the disease which we still cannot treat adequately with oral medication, although in these cases we have made substantial progress. One case in point is deep brain stimulation which has in the meantime gained world-wide acceptance. There are in addition systems for applying levodopa or a dopamine agonist subcutaneously or intrajejunally by means of a pump. But the high costs involved here, the invasive nature of the procedures and the possible complications have led to caution among our colleagues and ever more in the patients as well. But in this way we are giving up on any number of hopeful possibilities for the future. It is just not the case that delaying merely means postponing therapeutic effects for a later time. Quite on the contrary, we are losing therapeutic options now.

Previously the goal was to develop the best medication within its individual substance class: whether, for instance (1) within the group of dopamine agonists piribedil induces fewer ICD’s than pramipexol, or (2) opicapone, with its long half-life, is prognostically more effective than entacapone or (3) safinamide, with a dual approach, is superior to the MAO-B inhibitor rasagiline. But today we have to pose different questions. We cannot assume that major progress will be made steadily every few years, instead we have to reckon that progress will be made continuously but in simple, low-keyed steps and we have to take care that we do not get bogged down and come to a halt in our work. Whoever becomes antagonistic towards progress, for whatever reason, can impede all further developments by simply claiming that the next step forward is only too small and meaningless. This only serves to distract from one’s own failures. Of course, really significant jumps forward are better than smaller steps, but such small steps are better than any standstill: because every standstill eventually means a step backwards.

The essential question remains: how can we improve on the, at present, best-functioning medicament in a specific substance class? Admittedly, apomorphine is apomorphine, levodopa is levodopa, but still: how can we improve their efficacy or reduce their side effects and complications? The answer to these questions may only signify small steps forward, but this is the reality at present.

An additional problem presents itself now: the discussion on the most meaningful therapy is unfortunately more and more dominated by financial concerns, which frequently cover, not the expected total costs, but rather more the product pricing, which in the long run is in fact irrelevant. These concerns should be taken into consideration, but they should not be the primary concern. The question as to whether a medicament is or is not effective does not yet involve any questions whatsoever as to its pricing. The financial concerns are only pertinent when we ask whether or how we might use that medicament. Here we must not confuse the different levels because that would otherwise confound the basic, necessary critical examination. These are completely different aspects which must not disturb a basic scientific evaluation. Evidence-based medicine is a scientific and not an economic approach. If we already take economic aspects into concern in the early phases of development, we will fail to evaluate matters objectively. In the long run, we should only consider these concerns when we are capable of judging them, which at present we are often enough not capable of doing. And therefore we should do what we can do best: evaluate new developments in the light of our clinical experience and then formulate recommendations. The financial aspects should only be taken into consideration afterwards by the competent services, not beforehand. Economic thinking, frugality, may certainly be relevant matters, but being overly economical or just too thrifty is not. These financial, ecological arguments can be seen as obscurantism which under the cloak of thriftiness in reality codes for antagonism towards progress and innovation.

“We've had our ups and downs but we're still playing together”: Stephen Stills and Neill Young.

We need better diagnostics and therapies to be capable of helping our patients better, and at the beginning that will surely cost us a good deal of time, energy and financial resources as well, but in the long run this will be advantageous for our patients and society as a whole. Having too many doubts about progress or even being tremendously critical of the concept of progress at all may be seen as opportune at the present, but is in the long run a form of nihilism. When I took my first course in computers in 1970, a good many people asked me what the sense of it all would be and thought it is better to teach children to read and write.