by Mimi Swartz
2
HOW HARD COULD IT BE?
Deep in the bowels of the Smithsonian Institution’s National Museum of American History is a section of a storeroom with a particular set of drawers. If you go through the proper channels, a friendly curator will let you in and, donning a pair of gloves, open the drawers to reveal some very strange and pretty unappealing-looking devices. Some are made of plastic faded to the color of old chicken broth—though that’s a nice way of putting it. Others contain discolored tubes and fabric stained the color of rust, or, more precisely, old blood. Virtually all of them have two parts stuck together and most have large holes on each side, giving them the look of cockeyed binoculars.
They do not look like anything a sane person would want stuck inside him- or herself. But in fact these devices represent what has been, for a very long time, the holy grail of medicine: a dependable artificial heart that works on its own inside the body, just like an artificial hip or knee. The cure for cancer runs a very close second to this pursuit, but the fact is, heart disease kills more people around the world than all cancers combined: 17.9 million people or 32 percent of all deaths in 2015. (Three million women in the United States had breast cancer last year, while 12 million had heart disease.) And while these numbers are declining in the developed world, about 26 million Americans currently have heart disease; 2,150 of them die of it each day, an average of one death every forty seconds, or one out of every six deaths in the United States. The number of people who die from heart attacks may have also fallen significantly over the years, thanks to better care and better technology, but now a greater problem is heart failure, a chronic, progressive illness interrupted with life-threatening crises. The American Heart Association’s figures show that 5.7 million people suffered from heart failure in the period from 2009 to 2012, but that number jumped to 6.5 million, a 14 percent increase, from 2012 to 2014. Heart transplants have become the solution of choice for disease that is beyond treatment with diet, lifestyle, and medication, but surgeons and their desperate patients know the truth: in any given year there were only 2,500 hearts available for transplant, with about 50,000 people on the waiting list. In other words, there are twenty times more losers than winners.
Meanwhile, costs are also increasing. The total direct and indirect expense of cardiovascular disease and stroke in the United States was estimated to be $312.6 billion in 2009, a number that includes not just deaths but lost productivity. And the numbers are still rising: the total number of inpatient cardiovascular operations and procedures increased 28 percent between 2000 and 2010, from nearly 6 million to 7.5 million.
If a heart attack or stroke doesn’t cause instant death, life still becomes circumscribed in unimaginable ways. Once the heart has trouble pumping, the lungs start working less efficiently, and begin to fill up with fluid. Breathing becomes labored, so the slightest move, from the sofa to a sunny patio, or from bed to the bathroom, might as well be a marathon. Every move causes dizziness and shortness of breath. With circulation reduced, the liver, the kidneys, everything, slows down because of a lack of revivifying blood. The stomach and ankles swell, creating the sensation of walking on a bed of needles. A fog of fatigue sets in and stays. Or, suddenly, the heart races as if frantic to escape the chest. Life could be taken away in an instant; that fear becomes a constant companion, like living with your own ghost. Drugs and surgeries help to a point, but eventually you run out of options and then you will land on a long list for a transplant that will probably never happen.
The person who comes up with a way to replace a failing heart with an artificial one, then, will save countless lives and change the future of humankind, much as Louis Pasteur or Sigmund Freud did, or Jonas Salk or Marie Curie. And, of course, the doctor or engineer (or, more likely, the team) who figures out how to make one will likely become very, very rich. The perks, on the surface at least, look incredibly attractive, which is why inventors around the world are desperately trying to come up with a dependable, implantable artificial heart.
But just as the public is not very open to changing unhealthy habits, it’s not very tolerant of mistakes in innovation, especially when lives are at stake. Many modern-day inventors of almost any stripe would probably say that if they had known what they were getting into—the maze of technological, legal, medical, and ethical challenges—they might not have even tried.
There are also the unique questions that have swirled around the creation of the artificial heart since its beginnings more than fifty years ago. Is it ethical to spend millions on the development of a machine that could help comparatively few, when preventive care could help 90 percent of all those who develop heart disease? What would it mean if human life could be extended not just by years but by decades? How much is that worth, not only in dollars but in some undefined and unfathomable emotional currency? What would it mean to be alive but literally heartless?
* * *
To explore the workings of the heart is to discover a form and a function that can inspire thoughts of the divine in the most determined atheist. It is a marvel of strength, efficiency, and tenacity. About the size of a human fist—your fist, custom-designed to your unique size—it nestles perfectly at an angle deep inside the chest, protected by the rib cage and a cushion of lungs. Weighing about eight to ten ounces, less than a one-pound sack of sugar or a running shoe, it has four hollow chambers, atria and ventricles that look, in pictures, like ancient temples carved out of caves. Those hollows hold perfectly regulated amounts of blood as they pass through on their way to the body. The heart also has its own system of valves, muscles, and electrical currents that make sure nothing goes wrong. In fact, it’s easy to believe in the heart as a near-perpetual motion machine: it beats 60 to 80 times per minute, about 115,000 times a day, more than 2.5 billion beats in an average lifetime. Someone trying to squeeze a rubber ball at the same rate would last about a minute or two, yet the heart keeps pace continuously, whether a person is running a marathon, making love, arguing with a coworker, or getting a good night’s sleep. The heart is always there, keeping time to life itself.
The heart is actually two pumping systems in one, and the two sides never meet, a little like trains passing in a station. At the center of this station is one muscle contraction that works a little like a dispatcher. Blood comes into the heart through two large veins, depleted of the oxygen it’s used for its long journey through the body’s circulatory system. It first arrives in the right atrium, which, once full, contracts, pushing the blood down into the right ventricle through a one-way valve (imagine a system of locks). Another contraction pushes the blood that was already occupying that space through another one-way valve into the pulmonary artery and into the lungs, where oxygen refreshes the blood.
From there, the blood exits through the pulmonary vein back into the heart, this time into the left atrium. This side of the heart is responsible for the hardest work: with each contraction, the muscles here have to be strong enough to send the blood from the left atrium into the left ventricle, and then into the main artery, the aorta, and out into the body. In a healthy person, the heart pumps about two thousand gallons of blood a day for this trip. That’s six or so quarts, or a little more than five and a half liters* in medspeak, a minute.
Like a home, the heart has an electrical system in addition to its plumbing system of pipes and pumps: the heart contracts thanks to an invisible current that stops and starts. In between, it rests. This contraction and release—systole and diastole to professionals—is, of course, the heartbeat or pulse, the phenomenon known to virtually everyone on earth as the lub-dub sound that tells us we are alive.
That’s how things work when all goes well. If there’s a problem with the electrical system, the heart can stop abruptly, like a car with a dead motor. A worn-out artery can rupture like an old garden hose. If the heart muscle is not strong enough to push blood out into the body, clots in the pooling blood block arterial passa
ges and cause strokes. A heart the size of a basketball might sound like a very strong organ, but in fact it’s a sign that the muscles of the organ have had to grow larger and larger just to keep a weak system pumping.
Most cardiac surgeons approach these problems with all the romance and sentimentality of an oil field worker confronting a leaky pipeline. The heart is just a pump, they will tell you, usually with a shrug—a statement that actually tells you a lot more about heart surgeons than the heart. These are physicians who have less in common with your kindhearted family doctor than with the first people who crossed Everest’s Khumbu Icefall or took the first steps on the moon. Medical explorers, like all explorers, tend to be brilliant, obsessive, brave, and arrogant; many of them were and are ill-suited to societal norms, craving adulation while, at the same time, behaving in ways that don’t exactly build affection. Maybe they have to be all those things: you don’t really want the person who cuts into your heart to lack self-confidence.
If the heart is truly simple and reducible, something challenging but ultimately conquerable…well, maybe minimizing its power is the only way we could have gotten where we are today. Bud Frazier likes to say that practicing medicine satisfies needs that are more metaphysical, for both doctors and their patients: “It’s something we do, like art or music,” he says. “Every primitive tribe has a Medicine Man,” meaning that in every era humanity wants to believe in its healers, who might be nothing more than salesmen with a good line.
* * *
Heart disease is, in fact, a fairly modern phenomenon. Throughout most of history, people didn’t live long enough to die of it, though it has been found in Egyptian mummies—nature’s revenge, maybe, for royal Egyptians who ate too much rich food. Most people died from other causes, including war, famine, and plagues, until fairly recently. One reason our understanding of the heart progressed slowly is that for centuries the idea of cutting open a body and actually touching the heart was seen as an act against God. The heart was not “just a pump” then—it was the seat of the soul. “For where your treasure is, there your heart will be also,” says Matthew 6:21; or, to take a sample from Shakespeare’s Hamlet: “Give me that man / That is not passion’s slave, and I will wear him / In my heart’s core, ay, in my heart of heart.”
As late as 1900, the leading cause of death was pneumonia. All the way through the first half of the twentieth century, people died of things like the flu, pneumonia, and tuberculosis, and medical researchers frantically searched for drugs that cured infectious diseases. When they succeeded, greater numbers of people started living much longer lives. But then the medical profession had a new, mysterious epidemic to contend with. People—especially middle-aged white men—began dropping dead at astounding rates from something that was soon called a heart “attack.” So swift was the rise of this new blight that it was already killing more people than TB, pneumonia, kidney disease, or cancer. The symptoms were hard to detect, because, as one doctor wrote during the Depression era, “There is not a single sensation associated with real heart disease which may not be caused by some other, and often insignificant disorder.” Physicians weren’t necessarily wrong to insist that avoiding infection, “as from the mouth and tonsils,” was one way to prevent heart disease, but they didn’t have many ideas beyond that. And if a heart problem happened to be diagnosed before it was fatal, there wasn’t much to be done: bed rest—six or so months at the least—was pretty much all they had to offer.
Then, on September 24, 1955, President Dwight D. Eisenhower was enjoying a much-needed vacation in Denver. He loved nothing more than a good game of golf, and that afternoon he was playing at the cushy Cherry Hills Golf Course. But he was the president, and interruptions then could not be easily dispatched with an iPhone. Eisenhower had to keep returning to the clubhouse to take calls from his Secretary of State, John Foster Dulles. By the fourth interruption, Eisenhower was so angry about the disruptions that, according to one writer, “the veins stood out on his forehead like whipcords.” At around the same time, his stomach started bothering him. Eisenhower thought it was just indigestion—after all, he had eaten a burger with a slice of Bermuda onion for lunch. But later that night, he woke up with a crushing pain in his chest. His wife, Mamie, had the good sense to call his personal physician, who dashed to the president’s bedside at 2:00 a.m.
Depending on which account you believe, he may or may not have misdiagnosed Eisenhower’s condition. Over the next few days, the president was examined by army doctors, and then civilian doctors. There wasn’t much debate about the diagnosis at that point: Eisenhower had had a heart attack. “I had the unpleasant fact that I was indeed a sick man,” he would later write in his memoirs.
The illnesses of Woodrow Wilson and Franklin Roosevelt were never made public. Eisenhower’s heart attack changed that custom, though when his condition was made public, aides played down its seriousness, fearing for his reelection prospects and his power on the world stage. Indeed, the next Monday, the Dow Jones dropped by 6 percent, a loss that came out to about $14 billion and was the biggest since the 1929 crash. The head of what was then the nascent National Heart Institute tried to calm things down by declaring that at least half a dozen members of Congress had sufficiently recovered from heart problems to return to work, including Texas senator Lyndon Baines Johnson.
There was a lot of very public speculation over what might have caused Eisenhower’s heart attack, including his age and sex, heredity, and “an ambitious personality.” His high-altitude golf game came up, and so did drinking alcohol, “local religious and social customs,” and smoking. The president was a lifelong smoker, up to four packs a day. But the curious thing was, Eisenhower didn’t need to spend the usual six months in bed to recover from his heart attack. And he really didn’t want to. He was up and about in several days, and it was a matter of a few weeks before he was back at the office. Any thoughts that he would not be able to run for reelection were promptly dismissed. In fact, as Eisenhower’s health improved, both his doctors and his operatives proved themselves masters of the newish art of spin. One doctor reported, for instance, that Eisenhower had had a “successful bowel movement,” believing such news would reassure educated physicians around the country that he was on the mend.
And he was. Eisenhower finished his second term, though there were a few more health-related cliff-hangers, most of which, in an interesting turnabout, were kept secret. By some estimates, he suffered a stroke and four more heart attacks. When he died in 1969, the cause was said to be congestive heart failure. But the fact that he did recover from the first attack well enough to return to work and win reelection suggested that, maybe, the conventional treatment for heart disease was, in a word, wrong.
* Since liters are the standard measurement in medicine, I have used them throughout this book. One quart is equal to .95 liters.
3
THE MAKING OF A SURGEON
When Bud was a kid in the 1940s and 1950s, Paul “Bear” Bryant, who would become nationally famous as head coach of the University of Alabama football team, spent some time as the coach of the Aggies, at Texas A&M. The winningest coach in football history began his tenure there in 1954 by hosting a ten-day “summer camp” in the tiny town of Junction, 240 miles away.
Junction, on the northwestern edge of the Texas Hill Country, has its merits—two lovely, limestone-lined rivers converge there—but few are obvious in the August heat, which was when Bryant set up his training camp. That year, the community was also experiencing the worst drought in recorded history, along with a heat wave that had temperatures hitting 100 degrees almost every day. Despite that, Bryant ran his boys from dawn until 11:00 p.m. He didn’t allow water breaks. Offensive players got one towel soaked in cold water to share, defense got the other. In the context of Texas football, especially small-town Texas football, Bryant’s techniques were seen as nothing short of brilliant. You had to be tough to win, after all, and winnin
g at Texas football was about the only thing there was. It didn’t matter if you were smart, good-looking, or your daddy owned the bank. If you couldn’t stop some two-hundred-pound sixteen-year-old churning toward you on the field, or if you couldn’t throw a long pass without some pimply-faced knucklehead from the next town over intercepting, you’d get your ass handed to you by the whole damn town. The coach wanted laps when it was 105 degrees in the shade? Called you a goddamned idiot and threatened to bench your sorry ass for the remainder of the season? You did what you were told, or killed yourself trying. Maybe you hadn’t read Darwin in high school, but if you played Texas football, you didn’t have to.
In one sense, Bud Frazier was lucky: he was a big kid with natural talent. If he hadn’t been, his life would have been hell, because he liked nothing more in the world than reading books—the kiss of death just about everywhere in Texas in those days, but particularly in his hometown of Stephenville, a small town about one hundred empty, arid miles southwest of Fort Worth. Both Bud’s parents were teachers—Bud’s father had missed the first three years of his son’s life while fighting in World War II; he returned quiet and easygoing, if distant, and took a job as a chemistry teacher and coach at a local junior college. His mother, who was far more demanding—at eighty-one she was still correcting Bud’s grammar—taught high school English. With neither parent around during the day, Bud and his older sister Marilyn grew up in the care of his maternal grandmother, who taught him to read before he was four. There were also frequent drop-ins from his uncle Mule, whose tall tales of West Texas would forever shape Bud’s love of narrative. As Bud grew up, he spent his spare time—and there was a lot of it in Stephenville—consuming everything from Classics Illustrated comic books to Hamlet (he liked the swordfights but found the love scenes dull). “I read a lot because I hardly ever went to class,” he recalled. “I knew if I would feign illness enough my mother would just give up.”