by Rob Dunn
Why all of this happens has been poorly studied, but so has the simpler question of when, historically, it began. Compared to the history of heart surgery, heart transplants, and artificial hearts, the history of heart disease is not sexy; context rarely is. Christiaan Barnard, the man who first transplanted a heart, did not study why hearts become diseased or why hearts are sometimes malformed. For most of his career, he was not interested. Nor were his mentors. Nor were his competitors racing to transplant the first heart. They did not, except in passing, seem to really care about the history of the diseases they treated. For the most part, they did not even seem to have very informed opinions about their causes. Although they spent more time inside hearts than anyone else who had come before, these doctors were the mechanics at the accident—happy to have something to fix but not very aware of the tire tracks or other clues on the road. Of course, they saw evidence in details and problems, but they were too close to see anything resembling a big picture.
So why were hearts becoming diseased? Fate. Gods. Bad living. Bad luck. These were the things surgeons said when asked. They also might have said that heart disease was a modern condition. This assertion was based on intuition, but very, very few data. When Thomas and Allam became interested in the question of when hearts first began to break, the first discovery was that no one knew for sure when atherosclerosis had begun.11
Many diseases, most of them far less common than heart disease, have had their histories explored in detail. But those diseases tend to be the ones caused by pathogens. If a disease is caused by a pathogen, the genes of the pathogen can be studied to reconstruct its history. One can study the malaria parasite—plasmodium—or even the mosquito that carries the parasite from body to body and learn about the history of the disease that they, together, cause. But heart disease is not caused by pathogens (at least, not directly). No set of genes exists to be considered other than the afflicted host’s genes, whose stories are often hard to translate. To understand the origin of heart disease, then, one of the only recourses is to look for ancient examples of hearts, and for this, one needs bodies.
Despite having no experience whatsoever in working with ancient bodies, Thomas and Allam found themselves compelled to study them. During the reign of Napoleon, the Rosetta stone was discovered in Egypt and allowed the messages in the hieroglyphs to be read. Thomas and Allam thought the bodies of ancient Egyptians might allow scholars to decode another mystery, the story of our weak hearts. For one, there were many ancient Egyptian bodies in museums. For another, ancient Egyptian society was a reasonable cultural antecedent of modern society. (The influence is direct; the culture of Egypt strongly influenced the culture of Greece, and the culture of ancient Greece has influenced every bit of modern Western culture.) Thomas and Allam were experts in the heart, and Allam in particular was an expert on imaging the heart and blood vessels through the skin using CT scans. It could not be so much harder to do the same through the mummies’ wraps.
Soon, Thomas and Allam had enlisted a large number of colleagues to work with them, colleagues who were experts in each of the necessary steps and details of the process (a photo of the team in 2010 shows nineteen smiling scholars).12 But in order to compare modern hearts to ancient ones, Thomas, Allam, and their team needed mummies. But working with Egyptian bodies is now an ordeal nearly as elaborate as becoming mummified, and for good reason. The mummies are not just artifacts; they are also ancestors, and therefore, handling the mummies requires layers of approval so enveloping that if one is approved, it feels as though passage has been granted to the afterlife (it often seems far more likely that the research proposal will be consumed by Ammit, the crocodile beast). All Winlock had had to do was buy some shovels and start to dig. But for Thomas and Allam, the approval process consumed valuable time. Finally, amazingly, after testifying before a committee of seventy Egyptian archaeologists, writing and more writing, and then, when all of that did not seem to be working, a bit of begging, Thomas’s application was approved. It helped that his study seemed to be important. Also, most of the individuals on the panel determining whether he would be approved were of an age at which heart disease would have concerned them in more than just abstract ways.
The team came together in Cairo in 2009, where they were taken to the Egyptian National Museum of Antiquities in Cairo. At the museum, they were asked to choose the bodies they wanted to study. They chose the 45 best mummies out of the 120 or so available. Inevitably, the team knew less than was ideal about any particular body’s history. They were researchers, clinicians, and surgeons, not archaeologists. Yet they were so tickled by the possibility of studying mummies (who wouldn’t be?) that any body would and could work. The queen’s was among the chosen, but the doctors did not yet know her story or anything about Winlock. Hers was just another body among the many stacked in the museum in the most ordinary of ways.
Once the bodies were chosen, the men carried them to the hospital, where they would be reweighed, at least figuratively. The men looked like pallbearers, but they were on their way to a rebirth. The coffins were heavy. But coffin after coffin made it down the road and up the elevator to the whole-body CT scanner, where the bodies (including the hearts, if they were present) were slid into the machine just as you might be if you were getting a CT scan. Not surprisingly, a richness of details was visible through the shrouds of cloth wraps and skin. Even through the wrappings of mummification and time, atherosclerosis showed up on a CT scan, a white smudge where a plaque has calcified. With the scans, the hearts were weighed once more, though not against a feather this time. They were weighed against modern hearts. Here would be the test of just how much the hearts in the good old days were like the hearts in the bad new ones. The scientists compared the images they made of the ancient hearts to images of modern hearts to see if the modern condition really was modern or, instead, a reflection of a deeper human condition.
Some of the bodies were from individuals who’d died relatively old, others younger, though they were all adults. Some, such as Lady Rai (who died in about 1530 BC), nursemaid to Queen Ahmose Nefertari, were from the first days of the Egyptian empire, when only kings and those closest to them were mummified. Others were from later days, when far more individuals had a shot at the afterlife. The earliest was from 1981 BC, the most recent AD 364. The bodies were those of people who had not previously interacted with one another. Using them to characterize “ancient Egyptians” is like using a dozen people you meet at the queen’s palace in London to characterize modern Europeans, and yet it offered the best look to date at the ancient history of our hearts. None of the bodies would have been from working folks. While mummification became increasingly common as time went on, most Egyptians and all of the block cutters and builders, for example, were buried with little fanfare in the drifting sand.
Though it was possible, the scientists and doctors did not think it was likely that they would see concrete evidence of the ultimate consequences of atherosclerosis: heart attacks or strokes. What they could find, though, might be the white reflection of the atherosclerosis itself. In modern bodies, the presence of atherosclerosis in any part of the body is a good predictor of its presence in the arteries of the brain or even, that most dangerous place, the arteries of the heart. It was also possible the men would find no atherosclerosis at all, even if it was there.
If the ancient Egyptians were found to have atherosclerosis, it might be due to their similarities to modern humans. Although removed greatly from us in time, wealthy ancient Egyptians may have eaten and lived enough like modern Egyptians or Americans to have similarly plagued hearts. The Egyptians were, in general, thin. As Allam and colleagues put it in one article, “After all, the ancient Egyptians built the great pyramids by hand without modern machinery, and ‘fast food’ was not yet invented.” But the individuals prestigious enough to be mummified were also, almost certainly, the same individuals likely to eat a lot and move relatively little. The food available to the most gluttonous Eg
yptians, like that available to modern Americans, included meat, dairy products, eggs, processed grains, salted meats, and beer. Researchers studying Queen Hatshepsut have described her as a big woman with “huge pendulous breasts.”
But there was another, more interesting possibility. Perhaps atherosclerosis is not associated only with rich, slothful living. Perhaps it is more universal than previously suspected. The Egyptian data would not, on their own, allow Thomas, Allam, and crew to distinguish between the good-living hypothesis and the universal-atherosclerosis hypothesis, but it would be a start. Despite what the sign on the mummy in the museum had said about Menephtah, the most likely scenario by far was that the mummies would be devoid of atherosclerosis.
The team examined the mummies as a group, looking at CT scans together and conferring, the way doctors might about a living patient. They consulted with one another to reach a consensus about what each scan showed. They looked together and what they found astonished them. Vascular tissue, be it from veins or arteries, could be identified in forty-three of the mummies, and at least pieces of hearts could be found in thirty-one. The doctors saw plaques in one body, and then another, and then another. Amazingly, plaques were visible in nearly half (45 percent) of the mummies. The plaques were more likely in older mummies, just as they are more likely in older people today,13 but were present in mummies of many periods and across a range of social positions (at any rate, from pharaoh to pharaoh’s attendants).
In general, the mummies provided clear evidence that cardiovascular diseases were likely to have been common among Egyptians, at least those Egyptians who were mummified, even if the individuals did not often live long enough to die of those diseases—though some of the mummies may well have died of their blockages. One of the mummies was the husband of Queen Hatshepsut. It was when he died—perhaps as a consequence of atherosclerosis—that Hatshepsut became queen (their oldest heir was too young to rule). But the team did not initially see in the mummies what one might expect to find in a modern sample of people of ages similar to those of the mummies: atherosclerosis of the coronary arteries. True, the hearts were present in only a minority of bodies. But still, it would have been nice to confirm that atherosclerosis of the coronary arteries had occurred at least sometimes. Seeing a clogged coronary artery would be as close as one could hope to get to evidence of an ancient heart attack.
The team members found only a few coronary arteries they could easily study. But then they looked at Queen Meryet-Amun after sliding her into the CT scan. The queen had atherosclerosis in every artery bed examined, including her coronary arteries. Her arteries looked like those of someone who might turn up at the hospital having just suffered a heart attack. Thomas would later say of her condition that if she had come into his office, he would have recommended a double bypass. Her body, although draped in ancient finery, could have passed as modern. The Egyptians, Meryet-Amun’s body revealed, were not just a little like us; their hearts and our hearts seemed the same. Meryet-Amun might even have died of her broken heart; that might be why she disappeared from power in the first place. If we are to reconsider the drawing on her sarcophagus, her heart was, in a way, far heavier than a feather. It was weighed down with our “modern plague.” Nor are the Egyptian bodies totally unique. A later study found that the Tyrolean iceman discovered in present-day Italy, a man who’d died from an accidental fall at the age of about forty-five around 5,300 years ago, had plaque in his carotid arteries, as well as in his aorta and iliac artery.14 Clogged arteries seems to be an ancient human phenomenon and yet there was still a lingering doubt in the minds of Thomas, Allam, and others. They had proved atherosclerosis to be ancient, but they could not distinguish whether it was ancient because humans have, for many millennia, indulged in lifestyles that cause their arteries to clog or because atherosclerosis is universal, a condition of being human. Maybe poor Egyptians (the men and women who built the pyramids, for example) and hunter-gatherers were very different. Perhaps atherosclerosis was only as old as excess.
Thomas, Allam, and friends thought they could figure the answer out. The Egyptians were not the only people to mummify their dead. Mummies can be found around the world in those places that are cold or dry enough that one can bury one’s cousin and, without too much trouble, ensure that he or she will look the same in a few thousand years. In many places, such as Egypt and Peru, mummies are intentional, but in others, they just happen; for example, when the dead are left in cold, dry caves. And so, Thomas, Allam, and their colleagues reasoned, one could, in theory, consider the presence of atherosclerosis in mummies from around the world. One could also do this in practice. Thomas and Allam brought together an even bigger team than they’d worked with before to evaluate 137 bodies: mummies from the end of the Roman era, mummies from ancient Peru (900 BC to AD 1500), mummies of the ancient Pueblo of the southwestern United States (1500 BC to AD 1500), and five mummies of the hunter-gatherer Unangan people from the Aleutian Islands (about AD 1800). Together with the samples from Egypt, they provided bodies from farmers and hunters-gatherers from different periods, cultures, and regions.
Here I will pause for a personal aside. When I started writing this book, the results from this broader study were not yet published. Knowing what I know about hunter-gatherers, farmers, diet, atherosclerosis, and the heart, I would have predicted that the hunter-gatherers would be free of atherosclerosis, as might be many of the less affluent individuals from agricultural cultures outside Egypt. The folks in Peru, for example, had diets based heavily on fish. The Pueblo ate farmed foods, but far different kinds than the Egyptians. In light of how extremely different the lives of these peoples were, I would have bet quite a bit of money that they would vary greatly in their atherosclerosis. It is clear from interviews done before this study of members of the team that many of them would have bet the same as I did.
And we would all have lost. Just as in modern humans in affluent cultures, the degree of atherosclerosis tended to increase with age. Atherosclerosis was found in every sample of mummies, from each region and time. Probable atherosclerosis was discovered in 34 percent of the mummies. It is not modern; it is our ancient condition. Sixty percent of the Inuit and Unangan hunter-gatherers suffered atherosclerosis, which is to say that hunter-gatherers were in worse shape than the agriculturists, exactly the opposite of what everyone would have predicted. These results turn on its head the idea that atherosclerosis is a modern condition, the result of our terrible lifestyles. Our terrible lifestyles play a role, but, as the authors of the study put it, “The presence of atherosclerosis in pre-modern human beings suggests that the disease is an inherent component of human ageing and not associated with any specific diet or lifestyle.”15
Had the surgeons working in the 1960s and 1970s known all of this, and had they had the perspective of time, they might have paused to reflect upon what was going on in the heart. They might have begun to think of coronary atherosclerosis in particular as a natural death, a part of aging we want to forestall and yet, still, part of aging. This is what da Vinci thought. Or they might have approached it from the perspective of evolution to understand whether coronary artery disease is even more ancient than ancient Egypt, Peru, and North America. Instead, upon confronting the atherosclerosis that Sones and others saw early on in coronary and other arteries, those who weren’t trying to transplant hearts or build artificial ones began upon a trajectory suggested by technology, a trajectory with an emphasis on intervention, a trajectory toward precisely the technique, coronary bypass surgery, that Gregory Thomas suggested Queen Meryet-Amun needed for her heart.
10
Mending the Broken Heart
René Favaloro’s story began as a classic tale of self-motivated accomplishment. Favaloro was born in 1923 in a working-class neighborhood of La Plata, a town thirty miles south of Buenos Aires, to Sicilian immigrant parents. His mother was a seamstress, his father an artful carpenter. While Favaloro lived at home, he stood with his father and built useful furnitu
re. He could have followed in his father’s footsteps. But for some reason, even in grade school, he imagined himself as a doctor, and so he kept moving, going to college and then, eventually, medical school (although each year he would come back on his breaks to help with the details of carving and veneer work). When he graduated in 1949 with his medical degree, his mentors agreed that he was a great young doctor. But there was one thing at which he was truly outstanding: working with his hands. He had the hands of his parents, with a carpenter’s strength and a seamstress’s subtlety.1 He trained himself to work with both his dominant right hand and his lagging left. He would hold his breath and cut and sew with both hands. When he did, he could weave together the body so perfectly that it seemed as though it had never been apart. Everything was going right. Favaloro was headed for a successful life as a big-city surgeon, his high-school sweetheart, by then his wife, Maria Antonia, at his side. But this simple future was not to be.
In 1946, while Favaloro was finishing his medical training, Juan Domingo Perón was elected president of Argentina. Perón quickly concentrated power, including power over the contracts of many doctors and academics, power he used to quell dissent. Faculty who disagreed with Perón, and there were at least fifteen hundred of them, resigned or were fired. Favaloro knew all this; he had watched his colleagues and mentors leave. The oppression these departures symbolized boiled under his skin. He was an idealist in a country where such people faced difficulties. This idealism had its first test when Favaloro graduated. He was offered a prestigious job, but on the condition that he profess his loyalty to the Perón’s Justicialista Party. He refused. This refusal exiled him from big hospitals for as long as the Peróns were in power. This man who exuded a kind of inevitable greatness left for a small village in the southwest of the gray dry pampas in 1950. He found a house he could turn into a clinic. All around the wind blew. Cows stood in the grass. He was, as he would often say later in his life, an urban kid who had suddenly become a country doctor.