Open Heart

by Jay Neugeboren

  “Snatching victory from the jaws of defeat of the verdict of the [cholesterol] trials,” James LeFanu, a London physician and author (a regular columnist for the London Times, and Daily and Sunday Telegraph), writes in an examination of the subject in his book, The Rise and Fall of Modern Medicine, “dozens of expert committee reports had persuaded most people that ‘Western food is the chief reason for our modern epidemic of heart disease.’* This in turn had been the Trojan Horse by which millions had been prescribed cholesterol-lowering drugs.”

  LeFanu subjects the claims of the pharmaceutical industry to close analysis—in one instance, when they assert that according to a “landmark study” there is “conclusive proof” that taking the drug cholestyramine reduces the chances of dying from a heart attack by 25 percent, he sorts through the data of a seven-year study used in support of such a claim.

  “After seven years…thirty out of the 1,900 taking cholestyramine had had a fatal heart attack compared to thirty-eight of the similar number in the control group,” he informs us.* “This indeed can be interpreted as ‘reducing the chances of dying from a heart attack by 25 percent…’ But put another way, almost 2,000 men took cholestyramine for seven years to increase their chances of not having a heart attack by less than half of 1 percent. This seems a modest enough achievement, except that overall cholestyramine made no difference at all, as the total number of deaths in the ‘intervention’ and ‘control’ groups were exactly the same, with the modest reduction in heart disease mortality in those taking cholestyramine being balanced by an increased risk of death ‘from other causes.’”

  “It is much easier to promote a drug on the grounds that it reduces the ‘risk of a heart attack by 25 percent,’” LeFanu observes, “than by pointing out that ruining one’s meals with cholestyramine for seven years increases one’s chances of not having a heart attack by 0.5 percent, at the price of chronic bowel symptoms, depression and increased risk of death from other causes.”

  The enormous number of studies on the relation of dietary fat to heart disease validate Rich’s assertion: that while reducing cholesterol levels, especially LDL (the so-called bad cholesterol), for individuals who have already had heart disease, or are considered to be at high risk for heart disease, is probably wise, there is a distinct absence of evidence to persuade one that otherwise healthy individuals with normal or borderline cholesterol levels need to take what will, in most instances, become lifetime medications.

  “The ideal way to treat atherosclerosis,” Rich says, “would be to give patients a pill that would be a medical roto-rooter and ream out the blocked arteries. But we don’t have that pill, and we won’t have it, if ever, for a good while. In the meantime, we have millions of people taking these medications because Dan Reeves or their doctors tell them to—and taking these meds is not like taking an antibiotic for an infection.

  “You take an antibiotic for ten days to two weeks and the bug is killed and that’s the end of it,” Rich goes on. “Yes, when you need these cholesterol meds, of course you should take them. But these are lifetime medications, remember, and every pill that has ever been manufactured by humankind has its own side effects, and nobody really knows what the effects of these medications will be in your body over the course of a lifetime.”

  While Rich is exceptionally knowledgeable about the many useful technologies available for the treatment of heart disease (and is himself responsible for the early and ongoing development of several of these technologies, including nuclear cardiology, cardiac electrophysiology, angioplasty, and the use of calcium channel-blocker drugs to treat coronary artery spasm and hypertension), in recent years he has become more attuned to, and passionate about, the role that non-technological elements play in the healing process.

  Increasingly, his life, and his work, have become informed by a range of activities—daily meditation, reading and study of Eastern thought and philosophy (especially, as with Arthur, the writings of the Dalai Lama), and his own writing—that explore experiences that cannot be fully understood or explained rationally.

  In one of the books he is working on, he tells the stories of patients whose experiences of, and recoveries from, heart disease cannot be accounted for by conventional scientific reasoning or observation.

  “After a lifetime of caring for sick people, there is no question in my mind that belief is a powerful force for those good, bad, or indifferent things that happen to people, whether in what we call ordinary life, or in things pertaining specifically to health,” he says. “And I think an awful lot of what happens has to do with what has come to be called the mind/body connection.”

  When I recount some of what I’ve been reading about placebos, and the placebo effect, Rich shakes his head sideways, and laments the fact that the word placebo has become synonymous with worthless.

  “The placebo effect is enormously powerful, and enormously healing,” he says, “and should be mobilized to the max, in addition to whatever else we may bring to bear on a specific condition. But the placebo effect is only valuable to the extent that a patient believes it’s valuable.”

  What I wonder about, I say, is this: If the doctor-patient relationship continues to be seriously weakened and devalued—if, increasingly, we and our doctors become strangers to one another—what happens to all those conditions that have no apparent organic cause, yet are ameliorated by the simple act of going to a doctor one knows and trusts?

  “Well, we know very little about the causes of illnesses that would appear to have obvious chemical, biological, genetic, or environmental origins,” Rich says. “And we know even less about the mysterious interactions between the mind and the body—and these interactions are crucial in enabling the body to heal itself, and to modify the course of illness. Thus the great danger if we lose sight of the doctor’s ability to make use of the body’s natural power to heal itself.

  “But let me be more specific, and talk about something I call paragenetics,” he continues. “Now we know that genes per se are rarely the sole or even decisive cause of most common diseases, but if your father died of a heart attack at age fifty-nine, that festers in your mind, and through the mind/body connection, in your body as well. You’re forty-eight, and then fifty, and then you reach fifty-nine and something starts to happen.

  “Now we know that genetics usually confer a propensity—a potential vulnerability. But will the heart attack that got your dad land on the same part of the time clock for you? Of course not. Still, your mind is programming your body in some way to believe that it will, and what I think about more and more is the power of the patient-doctor relationship to reset the mind/body clock—something that has largely been lost in the hoopla of technology all around us.

  “And there’s also this: in the absence of a healthy doctor-patient relationship—when somebody gets an impersonal lab coat doing all the stuff instead of a caring doctor like Phil or Jerry, or gets a different doctor for each visit—then fear kicks in, and becomes an element that itself inhibits the mind/body’s ability to heal itself. And we should never underestimate the role fear and apprehension play in a patient’s ability to deal with illness, and to recover from illness.

  “So what we’re really talking about here, I think, are questions of medical responsibility,” he continues. “What I’ve been teaching for years, for example, is that if you have a patient who is not taking medications, it’s your responsibility to see that he does. It is because you have not sat down and adequately explained the urgency, or if there are side effects, because you have not given your patient the space—the comfort, the confidence, the necessary trust—to talk with you so that you can look for a suitable alternative. People don’t want to talk about the cost of drugs or side effects with a doctor, often, because they’re embarrassed, or they’re ashamed, and so, here and in myriad other ways, I find that there is tremendous power in the doctor-patient relationship to help in the healing process—but only if we value it, encourage it, and understand its potenti
al both for ill and for good.

  “Excellence matters too, of course. Whether it’s managing a hotel or a cardiology program, there has to be a commitment to excellence and to care, and that starts at the top, with leadership. In the case of Massachusetts General Hospital, for example, ever since Paul Dudley White, who was Eisenhower’s personal physician, was in charge, there has been a standard of excellence there in cardiology and cardiac care that has been passed down from one generation to the next.

  “The way I see it, there is content and there is context. The content is the expertise—how good technically are the surgeons and the angiographers, and how up-to-date are they, and so forth. But then there’s the context. And the context is: Does the care work? Because the context, you see, is the caring, the wisdom, and the judgment about employing the knowledge and power we do have—this vast array of medications, treatments, and technologies—to best serve individual patients in the way that we were able to serve you, my friend.”

  15

  Natural Selection

  HOW CURIOUS, AND HOW wonderful, I think, that these four friends I have known across a lifetime did not start out wanting to become, or knowing they would become, doctors. I think of various small moments that led them to their choices: Rich hearing about a college named Tufts that was far from Brooklyn; Arthur, disillusioned with law school, remembering a sophomore psychology course he had taken; Jerry discovering that becoming a sociologist was not equivalent to becoming a social activist; Phil, believing (at twelve) that he would never be good enough to play for the Brooklyn Dodgers, deciding (at twenty) that he wasn’t smart enough to be a research scientist either—and I think, too, of how other such moments in their lives, as in mine, have made all the difference: Rich deciding to go to the Redondo Beach Library on a day when one of my books happened to be displayed; Jerry, about to examine a woman whose sexual partner was infected with HIV, putting his hands on the woman’s neck and feeling huge lymph nodes; and my deciding, just before getting off the phone with Rich, almost as an afterthought, to mention my shortness of breath.

  In our conversations, then, I remark on the fact that their delayed discoveries of their vocations, so seemingly serendipitous—yet, looking back, so apparently inevitable: can they imagine not having become doctors?—have their parallels in the ways many of the most beneficial medical innovations of the past century have occurred.

  The discoveries of penicillin and the fuller range of antibiotics that can destroy bacteria that cause infectious diseases (of streptomycin, for example, which provides an effective treatment for tuberculosis); of cortisone (steroids), which enhances the body’s ability to heal itself; of antipsychotic medications such as chlorpromazine and lithium, which alleviate severe symptoms of some mental illnesses; of the bacterium (Helicobacter pylori) that is a cause of peptic ulcers—these discoveries, along with a host of others, have come about not because researchers were specifically working to find the causes and remedies they happened upon (cortisone was originally developed for rheumatoid arthritis; chlorpromazine for its analgesic effects in surgery; lithium as a salt substitute for heart disease)—but through chance, accident, and serendipity.

  The stories of such discoveries provide a welcome corrective to the generally perceived notion that science proceeds from ignorance to discovery in a logical and linear way. Such a notion—reinforced in my own childhood by the worshipful attitudes that attended the advent of vaccines and cures for polio, smallpox, pneumonia, and other diseases, and encouraged later on by the optimism attending fund-raising campaigns dedicated to finding cures for cancer, muscular dystrophy, multiple sclerosis, cystic fibrosis, diabetes, leukemia, Parkinson’s disease, AIDS, and other diseases for which cures continue to remain nonexistent no matter the amounts of money, time, and research expended on them—dies hard.

  Witness, this past year, a Christmas letter in my mail from the actor Christopher Reeve, a letter reminiscent of the appeals I was hearing nearly forty years ago when Jerry Lewis, in his annual telethons, began soliciting donations of money to be used to find the cure for muscular dystrophy.

  “May I introduce myself?” Reeve writes. “My name is Christopher Reeve. Perhaps you remember when I portrayed Superman.

  “But after a riding accident in 1995, I’ve been paralyzed from the neck down, so I’m dictating this letter to you.

  “Still I’m alive, and full of enthusiasm, because I believe that a cure for paralysis will be found before long!

  “It can happen!

  “I believe it because I head up the Christopher Reeve Paralysis Foundation, and I’ve talked to some of the world’s leading specialists in spinal cord injuries.

  “Please believe me, they are zeroing in on a cure,” he reports, and in a postscript he asks us to “remember that research costs money and your holiday gift is going to help get people like me up and out of our wheelchairs.” (In a TV ad for his foundation, Reeve is shown getting up and out of his wheelchair and, like Superman, once again flying up and away into the skies.)

  How wonderful it would be if the multitude of diseases and ailments that continue to afflict us would be as amenable to reason, research, and the scientific method as, in the first half of the twentieth century, many infectious diseases were. How wonderful it would be if all we needed to find cures for disease would be to identify the problem, raise money, and set researchers to work. Our lack of success in finding cures for diseases we have expended great resources on, however—whether spinal cord injury or muscular dystrophy, breast cancer or influenza—hardly encourages such a hope.

  Still, like my friends’ discoveries of their vocations, or my discovery of my occluded arteries, the history of medical science and of scientific discovery reassures, and it does so because it turns out to be made up of what any interesting life, or story, is made of: the unpredictable and the unexpected—those small, unanticipated moments that turn out to have large and surprising issue.

  And there is this too: because we know so little about the causes of most diseases, how much more wondrous are our triumphs when we do discover the cause or causes of a disease, and do find treatments that alleviate illness and suffering. That we are able to do so—to have available to us an extraordinary range of medications and treatments which, like antibiotics and bypass surgery, were undreamt of a few generations ago—and that we often discover these marvelous technologies before we possess any true understanding of why they are effective (for example, our use of lithium and chlorpromazine for bipolar disorder and schizophrenia before we understood the workings of neurotransmitters)—this heartens because it reminds us that medical science is not separate from life, but is part of life, and so it too is informed by mystery, wonder, and chance.

  “The main discovery during this [twentieth] century of research and science,” François Jacob, Nobel Prize winner in medicine in 1965 for his work in genetics, writes, “has probably been the depth of our ignorance of nature.”*

  Thus Selman Waksman, a soil microbiologist who received the Nobel Prize in 1952 for his discovery of streptomycin and its uses in the treatment of tuberculosis, came to revise his initial understanding of the nature of antibiotics. Whereas at the time of his discovery he believed that antibiotics were “chemical weapons” produced by bacteria to maximize their own survival chances against other organisms, he later came to see that because antibiotics were limited to a very few species, they could not play a significant role in the ecology of microbial life generally. Moreover, the ability of microorganisms to produce antibiotics was highly dependent on the quality of the soil in which they lived, and could only be reliably produced in a laboratory. For these and other reasons, Waksman came to the view that antibiotics were “a purely fortuitous phenomenon…there is no purposeness behind them…[and] the only conclusion that can be drawn from these facts is that these microbiological products are accidental.”

  But why and how a small group of microorganisms that grow in soil should have the ability to create complex che
micals that can cure infectious diseases—why and how they exist at all!—remains, simply, unknown.

  That Alexander Fleming, returning from a holiday in 1928, noticed that a contaminating mold in a Petri dish, one that was sitting in a pile of other Petri dishes and waiting to be washed, had inhibited the growth of a colony of staphylococcal bacteria; that an exceptionally cool nine-day period during his absence had favored the growth of this mold (Penicillium notatum), and that a subsequent warmer period had favored the growth of the staphylococcus that the penicillin, due to its growth during the nine-day cool period, was now capable of subduing; that Fleming chose not to explore his observation further; that it was not until other scientists (Howard Florey, an Australian professor of pathology at Oxford, and Ernst Chain, a Jewish refugee biochemist from Nazi Germany), while revisiting Fleming’s observations about the ability of lysozymes in tears and nasal mucus to dissolve bacteria, came across Fleming’s observations about penicillin, and through a sequence of remarkable and remarkably serendipitous events (at the outset they assumed penicillin would have no clinical applications) not only discovered the miraculously beneficial qualities of penicillin (effective against staphylococcus, and also against the pneumococcus, gonococcus, meningococcus, and diphtheria bacillus, along with the bacilli of anthrax, tetanus, and syphilis), but elucidated the principles by which all antibiotics were to be discovered—such an unlikely and fortuitous series of events is an unexceptional (if marvelously instructive) example of how scientists have most often arrived at their discoveries and at technologies resulting from their discoveries.*

  When I reflect on the discoveries and technologies that saved my own life, and in so doing return to the moment, at Yale-New Haven Hospital, when I found myself wondering why it was we knew so little about how and why I had nearly died, I become aware of a paradox, one that, yet again, reminds us of nature’s curious and mysterious ways: that those very processes within my body that enabled me to survive my childhood are implicated in the processes that nearly did me in when I was sixty.