The Black Death came to Europe in the 14th century, probably mostly aboard merchant ships from the Crimean peninsula in the Black Sea, though soldiers returning from late, intermittent Crusade-type forays likely contributed to the pandemic as well.
One early episode in this notorious outbreak of plague demonstrates that its victims had the misfortune to learn firsthand that the disease could be transmitted from person to person.
In 1346, a Tartar army laid seige to Caffa, a port in Crimea, now an autonomous republic just south of Ukraine. Caffa, now called Feodosija, was then held by Genoa, a mighty Italian city-state and commercial power. The seige lasted three years, and the residents and refugees in Caffa were in a bad way by the end. But then the Tartars began to die in great numbers from a horrific disease, and the tide appeared to be turning.
The remaining Tartars got the idea of catapulting the rotting corpses of their plague victims into the walled city of Caffa. Apparently, the Tartars' hope was that the "intolerable stench would kill everyone inside," according to an account by the Italian notary and writer Gabriele de’ Mussi. At the time, "miasmas," or noxious airs from rotting organic matter, were thought to be one source of disease.
Soon, even though the cadavers were dumped into the sea, people began to die in the besieged city. And then, the survivors began to flee.
De' Mussi writes:
Among those who escaped from Caffa by boat were a few sailors who had been infected with the poisonous disease. Some boats were bound for Genoa, others went to Venice and to other Christian areas. When the sailors reached these places and mixed with the people there, it was as if they had brought evil spirits with them: every city, every settlement, every place was poisoned by the contagious pestilence, and their inhabitants, both men and women, died suddenly. And when one person had contracted the illness, he poisoned his whole family even as he fell and died, so that those preparing to bury his body were seized by death in the same way.
De' Mussi was not an eye-witness to the events in Caffa. However, his account preserved not only the details of what has been remarked upon as an early instance of biological warfare, but also what the survivors learned about how diseases can be transmitted.
The germ theory of disease, which holds that certain diseases are caused by living organisms, occurred to people thousands of years ago, but it was proved only in the 19th century.
In the western tradition, the Roman scholar Marcus Terentius Varro first laid out the germ theory in his book, On Agriculture,a practical guide published in about 36 B.C. In it, Varro advises the farmer against building near swamps because “certain minute animals, invisible to the eye, breed there and, borne by the air, reach inside the body by way of the mouth and nose and cause diseases that are difficult to get rid of.”
Varro was a prodigious scholar and well known public figure, and his works were highly influential. However, at least some of his contemporaries, apparently including the writer/philosopher/statesman Marcus Tullius Cicero, considered his germ theory a crackpot idea.
It is worth noting that the Atharva Veda, the first Indian book that addresses medical topics, includes a fairly detailed germ theory. The book identifies a number of living organisms that were deemed responsible for causing various diseases, and prescribes cures to kill the organisms. The Atharva Veda was written down about 200 B.C., but its ideas may date as far back as 1,000 B.C.
There is little hope of obtaining precise estimates of maternal mortality rates, as we do for under-5 mortality, for instance. The sources of data are heterogeneous, data quality varies substantially, and the issue of death after induced abortion remains important in countries where it is illegal. It seems a better strategy to separate estimates of obstetric deaths for countries with vital registration, and pregnancy-related deaths for countries that rely on surveys, to increase internal consistency and produce more reliable trends.
Maternal deaths and pregnancy-related deaths are not necessarily the same thing, the article states. A maternal death is one that "could have been prevented by proper antenatal and obstetric care," while a pregnancy-related death "can include infectious, non-communicable, and external causes."
The article's authors, Michel Garenne and Robert McCaa, also say that "one could note a decline in maternal deaths despite an increase in pregnancy-related deaths when confounding with other causes is very strong, as is the case in countries with increasing death rates from HIV, tuberculosis, accidents, and violence."
I would say two things about this article's thesis. First, in a country ravaged by HIV/AIDS and war, some women who are stricken with illness or murdered will be pregnant, but how those deaths are pregnancy-related is a mystery to me. A pregnancy-related death to me would be a woman murdered by her husband for being pregnant, or a woman whose pregnancy contributed to her death from swine flu, for example.
Second, just as a note, it's pretty grandiose to say that "proper antenatal and obstetric care" can head off every true pregnancy-related disaster, like amniotic fluid embolism, for example. Sometimes, in spite of the best efforts, women die.
Oh, well, the authors' point is a good one: Precise estimates of maternal mortality are hard to come by.
The fifth MDG is to cut the number of women who die in childbirth worldwide by 75 percent by the year 2015. Malawi, along with a number of other countries, has experienced disappointing progress on Goal 5.
Malawi shares Africa's dismal statistics on maternal mortality; a mother's lifetime chance of dying in childbirth there is 1 in 36, according to the latest figures from the World Health Organization. (HIV/AIDS is a major factor in Malawi.) Not only that, but decreases in the rate of deaths, presently 510 per 100,000 births, have only been running about 3 percent per year since 1990.
Banning TBAs was part of an earlier effort to get more women to deliver their babies with assistants trained in modern medical techniques, who would be able to recognize and respond to emergencies. Only 54 percent of Malawi women delivered their babies in a health-care facility in 2005.
However, one result of the ban has been that more women have delivered their babies without any kind of real birth attendant, traditional or modern, or with TBAs working under the threat of fines.
Dorothy Ngoma, executive director of the National Organization of Nurses and Midwives in Malawi, told The Nation, a daily newspaper in Malawi, "They [TBAs] never really stopped.... What happened is that they went underground."
It appears that President Mutharika decided after the UN summit that training TBAs to be part of the solution made more sense. The president married Callista Chimombo last spring, and the new first lady appears to be taking an active role in addressing the country's poverty.
The Nation reported that her Safe Motherhood Foundation will train 20 TBAs from the countryside next year in modern birth methods. They will then return to serve their communities as midwives.
Healthcare facilities tend to be concentrated in Malawi's cities, while 70 percent of the nation's 15 million people live in rural areas. There are reportedly two doctors for every 100,000 Malawians.
"We should not abandon TBAs, as they are very important to our program of safe motherhood," President Mutharika was quoted as saying in The Nation.
The "humoral theory" of disease, which originated with Hippocrates (who lived from about 460 to about 370 B.C.) and lasted until the early 20th century, held that a balance had to be maintained among four humors or liquid substances in the human body. If that balance got out of whack, the thinking was, people got sick.
The four humors were black bile, red or yellow bile, blood and phlegm. The ancients believed that these substances ruled our personalities as well as our bodies. They divided all the possible character types into these four — melancholic, choleric, sanguine and phlegmatic — depending on which substance dominated that particular person.
Treatments for disease were designed to restore the balance among the humors, but what worked for one person might not work for another, which helped let practitioners off the hook if a "cure" didn't work. Purges like enemas and emetics were popular, and physicians often advised changes to a patient's diet or routine. Blood-letting was an especially durable cure for just about anything.
During labor, for example, "some women were bled to unconsciousness to counter delivery pains" or any other complications large or small, according to Peter Conrad's The Sociology of Health and Illness.
The acceptance of the germ theory finally put an end to humoral theory in mainstream medical thought.
"There is not a corner in Britain where this formidable disease has not made many mourners,” John Mackintosh, an Edinburgh, Scotland "man-midwife" wrote of puerperal or "childbed" fever in the 1820s.
This bacterial disease of the upper genital tract typically began within the first three days after childbirth with abdominal pain, fever and respiratory difficulty, and very often ended with the new mother's death.
Medical writers had been remarking on childbed fever at least since Hippocrates, but in the early modern era, it began to attract attention for a number of reasons. For one, it began to appear in epidemics, with very high mortality rates. For another, accounts of outbreaks were written about and published. And at least some of the new, scientific man-midwives themselves were spreading the disease by going straight from autopsies to the birth chambers of homes and especially of hospitals, without cleaning up at all in between.
There were terrible epidemics of puerperal fever in the German city of Leipzig in 1652 and 1665, at the Hôtel Dieu in Paris, France, in 1745 and 1746, and at the British Lying-In Hospital in London, England, in 1760. It is possible that these were the first ever epidemics of childbed fever.
Birth is the most common reason for a person to be hospitalized in the United States, a major point of intersection for a healthy population with the health-care system.
But while birth may be common, it isn't cheap. The average cost of maternity care in the United States in 2004 was $8,800, according to a report by the March of Dimes, and that figure can take off for the stratosphere — into the tens and even hundreds of thousands of dollars — in the event of complications.
With the national mid-term elections just a few weeks away, many politicians are drumming up votes by weighing in on the health-care reform legislation Congress passed earlier this year, and on government programs that subsidize health-care services like maternity care for low-income people.
Rand Paul, an ophthamologist who is the Republican candidate for the Senate in Kentucky, remarked last week that half the state's 57,000 yearly births are paid for by Medicaid. “Half of the people in Kentucky are not poor. We’ve made it too easy,” Paul said.
You could say Paul is right. A woman doesn't have to be officially poor in Kentucky to have her baby's birth paid for by Medicaid. Kentucky allows Medicaid coverage for a woman whose income is 185 percent of the official federal poverty level of $18,310 for a family of three. That is, her family of three can make just under $34,000 and still qualify.
But remember, the average birth experience will cost her almost $9,000.
The March of Dimes analysis found that consumer costs for a birth averaged just under $500, but that pre-supposes that the mother has health insurance that covers childbirth and maternity care.
Analysts for The Guttmacher Institute, which concerns itself with sexual and reproductive health both in the United States and globally, working with recent figures from the U.S. Census Bureau, figure that 2.3 million women of reproductive age lost health insurance in the year between 2008 and 2009 alone.
The National Women's Law Center has found that individual insurance plans, which are exempt from the Pregnancy Discrimination Act of 1978, tend not to offer maternity care. The NWLC found that just 12 percent of the plans it examined offered maternity care, and that the provisions they offered were often limited.
"That’s why having insurance coverage is so critical. Employer-based group plans usually have good maternity care coverage, but most low-income women don’t get insurance through the workplace," the Guttmacher Institute states on its website today.
So looked at from that aspect, Paul is wrong. We're not making things too easy at all. The way thing are set up now, we're making it too hard for women to obtain coverage for maternity care.
Of necessity, research on fetal development involves observing pregnant women in their daily lives; no one would purposefully have one group eat in a possibly risky way or be exposed to a potentially dangerous substance, and compare outcomes with an unperturbed control group. We have, at best, only correlations between a mother’s lifestyle and her child’s future health, not clear causation.
And, in "The Case Against Breast-Feeding," Hanna Rosin's 2009 article in The Atlantic, she wrote, "An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies."
Really? Why not? Both Groopman and Rosin are writing about how vulnerable observational studies are to being tainted by hidden variables. Controlled trials are a better system for testing what works and what doesn't.
But if I am reading their statements correctly, Groopman and Rosin are saying that we cannot even think about practicing actual, rigorous science if babies and fetuses are involved.
Building up a body of "evidence-based medicine" around a segment of the population that is exempted from clinical trials — depending entirely on observational research, that is — seems unwise to me. We don't need to wonder what a worst-case scenario involving babies would look like; we have the 50-year-oldthalidomide catastrophe as a demonstration. Thousands of children around the world were born with deformed limbs after their mothers took the drug.
Subjecting drugs and behaviors that can affect unborn children to standard scientific trials that include pregnant women might save the population from potentially massive damage from those behaviors, and from the drugs once they are put on the market. This is especially true now that we suspect the experience in the womb has a huge influence on the course of an individual's life — the subject of Paul's book, Origins.
Now I understand why the medical ethicist Ruth Macklin, writing in The Lancet last winter, called for the inclusion of pregnant women in drug trials, and retaining women who get pregnant in such trials. Conventional wisdom seems to have rendered the concept so unthinkable that a call for change is necessary.
What do you think about including pregnant women in clinical trials? I would love to read your comments.
For the first time ever, the Nobel Prize committee has awarded one of its coveted medals — and $1-million-plus in prize money — to a scientist who worked in the area of reproduction.
The British biologist Robert G. Edwards won the Nobel Prize in "physiology or medicine" today for pioneering in vitro fertilization with a colleague, Patrick Steptoe, a gynecologist and medical researcher who died in 1988. The pair's efforts led to the birth of the first "test tube baby," Louise Brown, on July 25, 1978.
Since then, four million babies have been born with the assistance of IVF, in which sperm and egg are united outside the mother's body and then transferred to the womb.
The Nobel Committee waited more than 30 years to make the award. Edwards, who spent most of his career at Cambridge University, is 85 years old and "not in a position to understand the honor he has received today,” a colleague, Dr. Michael Macnamee, was quoted as saying in a New York Timesarticle by Nicholas Wade.
Edwards and Steptoe unlocked many of the secrets of the human reproductive system on their way to success with IVF. They tried 40 embryo transfers before they achieved a pregnancy, which turned out to be ectopic. The second try led to the birth of a daughter to Leslie and Gilbert Brown of Oldham, in Greater Manchester, England.
Like virtually all medical visionaries, Edwards and Steptoe were subjected to vitriolic attacks. The British medical establishment withheld all manner of support from them, even after Louise Brown's birth.
But the joy of millions of families all over the world who were able to hold their own babies as a result of IVF technology eventually quelled the critics.
Louise Brown, herself the mother of a three-year-old boy, said of the award today: "It's fantastic news; me and Mum are so glad that one of the pioneers of IVF has been given the recognition he deserves. We hold Bob in great affection and are delighted to send our personal congratulations to him and his family at this time."
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