Birth Story

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.

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 Times article 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."

The science writer Douglas Starr has made something of a specialty of blood.

His book, Blood: The Epic History of Medicine and Commerce, and the PBS documentary series it inspired, Red Gold, cover the waterfront on this vital component of life, and our relationship to it.

The PBS website has a great discussion guide that sums up the topic impressively, and includes a timeline of important developments in our evolving relationship with blood.

Even before we understood its function, humans invested blood with value and meaning. As Starr writes in an essay in the guide:

Blood: It’s strange that this most familiar of substances has always been so laden with feeling, so heavily freighted with mystery and symbolism. Consider the vocabulary: blood of our fathers; blood of Christ; the nation’s blood; lifeblood; blood brothers, blood sacrament, blood libel.…The history of blood involves not only medicine, but also culture and religion. It is a story of change — how a mysterious liquid became a global commodity and reflected the soul of each society that used it.

This is my 75th post, something of a milestone for me, especially as it coincides with roughly six months of blogging — and a change of status.

I was part of a group laid off last week from the Chicago Sun-Times, where I had loved, loved, loved being a features reporter. The economics of print journalism caught up with me, as they have with so many others.

Where do I go from here? This is no idle question for me, and I'm just beginning to work out the answer.

Over the course of the past couple of years, I have enjoyed learning about new media, and now here I am, with both feet in the 21st century. I blog three times a week, I tweet, I even built my own website (with lots of help).

At the same time, I believe in the values of old media — checking facts, maintaining a certain distance from sources, and allowing both sides to have their say in a civil discourse.

Even while I find myself slipping into the conventions of the new, I hang onto my belief that the best journalism serves the reader's need to know about, and understand, the society she lives in.

I think I have picked a great topic to write about, because it seems to me that birth is on the cusp, just like me. Modern medicine knows how to make birth safe, and yet the maternal mortality rate appears to be going up.

Not only that, but I can't help but notice that while 99 percent of American women have their babies in hospitals, most of the voices making themselves heard in books and blogs belong to women who are dissatisfied with and critical of the hospital experience.

And with Caesarean-section rates rising out of all proportion to any statistical need for their use, those voices are gaining an intelligent and often passionate following.

Where do we go from here? I believe that one thing that will help us answer that question is an understanding of how far we have come.

Cartoon by Shel Silverstein

At the ACOG meeting last May, Dr. Robert Wachter talked about a case in a teaching hospital in which two women with similar names -- Jane Morrison and Joan Morris are the pseudonyms assigned to them -- were confused with one another, resulting in one of them receiving an invasive procedure intended for the other one. This case did not involve a birth story, but every medical specialty can take lessons away from it.

This case, which Dr. Wachter and colleagues published as "The Wrong Patient," in June, 2002, in the Annals of Internal Medicine, demonstrates how easily a series of oversights can cascade into a shocking medical error. (It could have been worse. The procedure was a cardiac electrophysiology study, not, say, a leg amputation.)

Oops

In fact, the team that analyzed the mishap identified 17 junctures at which the process could have been stopped but instead moved forward. No single mistake would have been enough to keep this juggernaut moving. Human error fed into institutional weaknesses, including "frighteningly poor communication," a lack of standardized protocols and a culture that had become sufficiently dysfunctional that more than one person thought, incredibly, Gee, this doesn't seem right, but I'm going to do it anyway.

"Human performance can be improved but not perfected," the team concluded. Protocols must be in place to head off the inevitable errors before they converge into tragedy.

I notice that the American College of Obstetricians and Gynecologists is gearing up for its annual clinical meeting May 15 through May 19 in San Francisco.

The 2009 annual meeting was in Chicago, and I attended as many sessions as I could -- I don't want my ideas about what is going on in obstetrics to stop with my own birth experiences. (Sadly, I won't be able to attend the San Francisco meeting.)

I learned a lot last May, but one thing stayed with me in particular, Dr. Robert Wachter's keynote address.

Robert Wachter MD

Dr. Wachter,  chief of the medical service at the University of California at San Franciso, among other titles, is one of the founders of the hospitalist movement, and an expert in patient safety.

He spoke about efforts to improve safety since 1999, when the Institute of Medicine released its landmark report, To Err Is Human, which revealed that as many as 98,000 people were dying from medical mistakes every year.

Dr. Wachter's message is important for the birth story because obstetricians are the doctors most often sued for malpractice. A 2003 ACOG survey showed that 76 percent of OB-GYNs have been sued at least once.

Many of them would say that if anything ever goes wrong with a birth, they are sued whether the mishap was their fault or not. Dr. Wachter agreed that "the blame game" is "not productive."

He said, "Medicine is too complex to be error free." Some other complex industries have better safety records, though, he said, often because they have developed "systems thinking," standardizing procedures and accepting that some mistakes are a natural part of the process.

Canada's full-bore pursuit of gold at the Olympics the country is hosting in Vancouver, B.C., has attracted much comment, mostly about how out-of-character overt ambition supposedly is for Canadians.

Writing in the New York Times last week, Charles McGrath quoted the Canadian writer George Woodcock on the subject: “Canadians do not like heroes, and so they do not have them. They do not even have great men in the accepted sense of the word.”

Here's one for the books, then -- William Osler, the so-called "father of modern medicine," a great man if ever there was one, born in Bond Head, Ont., in 1849.

Dr. William Osler

Osler received his medical degree from McGill University in Montreal in 1872 but, critically, then went abroad to study in London, Berlin and Vienna before returning to join the McGill faculty. By 1883, he was one of two Canadian fellows of the British Royal College of Physicians. The next year, he accepted a post as professor of clinical medicine at the University of Pennsylvania in Philadelphia.

It was as a founding faculty member of Johns Hopkins School of Medicine in Baltimore, where he went in 1888, that Osler had the opportunity to put the innovations he had seen in Europe to work.

Osler insisted that the patient could teach medical students nearly everything they needed to know -- that the study of medicine was properly conducted at the bedside -- and that hands-on laboratory research must also be part of medical training.  He also introduced the German model of post-graduate training, a one-year internship followed by several years of full-time residency.

These innovations began a profound change in American medical education, which up to this point had been largely a matter of learning from lectures.

Osler was able to implement his ideas because he was an excellent doctor. In 1905 he moved to England to take up a prestigious post as professor of medicine at the University of Oxford. His book, The Principles and Practice of Medicine, was a major work in medicine for nearly half a century.

Osler died in England in 1919, of the Spanish flu.

Canadians might say that Osler's absconding to the United States and England rules him out as a national hero, but it says something when a boy from Bond Head can hit the heights of world medicine.