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Bad Medicine: Spycraft and Vaccination Efforts

120px-CIA.svgI admire many of the creative efforts used by our intelligence agencies to keep America safe.  Spycraft itself is a wonderfully fascinating area, both in reality and fiction.  But some areas should be off-limits.

The 2011 intelligence effort to locate Osama bin Laden included a vaccination program aimed at obtaining DNA from children at a compound where bin Laden was suspected of – and later found to be – hiding.

A Pakistani doctor involved with the effort remains in legal trouble for his involvement in the plot, and local suspicion of future vaccination efforts in the aftermath of this scheme has led to an increase in polio cases.  Fortunately, the White House has agreed to cease any future use of vaccination programs as cover for intelligence operations.

Vaccination has been one of medicine’s great triumphs.  Leaving this area off-limits for intelligence gives assurance to the world that vaccination programs can always be viewed as legitimate.

Polio Vaccination, India 2002

This will keep polio out of your future

The anti-vaccination effort in this country has been an unfortunate development, sowing doubt via unscientific and outright fraudulent information.  No further seeds of doubt should be developed, and it’s a good thing that the CDC continues to campaign against such misinformation.  By putting vaccination programs off-limits, the CIA has taken an important step and owned-up to its past.

Creativity from our intelligence services is normally a good thing.  Reality and fiction have given us everything from exploding cigars to sports-car submarines.  At least they will no longer give us vaccination ruses.

I’m glad we got bin Laden.  I hope we did not truly need the vaccination program to do so.

Remembering Transplant Pioneer Joseph Murray

Joseph Murray, M.D.At the end of every year, we recall the notable people who have departed our worldly domain.  Naturally, most are entertainers, political figures and other luminaries.  We should also highlight noted personalities in the sciences.  Before the first week of 2013 is past, recall one of the most noted individuals to pass in 2012 – an important figure who hailed from the scientific and medical arena.

Joseph Murray M.D. died on November 26, 2012, and though he may not be a household name, he was one of the most accomplished plastic surgeons in history, and one of the major figures in 20th century medicine.

Dr. Murray was the first surgeon to perform a solid-organ transplant when on December 23, 1954; he transplanted the kidney of Ronald Herrick into his identical-twin brother Richard, who suffered from end-stage renal disease.  The procedure ushered in the contemporary era of transplantation, and from this accomplishment Dr. Murray shared the 1990 Nobel Prize in physiology or medicine.

Today’s medical world is a bit different from the one in which Dr. Murray came of age and made his mark on medical history.  Laypersons may be surprised to learn that a plastic surgeon performed the first kidney transplant.  But in that era plastic surgery encompassed a wide domain, and surgeons could develop expertise in their areas of interest.  Dr. Murray became interested in transplantation after noting rejection patterns of skin grafts from unrelated donors during his work treating soldiers injured in World War II.

At this time, specialties developed based on advances in physiology allowing work that was previously not feasible.  Advances in anesthesia and critical care allowed bigger and bolder interventions to be attempted and accomplished.  The first kidney transplant was followed by refinements in technique, a better understanding of immunology, and an expansion of acceptable donor and recipient criteria.

Further advances led to success in liver, heart, heart-lung and other types of transplant procedures.  The early kidney procedures involved identical twins, avoiding the problem of organ rejection.  While developing the technical aspects of transplant surgery was critical, wider application came from better understanding of transplant immunology, which Dr. Murray helped lead.

Today transplantation of kidneys and other organs is commonplace.  That is largely due to the efforts of Dr. Murray and others in this developing field.  Science advances one step at a time, and in the field of transplantation many of those steps led to and from the work of Joseph Murray.

Medical Black Swans

A wild black swan Cygnus atratus . taken in so...

Image via Wikipedia

Anyone interested in learning more about the financial meltdown should check out Nassim Taleb’s book The Black Swan.  Published in 2007, it’s message makes the events of 2008 more understandable.  Taleb describes how “predicting the past” by using mathematical models to estimate the future can go very wrong.  When unforseen and unpredictable events, so called “Black Swans” appear, they render all such models useless.

What is the medical connection?  Often we think of medical breakthroughs as the result of carefully directed top-down research carried out in elite institutions.  Though such work does result in many advances, they often are building upon other discoveries which were made quite by accident; medical Black Swans.  Three developments immediately came to mind, and there are certainly far more.  Each is recent, occurring within the past several decades, and none the result of top-down research.

The discovery of penicillin
Antibiotics are ubiquitous today, but they have only been in regular use for about the last 60 yrs or so.  Alexander Fleming’s 1928 chance discovery of mold inhibiting bacterial growth was the spark that led to the antibiotic era in medicine.  Others had noted similar effects in prior decades, and Fleming did not bring penicillin into production.   But his discovery set events in motion that saw antibiotics in widespread use by the mid 1940’s.

The role of Helicobacter Pylori in peptic ulcer disease
In the late 19th and early 20th centuries, it was noted that there was a particular type of bacteria found in the stomach linings of patients with peptic ulcers, gastritis and gastric cancer.  A causative relationship between these bacteria and these disorders was not established until Drs. Barry Marshall and Robin Warren demonstrated it in 1982.  Doing so changed the paradigm of this field,  and transformed the management of peptic ulcer disease.  Prior ulcer treatments consisted of dogmatic behaviors (drinking milk and avoiding spicy foods and stress), and various surgical procedures.  Today, antibiotics are used to eliminate the bacteria and the role of surgery has been greatly diminished.

Laparoscopy
There were efforts in the early 20th century towards laparoscopy, mainly involving veterinary applications.   The technology was gradually improved, and gynecologists were the first specialty to perform laparoscopic procedures on a routine basis.  It was a German surgeon (Kurt Semm) who performed the first laparoscopic appendectomy.  Rather than being heralded as achieving a breakthrough, he was nearly disciplined for “unethical behavior” by the medical establishment.  Once this technique was applied to gallbladder removal (and surgeons had proceeded up the learning curve), cholecystectomy was transformed from a surgery with a  substantial recovery into one that can sometimes be done on a same-day basis.

John Adams and Colonial Era Medicine

I recently finished the audiobook version of John Adams, David McCullough’s masterwork biography of the second President.  Listening to Edward Hermann’s narration completed my third tour through the adventure of John Adams’ life.  I had already read the book, then viewed the HBO miniseries starring Paul Giamatti and Laura Linney.

The book is of course the most complete version, as editorial decisions needed to be made for the miniseries.  Although a few historical changes were made, the miniseries brings the era to life in vivid detail.

I have a particular interest in the medical elements of the story.  Let’s take a look at three of them:

Smallpox
One scene depicts an early form of smallpox vaccination.  Technically speaking this is variolation – the inoculation from a smallpox pustule into a small cut on the individual being immunized.  Given the 30% mortality rate of smallpox, the 1-2% chance of death from the variolation procedure seemed an acceptable risk.  This would remain the procedure of choice until Edward Jenner popularized inoculation with cowpox, which carried a far lower chance of death while still achieving immunity from smallpox.  Smallpox was eradicated in the 20th century, now found only in laboratories in the U.S. and Russia.  The debate today concerns whether the remaining smallpox should be preserved or destroyed.

Breast Cancer

Breast cancer. Image made by Itayba

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Another interesting and harrowing scene features Adams’ daughter Nabby, who was diagnosed with breast cancer, and underwent a mastectomy.  In the early 19th century the only possible cure was “the knife”, as Benjamin Rush told Adams.  It is likely that anyone cured in that era likely had a diagnosis other than invasive adenocarcinoma, or had a very small tumor.    We know today that breast cancer is treated both as a systemic disease as well as a local one.  Nabby’s mastectomy allowed for local control, though it probably wasn’t worth the suffering she endured in that awful pre-anesthetic era of surgery.  It struck me as unlikely that her longevity was improved by undergoing the operation.

Longevity
A final consideration is John Adams’ long life, which extended into his 91st year.  It seems apparent that good genes and good luck were as important to a long life then as they are now.  His smallpox variolation was helpful in avoiding contracting that scourge.  It is also noted that Adams badly cut his leg “to the bone” in a fall after retiring to his farm.  His healing of this wound is another testament to a hardy constitution.  Through most of his life, he drank hard cider, smoked a pipe, and carried a decent amount of weight.  Compared to 21st century medicine, most forms of medical intervention in Adams’ day were worthless at best and often harmful.  Good genes and good luck go a long way in any century.

References:

http://www.nlm.nih.gov/exhibition/smallpox/index.html