Understanding Modern Health Care

The Wonders We Created and the Potholes We Dug

Steve Fredman

• Publisher: Steve Fredman
• Year: 2021
• ISBN:
  9780578913070
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The Tin Woodsman, Dick Cheney, was given a new heart, and the scarecrow, Joe Biden, was allowed to keep his brain. (He had an aneurysm that bled).

But we don't live in Oz, and there is no wizard. A courageous lion named Lyndon provided socialized health care to the elderly and impoverished. Hillary tried to give it to the rest of us, and she was demonized. Barack managed to squeeze the Affordable Care Act through Congress. Eight years later, in defiance of a law that would have excluded thousands-that would have prevented many blind and lame from being healed-John McCain turned his thumb down.

We've allowed insurance companies to teach our young that med­ical care is not a shared responsibility, and many were surprised when the youth thought it unfair when we asked them to contribute to the cost of everyone's health insurance. We taught pharmaceutical manufacturers to not worry when they spend billions and buy other companies for their drugs. We will reimburse the acquisition cost and pay what the compa­nies charge for the medications. We tell the poor of the world who can't remotely afford expensive medications and whose countries belong to the World Trade Organization-"suck it up." And we tell the wealthy to buy stock and become part of the bonanza.

Modern health care is 120 years old. This book is about the history of mankind's remarkable accomplishments and the forces that are shaping its future. Those who read it may not live longer, grow a thick head of hair, or avoid Alzheimer's. But an understanding of how we got to this point and the challenges we face matters.

Understanding Modern Health Care: The Wonders We Created and the Potholes We Dug

Chapter One
Awakening to the Microscopic World

Modern health care’s creation was triggered by the observations of a Dutch man named van Leeuwenhoek. Like the fictional Gulliver, he became the first to make the voyage, the first to gaze at the unknown world through a powerful lens.

A contemporary of Rembrandt and Vermeer, Leeuwenhoek was born in 17th-century Delft. It’s a town in western Holland known for cool, foggy summer mornings, numerous boat-filled canals, wide streets connected by wooden bridges, and blue and white pottery. In his day, horses and carts clattered across the stones in front of a large open-air market, narrow rows of houses surrounded the town square, and food and wood were weighed before they were sold. Leeuwenhoek’s mother came from a well-to-do brewer’s family and van Leeuwenhoek first worked as a draper’s apprentice. While there, he used the lenses of the day to check the quality of a fabric’s thread. Later in life, he was politically active. He became a civil servant and was a chamberlain of one of the assembly chambers at city hall. At age forty, he made one, and later many, incredibly powerful, tiny magnifying lenses. Once he had created the devices, he started exploring the microscopic world, and he saw sights that had never before been seen or suspected. He drew pictures and sent them to the National Geographic of his day, the Royal Society. His images of bacteria, red blood cells, and sperm seemed fictional to some contemporaries who looked through ordinary polished and ground glass lenses. Others believed. During his life, Leeuwenhoek made an additional five hundred magnifiers. One person, then another, became aware of a microscopic world and learned it was often unfriendly. To this day no one really knows how Leeuwenhoek made his lenses. His process died with him.

Back then, 30 percent of those who got smallpox died, and it was known that survivors won’t get it again. That’s why some in ancient China and Africa blew crusts of a diseased person’s scab up the nose of an uninfected person. They hoped the illness they were causing would be mild, or at worst, it wouldn’t be deadly.

In 1796, Edward Jenner, a British doc, proved there was a safer way to prevent the disease. He heard that milkmaids who were infected by cowpox didn’t develop smallpox, and he checked it out. He took material from the pussy scabs on a young woman’s hand and “inserted it into small incisions he made in a boy’s skin.” Much as cats and tigers are members of the same species, the viruses that cause cowpox and smallpox are related. Each can cause pustular lesions. People who develop cowpox sometimes run a fever and are sick for a week, but the illness is mild, and when a person recovers (or is vaccinated) their body is protected from the oft lethal disease—smallpox.

Jenner submitted his findings to the Royal Society and they were rejected, so he self-published and became famous. Thomas Jefferson and James Madison read about his findings, and in 1813 Congress passed the Vaccine Act.

In 1853, the British Parliament made childhood vaccination with modified cowpox compulsory.

After widespread immunization contained the illness, people in the U.S. stopped vaccinating. In the 19th century, there were outbreaks, and states attempted to enforce existing laws or pass new ones. The disease finally disappeared from North America in 1952 and from Europe in 1953. As recently as 1967 (according to the CDC), 10 to 15 million people in Africa, Asia, Indonesia, and Brazil were contracting smallpox each year. That year, 2 million died and many were scarred for life. The World Health Organization started a program of worldwide vaccinations. Their efforts to eliminate the terrible disease seem to have succeeded. The bug’s last known “natural” victim was infected in 1977.

In 1848, hand washing was little more than a cultural or religious ritual. No one (best I can tell) connected “germs” and sanitation with infectious illnesses. That year, a Hungarian physician, Ignaz Semmelweis, was working at a hospital in Vienna and was troubled. Women whose babies were delivered by doctors and medical students developed a fever and died four times more often than women whose babies who were delivered by midwives.

Semmelweis investigated and learned that the medical students in question came from the dissecting room to the maternity ward without cleaning their hands. He introduced hand washing and the death rate plummeted. Unfortunately, his fellow physicians continued to believe that the high rate of childbed fever was due to “miasmas,” clouds of invisible matter, and Semmelweis lost his job. The son of a prosperous grocer, he returned to Budapest, his hometown. In 1881, he published a book on “childbed fever.” When he was in his late forties he was overcome by paranoia and dementia and he was committed to a psychiatric institution. It took a generation before his teachings were widely accepted.

While Semmelweis was investigating sanitation in Vienna, Louis Pasteur, a French chemist, was graduating and becoming a researcher. When he was young, Pasteur was an average student who loved to draw and paint. Then he got his act together and “won first prize in physics.” He eventually studied chemistry and physics at the prestigious Ecole Normale.

At age twenty-six, Louis married twenty-three-year-old Marie Laurent. “According to legend he spent the morning of his wedding day in the lab and became so wrapped up in what he was doing that he had to be reminded to go to church.^”

Pasteur was thirty-two when he became a professor of chemistry at the university in Lille, a market city near the Belgian border whose streets were paved with stones and whose skies were often gray and rainy. In Lille, and three years later in Paris, Pasteur showed his fellow scientists that living organisms, bacteria, caused fermentation. We call it the germ theory. In 1863, working for the French emperor Napoleon III, Pasteur proved it was possible to eradicate harmful bacteria at a temperature well below boiling. He prevented wine from contamination by heating fermented grape juice to 50–60°C (120–140°F). We call the process pasteurization.

In 1879, he and his assistants injected chicken cholera bacteria into some of his birds. The germs had been sitting on the shelf for a while, the infections they caused were mild, and the infected chickens were subsequently resistant to the bug. Pasteur realized it was possible to weaken a pathogen to the point where it wasn’t harmful but still triggered an immune response. He exploited the phenomenon to develop vaccines for chicken cholera and anthrax.

In 1885, a rabid dog bit a nine-year-old French child. We now know that after it enters a person’s body, the virus that causes rabies infects an axon, the “long slender projections of nerve cells that conduct electrical impulses.” The infectious agent then travels up the axon to the brain and eventually kills the person or animal.

The oft-repeated story says the young man was bitten fifteen times, and two days later his mother came knocking. Pasteur had for some time been injecting the agent that caused rabies into rabbits and had created pieces of spinal cord that were infectious. He had proven in dogs that when he dried the infected tissue in air it gradually became less virulent. Pasteur injected the boy with a series of fourteen increasingly virulent fragments of dried homogenized rabbit spinal cord. The boy survived and Pasteur’s fame grew. Doctors started using similar extracts to treat people who were bitten by a rabid creature. The vaccines of the 21st century contain inactivated virus that was grown in human or chick embryo cells.

The rabies virus is still responsible for the deaths of 59,000 humans a year. Ninety percent of the cases in Africa and Asia are caused by dogs. In this country, we worry about bats and wild animals, and the U.S. has fewer than five confirmed cases a year. In his later years Pasteur had a series of strokes and he died when he was in his 70s.

In the early 1800s, the quality of microscopes was variable. Then a few craftsmen started making clear, powerful magnifying lenses. One of them, Carl Zeiss, came from a German family of artisans and he apprenticed with a maker of fine tools. In 1846, he opened a workshop in Jena, a river valley town in the “green heart” region of eastern Germany. The first dozen years, his technicians, under the supervision of a short-tempered, authoritarian foreman, made single lens precision microscopes. Eleven years later, Zeiss introduced scopes with two lenses. Scientists could now look into the upper curved glass, peer down a tube, and view an object that was just below a second lens. With the help of Ernst Abbe, a mathematician, the company used calculations to determine the optical characteristics of their lenses, and it improved the illumination system. Smaller and smaller objects came into view. Doctors from Germany and beyond bought one of their scopes. Carl’s first wife died shortly after she gave birth to their first son. She was twenty-two at the time. Carl married two more times and outlived one of the women. All three of them were, in his words, “spiritually very much country folk.”

Robert Koch, the German “father” of the germ theory, once wrote that his Zeiss scope was responsible for a large part of his success. Koch was born twenty-one years after Pasteur. He was a gifted child and could read a newspaper when he was five. In Germany he ran a medical practice and spent hours peering into a microscope. When he was a district medical officer, he investigated a pasture where the cows that ate the grass got sick and died. He collected blood from one of the dead animals, injected it into a mouse, and the rodent died. Koch found rod-shaped microscopic creatures in the soil, grew them in a rabbit’s eye, and allowed them to dry out. They looked innocuous, but they were just dormant. When their survival was threatened, the bacteria surrounded themselves with a protein coat, became spores, and vegetated. They were able to endure harsh conditions, and when conditions permitted, they emerged. In the 20th century, these spores—anthrax—became one of the agents bioterrorists use.

Koch’s life as a researcher started after he returned from the 1870 war with France. When the conflict started, Koch, “a five-and-a-half-foot tall man with a stern face and thin high voice,” tried to become an army physician. He was rejected because he was nearsighted. As the conflict wore on, he reapplied and became a military doctor. He was with the German troops that besieged Orleans. It’s the city on the Loire River where, in 1429, Joan of Arc famously fought the English. Koch was troubled by the damaged bodies he had to deal with. He once observed that in wartime human life becomes “worthless.”

Years later, Koch was a famed researcher. When he was forty-seven years old, he met the other “germ theory father” in London. At the time, Pasteur was sixty-eight and partially paralyzed. The encounter was cordial, tense, and controversial. Both men were doing research on anthrax. After Pasteur presented the results of his research, Koch was judgmental. Neither man spoke the other’s language. Letters were exchanged, and one of Pasteur’s remarks was translated as a comment on “German arrogance.” After the apparent insult, each man started criticizing the work of the other.

Once doctors had good microscopes, they learned how to categorize bacteria by drying and dyeing tissue and sputum that contained germs. Koch used special stains on infected human and bovine (cow) tuberculosis and identified the bacillus that caused the disease. “A plodding worker and a careful seeker of facts,” Koch dazzled a group of colleagues on a Friday evening in 1882. He proved that the tubercle bacillus was transmissible and that it was the cause of TB in man.

Much as people today are investing our hopes and fortunes into a vaccine that will force our immune systems to reject the coronavirus, Koch tried to energize the (poorly understood) immune systems of people with tuberculosis. He isolated a glycerine extract of the TB bacillus and injected it into the skin of a person with an active TB infection. The fluid caused chills, fever, and an aggressive skin reaction. When it was instilled into infected guinea pigs, it seemed to “completely cure animals in the late stage of the disease.”

Koch unveiled his new treatment when he addressed the crowd at a Berlin auditorium. “I have at last hit upon a substance which has the power of preventing the growth of the tubercle bacilli not only in a test tube but in the body of an animal.” In the subsequent months, he began giving regular tuberculin injections to a number of patients with advanced disease who were in Berlin’s Charité hospital.

Arthur Conan Doyle, the Scottish physician who created Sherlock Holmes, admired Koch and wanted to meet and hear the great man. On November 16th, he arrived in Berlin by train. When the British embassy was unable to get him a seat at one of Koch’s demonstrations, he went to Koch’s house. He knocked on the door, and the butler showed him into the living room. While Doyle was waiting, letters were dumped on a nearby desk and on the floor. Doyle would later characterize them as pleas for help from people with “sad broken lives and wearied hearts who were turning in hope to Berlin.” The next day, Doyle visited the clinic where the infected were being treated. He saw people who were febrile, quite ill, and suffering as a result of the injections. Disappointed and dubious, he wrote about his visit and misgivings and returned to Scotland.

Koch’s supply of his “remedy” was “scarce,” but by the end of 1890 more than two thousand people with advanced disease had been treated. Most of the people who received tuberculin were not improved and only twenty-eight were cured.

Facing public scorn because his treatment failed, the now forty-seven-year-old Koch left his wife and married Hedwig, an eighteen-year-old art student who was “fascinated with his studies.” He traveled to Egypt and wrote his eighteen-year-old lover, “If you love me I can put up with anything, even failure. Don’t leave me now.” When Koch inoculated himself with tuberculin, she volunteered to be injected too.

During his later years, his reputation now diminished, Koch traveled the globe with Hedwig and weighed in on various issues—often to his detriment. He, for example, didn’t believe milk that contained bovine (cow) TB was harmful and opposed the pasteurization of milk. He also promoted the use of an arsenic-containing medicine to treat sleeping sickness. When he was sixty-seven, he had a massive heart attack.

During Koch’s lifetime, many who had tuberculosis spent a year in a sanatorium. Breathing clean air and leading a healthy life helped some of them go into a remission. The first antibiotic that killed TB, streptomycin, was discovered in 1943. Like penicillin, it was being used by a soil organism to defend itself from the bacteria that surrounded it. Over time, streptomycin-resistant bacteria started to emerge. In 1953, it was joined by isoniazid (INH). The medication was a chemical that a Ph.D. student in Prague synthesized in 1912. It was probably sitting on a shelf somewhere when, in the 1940s, industry researchers decided to test hundreds of random chemicals on mice with tuberculosis. The third powerhouse, rifampin, became available in 1963. It was a chemical that was produced by a soil organism, and it was isolated and modified by Italian researchers.

By the 1950s and ’60s, doctors were able to successfully treat most TB infections with a combination of the medications. Between 1954 and 1985, the number of infected people in the U.S. dropped from eighty thousand to twenty thousand, and experts predicted that within a few decades tuberculosis would disappear. Unfortunately, poverty, HIV, and bacterial resistance reversed the trend, and the incidence of TB started to rise.

At some point in their lives, one in four people alive today, will be infected by the cough of a person with tuberculosis. Ninety percent mount a cell-mediated immune response. Their body encases and imprisons the bug, but doesn’t always kill it. Years later, the bacillus sometimes escapes, grows, and spreads. In 2019, ten million people worldwide developed an active infection and 1.4 million died.

Koch and Pasteur had challenged the belief that diseases were the result of some mysterious force in the miasma. They used live organisms to energize the immune system and with others demonstrated that germs cause disease and cleanliness matters.

Joseph Lister, the man who was called the father of modern antisepsis, began his medical studies in the mid-1800s. After he graduated he became the surgical apprentice of James Syme, “the greatest surgical teacher of ...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Acknowledgments
• Introduction
• Chapter One: Awakening to the Microscopic World
• Chapter Two: The Late-19th Century
• Chapter Three: The 1900s
• Chapter Four: Insulin
• Chapter Five: Transfusions
• Chapter Six: Viruses
• Chapter Seven: Vaccines
• Chapter Eight: Surgery Becomes a Learned Craft
• Chapter Nine: Narcotics
• Chapter Ten: Penicillin
• Chapter Eleven: Hormones—Cortisone and Epinephrine
• Chapter Twelve: Surgery of the Heart and Blood Vessels
• Chapter Thirteen: Safety: Anesthesia—Checklists—Malpractice
• Chapter Fourteen: Minimally Invasive Surgery
• Chapter Fifteen: Transplantation
• Chapter Sixteen: Taxpayer-Funded Research Is Privatized—Bayh-Dole
• Chapter Seventeen: Medical Devices
• Chapter Eighteen: Vision
• Chapter Nineteen: Childbirth
• Chapter Twenty: Care of Kidney Failure Becomes a Right
• Chapter Twenty-One: HIV and the Plight of 23 Million Africans
• Chapter Twenty-Two: The Right to Emergency Care
• Chapter Twenty-Three: Hospitals
• Chapter Twenty-Four: Generic Drugs
• Chapter Twenty-Five: The Price of Everyday Drugs
• Chapter Twenty-Six: High-Priced Drugs
• Chapter Twenty-Seven: Expensive Pharmaceuticals
• Chapter Twenty-Eight: Gene Therapy and CRISPR
• Chapter Twenty-Nine: Gaming the System
• Chapter Thirty: Are Generic Drugs Safe and Effective?
• Chapter Thirty-One: The FDA—The Fox That’s Guarding the Henhouse
• Chapter Thirty-Two: The For-Profit Insurance Companies Take Over
• Chapter Thirty-Three: Obamacare—The Affordable Care Act
• A Note on Sources
• Selected Bibliography