medicine – Roger muses about Nature

Tiny Terrors

Peel back the soft green cover, and you might find menace skulking in a Virginia garden. A neighbor picked up a copperhead by its tail, which turned round to bite him (can you blame it?). Large wolf spiders enjoy nipping me while gardening (so far I have avoided black widows in our wood piles). As for brushes with poison ivy, I lather cortisone cream every week.

But it is not the bigger things that always hurt us most: sometimes we should fear the tiny ones even more (words are like that too.) Yersinia pestis slew more Europeans during the four peak years of bubonic plague than all the swords, pikes, bows and arrows of the Hundred Years War; the smallpox virus slaughtered more native Americans than the Winchester rifle; the Spanish flu killed more people than all the bombs, bullets, and gas grenades in the preceding First World War; and David Livingstone died from tropical diseases, not the mauling from a lion.

Poison ivy- "leaves of three let it be" — Poison ivy- “leaves of three let it be”

After breakthroughs with pencillin, sulfonamides, and new vaccines, there was a short period of medical hubris—it was believed that infectious diseases were in retreat and would soon be eliminated. The dream was quickly scuttled by the arrival of HIV-AIDS and drug-resistant bacilli, and now we have something else to worry about. TICKS.

They were always part-and-parcel of a tramp across a heather moor in northern Britain or through dense underbrush in the mid-Atlantic States. Back in the mid-1970s, I had heard that Rocky Mountain spotted fever was carried by ticks, but it sounded far away and nothing to worry about. Around the same time, there was news of a danger prowling backyards and woods where children play in Lyme, Connecticut. We learned that the new disease rides inside a tick as a spirochaete bacterium, Borrelia burgdorferi. (Taxonomists, please choose more memorable names, like, Lyme horribilis).

The first reports did not sound particularly alarming. The problem was rare and localized, and the symptoms mild. None of this is now true. Lyme took 20 years to reach Virginia and is spreading to all points of the compass and overseas (where it may have originated). We were told that if we removed a biting tick within 24 hours we would be fine even if was infected. If too late, then we were urged to rush to the doctor’s office for a course of tetracycline to stop the infection, whose signature is a bull’s eye rash, fever, and fatigue. Treated in time, we could forget about it—until the next bite. But if untreated, Lyme would likely progress to arthritis and painful joints.

That was the medical consensus, but untold numbers of people whose lives have been wracked with pain and wrecked by permanent tiredness never had a positive lab test result, even if they had good reason to suspect they had Lyme. Perhaps the disease agent had become disseminated to parts of the body that drugs and antibodies hardly reach? This is where the controversy called “Chronic Lyme” started. When tests are negative (even admittedly poor tests), doctors presume an ailment probably has another cause and are understandably reluctant to start a long course of antibiotic treatment. Those doctors moved by their patients to go against standard medical protocols by providing aggressive i.v. antibiotics invoked the wrath of their own profession. There are many touching stories online of students who had to withdraw from school and adults who quitted work because of a suspected tick-borne illness, and so many more less well-known cases, like a young father we know of who died from complications of Lyme. It is natural to come down on the patients’ side of the argument, especially when they frustrated at being sidelined by mainline medicine and suspected of being malingerers or having a problem “all in their head.” To us, it seemed like a rerun of the doubts that used to surround chronic fatigue syndrome, of which our family has first-hand experience. For her remarkable book, Cure Unknown, the science writer, Pamela Weintraub, dug exhaustively into the science and sociology of Lyme, drawing too from the tragedy it brought to her own family.

Perhaps the storm is beginning to pass since the CDC announced last week that Lyme is an emerging public health crisis that is ten-times more prevalent than assumed because it has been under-reported and under-diagnosed. Every year in the United States alone there are 300,000 new cases, and numbers are probably going to rise.

The deer tick is mainly held responsible for transmitting Lyme, although it is not the only tick that feeds on deer, and deer are not the only animals that infect ticks. Even more complicated, ticks often carry more than one type of pathogenic bacterium, and the deer tick may not even be the worst of the bunch. Not much is plain and simple in parasitology.

One of my fellow master naturalists had hundreds of ticks on him after hiking in local woods in advance of a school party (the party was canceled). My record is a mere 16 ticks after mowing the lawn. I save them in alcohol until the end of the year when I identify the species to alert me to hazards. A more scientific way of surveying ticks is to drag a cotton sheet across a field or woodland floor, to which they cling hoping it leads to a meal. Half of the ticks I found in our yard last year were lone star ticks, 10 % were “deer” ticks, 2% were dog ticks, and the rest were nymphs (too small to identify species).

Lone star tick James Gathany: CDC — Lone star tick
James Gathany: CDC

Lone stars are not named for Texas (though they are found there as well) but because the females (the big-eaters) have a single white spot on their shield-like back. They probably don’t transmit Lyme or Rocky Mountain spotted fever, but are vectors of a small menagerie of bacteria, some of which are definitely pathogenic. Ehrlichia chaffeensis causes human monocytic ehrlichiosis in which the first symptoms resemble Lyme (generally without the bull’s eye) with pain, a blunted immune response, and even toxic shock syndrome. Half the cases can be serious enough to require hospital treatment, and according to the CDC the mortality rate peaked at 3.7% in 2003 (close to Spanish flu).

E. chaffeensis inside a white blood cell. CDC

Now the good news is that not every tick is infected, but you never know which ones can be safely ignored. They can however be tested for genetic tell-tales of the bacteria they harbor. At the College of William & Mary, Matthias Leu is leading a study of the distribution of ticks in the Virginia Peninsula and is testing lone stars for E. chaffeensis using an extremely sensitive and specific DNA test (PCR). So far, he has found that almost 10% of the samples were positive for this bacterium, and most of them were found in public parks and recreation areas. Why there?

Well-fed lone star tick James Gathany: CDC — Well-fed lone star tick
James Gathany: CDC

He found that in places where ticks are abundant so are the deer, but birds are scarce (they predate ticks). The Virginia Peninsula was originally a blanket of almost unbroken forest, but development is breaking it into small wooded fragments. As more woodland edges are formed, vegetation grows up that deer love. Throughout the East, the white-tailed deer population density has exploded; some biologists estimate there are 10- or even 100-times as many as in pre-colonial times. Not only have developers created ideal habitats for deer, but the major predators have been extirpated, hunting is limited, gardens are salad-bars for deer, and sometimes they are even fed deliberately.

When deer move into new areas they bring disease with them. Ticks become infected with the disease and the bacteria pass through their life cycle into other mammals, including mice, which become a disease reserve without suffering from it themselves. Setting up tree stands for hunters or bringing back wolves probably won’t make the problem go away. Chickens can help by gobbling up ticks and copperheads by swallowing rodents, but when we started tampering with nature we set in motion ecological changes that are hard or even impossible to reverse.

I wish I could end on a more optimistic note, but in the near future only constant vigilance will provide peace of mind. Those who venture out into woods and gardens during the warm months of the year should cover up with permethrin-treated clothes, but indiscriminate spraying is a bad idea because it kills our good friends, the pollinators. Each of us needs an intimate friend for daily inspections of our crooks and curves that we cannot see for ourselves. Choose someone with good sight because the tiny nymphs responsible for most cases are not much larger than the period at the end of this sentence. Antibiotics used promptly are safeguards, but people who pick up ticks most days can’t use them forever. We need a vaccine, but the only one available is for dogs. Smith Kline Beecham withdrew their human anti-Lyme vaccine years ago after lawsuits claiming it caused arthritis. We may want to knock government down in size, but we need it to step in for vaccine development where big pharma fears to tread.

Next Post: A Scythe for All Seasons

Baby’s First Picture

The first picture of a baby is usually in the mother’s arms soon after delivery, and becomes pasted into an album for posterity. My mother missed out on that snapshot since I was born in austere post-war London when a box Brownie camera was a luxury my parents couldn’t afford. But nowadays the picture is taken earlier and with a much more expensive camera. My granddaughter, Pippa, was snapped by an ultrasound scanner when she was barely past the fishy stage in her mother’s womb. The next picture taken a few weeks later showed her looking like a real child, and the obstetrician could confirm everything was fine, including beating heart and nuchal transparency. Pictures reassure us all is well, even if we can’t put absolute trust in them.

The first picture can be taken even earlier nowadays – in fact, as early as can be. For most of her thirty years as an embryology lab director, Lucinda gave prospective parents of IVF children a picture of their embryos which she had taken immediately before medical staff transferred them to their Mom’s body. These were embryos that had been fertilized in a Petri dish and grown to a ball of about 8 cells in three days, or had formed a blastocyst with about a hundred cells after a slightly longer incubation. Giving these photos to patients is now a common courtesy in fertility clinics, and more and more couples are having this extraordinary preview. Last year there were over 60,000 babies born after IVF procedures in the USA alone, or 1% of all births.

For such couples (and single mothers undergoing the same treatment) pictures of their embryos probably find a temporary place of honor on a kitchen bulletin-board until the next picture at the six week ultrasound scan – or taken down if the pregnancy test proves negative. But for embryologists and physicians, pictures of embryos are records of the best-looking in the bunch which they hope stand the best chance of getting Mom pregnant. Generally one or two are chosen (sometimes three) for transfer from the half-a-dozen eggs (more or less) that were fertilized, but these pictures say so much less about the embryos’ prospects than my first picture or Pippa’s, and even ours hardly say anything about things that most matter to us – future health, vigor, brains, and beauty.

Upwards of 50% of all human embryos conceived in the IVF lab (and probably the same in the body) have abnormal sets of chromosomes, and therefore no chance of making a healthy child. It is possible to genetically screen embryos so that only the healthy ones are placed in the uterus, but although this can be helpful it is far from foolproof. Some embryos are mixtures of normal and abnormal cells, meaning that a test produces misleading results if only one cell is removed, which is all that most embryologists dare take. And then there is the unanswered question of whether certain kinds of abnormalities can correct themselves spontaneously, implying that embryos could be discarded unnecessarily.

The upshot of this uncertainty is that deciding which one to transfer is still mainly based on how they look at the time when the photo is taken. It’s a beauty contest which Machiavelli would have derided because “men in general judge more from appearances than from reality.” Unfortunately, “reality” is much too deep to plumb, and so, despite the best efforts, the embryos with the best chances of success are not always chosen.

A single snapshot at the end of a growth process that had been going on for days mostly unseen inside the lab incubator is not much to go on. We wondered if a picture is worth a thousand words, perhaps a thousand pictures would better convey the whole story.

Back in the 1990s Lucinda had already started making movies of embryos in Petri dishes, but had to build her own equipment and record them on magnetic tapes. When I joined the project some years later, digital time-lapse recorders, more advanced microscopes, and miniature incubators were available for the job. We could take a snapshot of individual embryos every few minutes, which over five days added up to over two thousand frames. Imagine how eager we were to compile them for a motion picture of the first days of human embryo development! But we didn’t anticipate surprises, accustomed as we were only to static images, but the embryos educated us.

On the first day nothing seemed to be happening, although appearances are deceptive because there was a lot of activity at the sub-microscopic level. But the next day the fertilized eggs made an almighty heave and in a strange contortion never to be repeated divided into two equal halves within their shells. They tolerate only so much fragmentation of cells at this stage, which you can see in the movie. The next division to make four cells started later in the day, and more divisions created a ball of tiny cells without any net increase in overall size. Clinics are now using customized equipment to monitor the rate of embryo development to help to choose which to transfer.

On the fifth day, healthy embryos became blastocysts, hollow balls of cells with a tiny knot at one side that make up the embryo proper. The movies revealed that blastocysts undergo cycles of swelling and collapse rather like a beating heart, although far more slowly and not from muscles contracting because no such cells exist yet. Just as a heart sound or pulse is a sign of life, the blastocyst’s beat is a sign, and probably a better token of vitality than a static picture ever gave.

We had another surprise after pressing the PAUSE button at a random frame if the embryo looked sick, its cells more opaque and less plump. Sometimes it really was unhealthy and had reached the end of the road to development, but in other cases when we pressed RESUME the embryo would shrug off its frumpy appearance to continue growing, often even turning out to be a beauty. So Plato was right for embryos too – beauty really is in the eye of the beholder. A sad-looking embryo might have been discarded or, at the very least, frozen in reserve if its fate had hung on only one picture. Besides, we already knew that, like judges scrutinizing models on a catwalk, embryologists don’t always agree on their scores for embryos. They can tell you stories about patients who produced only a very few scrawny-looking embryos which were transferred to wombs “just in case”, only to find that at least one was successful and made a bonnie baby.

What about the rest, the ones that never survived long enough to be photographed? We seldom mourn things that pass beyond the focus of our eye or camera lens, nor give a moment’s thought to the far, far greater slaughter going on day-in and day-out in the wombs of the world where most embryos never thrive. Embryos may have started out looking hopeful after fertilization and even grow some, only to perish in the dish unnamed and unknown in a Greek tragedy of their own.

Sometimes I am moved to wonder about wasteful nature. I wonder why I can watch in deep sympathy a bee writhing after it has strayed into an insecticide spray or an earthworm wriggling its last as it dries out on the pavement, while we never spare a thought for the anonymous multitudes ending their lives prematurely by being trampled physically or chemically.

I suppose it is the connection with individuals, especially at tender ages, that makes the difference. No matter how alien to the subject we feel there is a biological link and by witnessing the life and death struggle of another creature we are jolted into thinking about our own. Patrick Steptoe (1913-88), who was Bob Edwards’ clinical partner in pioneering IVF, pondered the same thoughts as I do in idle moments. I remember him playing at a conference his musical elegy, For a Dying Embryo. Steptoe_PCS Before striking a key he told us he was sad for the couple who would never have that proud picture of their offspring, but he also had some sort of feeling for the embryo in his care, wondering what it might have become and achieved. Thank goodness Pippa and have pictures so we can muse in the future how we got here.

Next Post: Stem Cell Stuff

Robert Edwards (1925-2013)

A memorial service for Bob Edwards was held last weekend at Bourn Hall, near Cambridge, England. That is the Jacobean mansion house where he founded the world’s first in vitro clinic for fertility treatment (IVF) with Patrick Steptoe in 1980. Lying in its beautiful grounds, Patrick’s grave is often visited by grateful patients. On Saturday the ancient wooden front door swung open for Bob’s wife, five daughters, twelve grandchildren, and a troop of colleagues, friends, and admirers who came to give thanks for his life. He leaves a legacy with few parallels in science and reproductive health, and most of all he gave joy to parents of five million babies who owe their existence to his pioneering struggles for a medical revolution with Patrick and Bob’s assistant, Jean Purdy.

We miss him terribly. It seems impossible that anyone endowed with that much vigor is gone. We imagine him turning up at any minute when the angels push him out after disturbing the peace upstairs. Well into his eighties, Bob was still full of boundless energy and infectious enthusiasm. After retiring from Cambridge University and Bourn Hall, he was busy lecturing and collecting honors and awards around the globe, and he founded several new biomedical journals which soon attracted the best research papers. But, finally, time caught up and frailty captured him.

Bob needed lots of energy and a gritty Yorkshireness seasoned with humor for the hard journey to a controversial goal. The uproar that his research agenda caused between the 1960s and the 1980s is becoming a fading memory, and may even puzzle a younger generation for whom IVF is conventional treatment and knowing people who depended on it for building their family. But for those who remember the old times it’s hard to understand how he endured so much professional antagonism, even personal animosity, that tried to stop him in his tracks.

Most people would have quit. He told us it was the appeals of childless couples and heart-rending stories that drove him on. A reactionary medical profession in those days had nothing much to offer for infertility and, too proud to admit defeat, often ignored the problem. No one could have guessed that the boy who grew up in a northern mill town would become their champion and one of Britain’s greatest scientists, any more than we expected a grocer’s daughter from Lincolnshire would become the first woman Prime Minister and the Iron Lady.

Bob obtained his PhD in genetics and embryology at Edinburgh University in 1951 where he collaborated with Ruth Fowler, whom he later married. After short spells in the USA – at Caltech, Johns Hopkins, and Chapel Hill – he returned to London to take up contraception research, but it wasn’t long before he was studying his first love again – eggs and embryos. Ever boiling with ideas, he started to air dreams of launching IVF in medicine, but babies had only been born after IVF in rabbits and in no other species. He imagined how IVF could help women with blocked tubes and avoid children being born with cystic fibrosis, hemophilia and other inherited diseases. In the end, it had many more applications, but then almost everyone thought he was barmy. To be sure that he didn’t cause any trouble, a new director in London banned his work on human ovaries.

He moved to Cambridge University to join Sir Alan Parkes, whom I remember as a crusty old school chap, but who had an eye on the future. Bob flourished there, staying the rest of his career and ascending the academic ladder to full professor. For human IVF he needed help from medical doctors as gatekeepers to patients, but they were keeping the “maverick” at arm’s length. In 1968, Bob met a gynecologist who not only welcomed collaboration but had developed a new technique, called laparoscopy, which he needed to collect eggs from patients’ ovaries. That man was Patrick Steptoe. He was based in the north of England, far from the seats of power, and he too was regarded as an outsider by the gynecology community.

They were the perfect pair as it would take a special chemistry to spark a medical revolution in a climate in which colleagues constantly poured water over them. One day their story will no doubt become one of those Hollywood movies that will make people who remember them and their times cringe to see the story crafted for the box office.

A year after starting together, Bob and Patrick reported a breakthrough – they had fertilized human eggs in the Petri dish (or test-tube, if you prefer). It would take almost a decade of flip-flopping between Cambridge and Patrick’s hospital, with many disappointing results and hostility along the way, until the next breakthrough. That was when they were rewarded with the birth of the world’s first test-tube baby, Louise Brown.

Back in the 1960s, few people took him seriously. He was regarded somewhat like a cranky Old Testament prophet, and the venom didn’t pour out until his research started to make traction. There were ghastly newspaper headlines demonizing the pair for creating human embryos in the lab. Being called Dr. Frankenstein was the least offensive. Perhaps hardest of all to bear was condemnation by so many in their own professions, as well as a good number of politicians, theologians, and even Nobel Prizewinners. After Louise’s birth, The Daily Mail ran the headline, “Baby of the Century”, and so the news echoed around the world. Had she been an unhealthy child, fertility treatment would be different today, but she was bonny and it seemed heartless to say an in vitro baby should never have been born.

I joined Bob’s lab to study for a PhD in 1970 when his work was starting to heat up. I thought it would be cool studying embryos, although it would mean I had to sacrifice a love of animal behavior which I could have studied in another lab. That post was taken up later by an American in my college, Dian Fossey, who, as you probably know, went off to Rwanda to study gorillas in the misty mountains. A decision made at a fork in the road when aged 21 often has a lifelong impact.

Bob was different to other Cambridge dons, perhaps because he hadn’t been born with privileges but had to earn them. He led his graduate students and fellows in a very egalitarian way, encouraging us to think and explore, teaching us to argue about data and theories, sometimes teasing us by playing the devil’s advocate. With the exception of Barry Bavister who had developed a culture medium for fertilizing eggs, we were hardly involved in the clinical program which was out of sight nearly 200 miles away. I have been asked why Bob didn’t draw on the growing expertise in his own group, but I think he was keeping us at arm’s length from a controversial program that might have been harmful at tender stages of our careers. Today, he might be criticized for supervising students so lightly because of frequent absences, but in those days Cambridge had an unofficial “sink or swim” policy. We could swim because he had built a strong team that provided mutual support,

Bob and I chairing a scientific session. Helsinki, 1983

and I never again knew a happier workplace. Besides, we often felt happy to see the back of him to a conference or loading his station wagon for another trip to see Patrick. You would have to know Bob to understand what I mean, how maddening our beloved professor could be. Ideas poured out of him like newsprint from a press. When he proposed to us an exciting experiment, you feared that by the next morning the idea would be scrapped and he’d have a better one. I never encountered a more fertile scientific mind, and although most of his ideas were raw and forgettable, some were so precious that they have already been absorbed into mainstream medical practice or their implications are still being worked out.

My first project was to test his brilliant theory about the cause of Down’s syndrome, which is so much more common in babies of older moms. I labored over it for several years but, never able to prove it, grew more skeptical. Long after I had left Cambridge, he continued to rib me, “Haven’t you proven my theory yet, Roger?” The supple balance between scientific seriousness and light-heartedness was so endearing.

My wife, Lucinda, has fond recollections of his visits to Virginia when she was the embryologist for Drs. Howard and Georgeanna Jones’s team, which was the first in America to have an in vitro baby. One day she gave him a tour of the lab of which they were so proud and had taken great pains to maintain a sterile work area. Not wishing to be impressed too easily, he stretched up to the top of a tall incubator to wipe a minute film of dust on his finger, before grinning like a Cheshire cat.

On another occasion when he was visiting my young family in Scotland, he took us out for dinner. After my boys turned up their noses at whole fish on the menu he ordered a plate piled high with whitebait, which he then started devouring, his eyes darting from one boy to the other to watch them wide-eyed with horror as he swallowed each little fish head-first. We cherish pictures of him sitting on the lawn at Bourn Hall in the middle of a crowd of children conceived by IVF.

If he had any disappointment at the end I think it would be that his gift of fertility treatment was too expensive for low income couples to afford, especially in the U.S.A. It had made some doctors, and now the companies behind them, rich, which seemed to run against his socialist principles. That’s how he styled himself, but he was impossible to label.

The last time I saw Bob and Ruth was over three years ago when I visited them at their mini-farm outside Cambridge with Kay, a doctor from Bourn Hall. His health had obviously deteriorated. Although Kay said he was having a good day, he seemed far-away, locked in an old memory or stewing over something. He showed us his honors and awards that completely covered the wall of a side room, then explained them in turn – Legion d’Honneur (France), C.B.E. (UK), Fellow of the Royal Society (London), honorary degrees (Cambridge, York, Wales, Belgium, Greece, Romania, etc.), King Faisal Prize (Saudi Arabia), Lasker Award (USA), and many more that I can’t remember. But despite so many tributes I knew him well enough to see he was holding back a disappointment.

We were sorry he was passed over for the 2007 Nobel Prize which was awarded for stem cell research, something that he was pioneering as long ago as the 1960s. It seemed that his chance had passed and, unless a call came from Stockholm soon, time would run out. Nobel Prizes are not awarded posthumously, so Patrick was already out of the running, having died the day he was due to receive a C.B.E. with Bob from the Queen at Buckingham Palace. We knew there was Vatican pressure on the Nobel Committee to stop an award for IVF, so it was with a mixture of surprise and delight when the following year Bob did indeed receive that call. He won the 2010 Nobel Prize for Physiology or Medicine, the highest scientific accolade he could be given, and one to savor as it finally vindicated his work.

Sadly, he was too unwell to travel to Stockholm so one of his former students, now himself an emeritus Cambridge professor, accepted the Prize on his behalf. Two weeks ago in an obituary notice, the New York Times printed that Bob was “unable to appreciate the tribute”. I am delighted to correct the writer – he knew and celebrated it.

A few weeks before he died, I attended a conference in his honor at his college, Churchill. Displayed in a glass cabinet next to his papers was Margaret Thatcher’s famous handbag. Wags have told a story that the bag was full of iron weights for swinging at her liberal opponents or at conservative “wets”.

Bob and Margaret were born and died within days of each other and, although from opposite political poles, they were both visionaries who drew immense loyalty and intense opposition in equal measure. The juxtaposition of their artifacts seemed odd until I recalled that she had never openly criticized IVF, as a good number of her party had, and, moreover, it was her government that had awarded his first public honor in 1988, albeit a ‘middling’ one. It would take another twenty years and the Nobel Prize before one of her successors as prime minister recommended him for a knighthood. But I guess he would still prefer to be remembered as just plain “Bob”, the family man who helped folks to have children.

************************************

Bob never belonged to a faith community and once told me he didn’t like “churchy music”. But there was an undefinable spiritual core in his heart, and he would have enjoyed the Gaelic Blessing on Saturday. Composed by John Rutter, this rendering is sung by the Cambridge Singers. Click here. (Sorry I can’t cut the ads.)

Deep peace of the running wave to you

Deep peace of the flowing air to you

Deep peace of the quiet earth to you

Deep peace of the shining stars to you

Deep peace of the gentle night to you ….

This personal tribute to Bob was posted because copyright law prevents me from posting the obituary I authored in Nature or another I wrote for Fertility & Sterility with Dr. Howard Jones. Pdf copies are available by email after publication.

Next Post: Marvel in the hive

Tag: medicine

Tiny Terrors

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Baby’s First Picture

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Robert Edwards (1925-2013)

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