Thursday, April 25, 2013

WWII: the horrific medical 'Triaging' of New York Jews and Blacks

Here is a challenge I throw out to New York City's many amateur historians and genealogical detectives : find out more about the young New Yorker who was the first person ever in the world to be treated - successfully - with penicillin-the-antibiotic.

Particularly if you interested in uncovering more about the harsh wartime treatment afforded many first generation inner city New York Blacks and  Jews.

So, again, a challenge : find out more about PATIENT ONE , the young New Yorker(s)  who first introduced the Age of Antibiotics against fierce resistance from the medical establishment.

Here's a little what we already know for certain (past and future posts on this blog will add more details : the keywords to search are Charles Aronson , Aaron Alston and (Martin) Henry Dawson.)

Patient One , A and B

Actually, two young New Yorkers were given a needle of penicillin by Doctor Martin Henry Dawson on that same history-making day (October 16th 1940) at the famed Columbia Prebyterian Medical Centre : a young Black and a young  Jew, both probably poor.

Its quite a story from how these two young ,poor, men from these ethnicities, traditionally regarded as 'last' , came to be 'first' ever in the world to receive the miracle of antibiotics.

Both young men were dying of then common dreaded and 99% invariably fatal SBE (Subacute Bacterial Endocarditis), a disease that hits the heart valves.

Heart valves damaged earlier by RF (Rheumatic Fever).

Working in tandem, these two related diseases were the most common way for school age children to die in the 20th Century , until about 1960.

The Polio of the Poor

RF was "The Polio of the Poor", because just as the much less common Polio was highly selective and tended to hit the children of well to do WASPs in the leafy suburbs, RF tended to hit  hardest among the poor children of inner city immigrants and minorities.

Unless you are wilfully naive , you probably have guessed by now why you have heard so very much more about relatively uncommon serious cases of Polio than about the much more common - and commonly fatal - RF & SBE !

There is no doubt at all that first patient to be selected for this experimental treatment was a young black man, Aaron Alston.

Penicillin had been discovered exactly 12 years earlier and a little ( very primitive work) had been even been published on growing it , but it remained basically unknown and unused in 1940.

So Dawson and his co-workers ( Meyer, Hobby and Chaffee) were still at the square one of square one, a few weeks into their first attempt to try and grow the mold in their hospital lab,  when a seriously ill Aaron Alston arrived on a ward that Dawson 'attended' (had some limited medical authority over).

It had not been expected that they would have enough penicillin made, purified and tested for clinical trials for another four months.

But Dawson's heart went out to Alston, because Dawson reasoned, based on what little he knew of penicillin, that  penicillin might finally conquer SBE.

(A disease by the way he had never published even one word on - he was in fact hired to work in an area that was very neglected and directed to leave a well researched disease like SBE to the time- proven experts.)

The disease then (and perhaps still now) was regarded as the Mount Everest of all infectious disease, the Gold Standard test of any new anti-bacterial medication.

Delay meant Death

He decided to ignore laborious hospital protocols for pre-testing new drug treatments : Alston would die before he got this one last shot at life , if they choose to wait four further months  down the road.

Dawson would first test penicillin's potential toxicity (of which there was , to put it extremely mildly, absolutely no evidence of, judging by lots of  previously published work on small animals and human blood cells) on himself.

Then he'd give a little at a time to Alston, slowly and cautiously.

The team was only making very little amounts of a very weak penicillin at that time, so this was really just making a virtue of necessity !

How did Dawson know that Alston was so rapidly dying, that haste was imperative ?

There is no direct evidence but the indirect evidence is compelling, I believe, that Alston had already received the conventional treatment for SBE in 1940, prolonged and massive treatments by the new miracle drugs, the sulfas.

Most SBE patients in 1940 got at least a brief improvement with sulfa drugs.

 But the bacteria fought back and the same miserable one percent survived with sulfa treatments (only to die when the disease returned a year or two later)...... as with those receiving no treatment what so ever.

However some patients got no relief from sulfa - the number of bacteria colonies in the blood went up (and not down) after treatment and the doctors then knew these patients' particular strain of oral strep bacteria in their heart valves were particularly resistant to the sulfa drugs and that death would be swift and certain.

 I believe Alston was one of these patients and this is why Dawson decided to go to clinical trial four months early, and after only five weeks from first even learning of what very little was known about penicillin.

And why the other more senior doctors let him try his penicillin on the clearly dying Alston.

Since massive and prolonged amounts of sulfa had failed to kill off all the heart valve bacteria, it seemed pointless to hope that a very little bit of very weak penicillin would do the trick.

But it was worth the effort to Dawson and the others doctors really couldn't see why he couldn't at least try, this once - but only in his own spare time, when he won't be neglecting his own proper duties.

 Dawson's ideas on the immense worth of penicillin were regarded as madness by his hospital colleagues and he really needed to show even a small , if temporary, reduction in the number of bloodstream bacterial colonies if he hoped to receive further help, not further hinderance, from his hospital chiefs.

In fact, it took three more years before any more than a few dozen doctors in the whole world thought that penicillin was worth bothering about.

 Need I add, three more war years, filled with additional millions  of patients dying from war-related bacterial infections ?

For the fact is that for the first fifteen long years, penicillin's worst enemy wasn't bacteria but rather doctors themselves.

Antibiotics arrives, despite doctors' best efforts

By and large, the Age of Antibiotics arrived in this world despite the best efforts of doctors, not because of their efforts.

Hence Dawson's decision to use all of a tiny amount of a weak solution, pushed into just one patient, in hopes of seeing even a hint of successful, if temporary, results.

 A chance to keep his hospital bosses off his back and a chance they'd let him continue his massive mold-growing efforts inside their precious neat and tidy ultra-modern medical centre.

That first needle offered up a potential lifeline to a young dying black man.... and a potential lifeline to billions of future patients.

Enter Charles Aronson

But then Dawson deliberately chose to blow it - or so it seemed.

Another dying young man, a  twenty seven year old Jewish boy named Charles Aronson, arrived on the ward, days before Alston was to get all the meagre penicillin that had been hand-grown so far.

Spontaneously, Dawson added him to this first clinical trial, dividing the meagre lifeline into two thinner lifelines, like a latter day Solomon.

Why ? Why when this further weakened any slim hopes of observing a clinical response?

Several reasons.

Firstly, lots of test tube results had confirmed that penicillin, by weight, was thousands as times potent as the sulfas.

This, despite the fact that their 1940 homegrown 'penicillin' was actually 99.5% dross -- but luckily they'd didn't know this .

Ordinarily, even their small amounts of weak penicillin, even divided in two, would have given clear signs of response, in almost any other bacterial disease.

Except SBE : its unique combo of 'gotchas' rightly made it the Mount Everest of infection, and thought Dawson ultimately did cure SBE with penicillin, he did so only after rolling many massive stones of Sisyphus  penicillin up that Mount.

But again they didn't know this at the time.

Secondly, Aronson had an uniquely complicated, and sad, medical history revolving around repeated attacks from all kinds of seemingly different strep bacteria diseases.

To Dawson, 'seeming different' was the key phrase.

For Dawson's personal/private research interest was in relating all the varied survival techniques he saw as shared by the strep bacteria that co-exist with us.

They live in our mouths, throats and nose much of the time and very occasionally causing serious disease by the ways some of our bodies choose to respond to those sophisticated survival techniques.

But I think this was a minor part of what got Dawson to add Aronson to that first clinical trial.

Dawson hated Triage

Because one of the abiding qualities of Dawson was his lifelong hatred of Triage , which unfortunately happened to be the chief and defining characteristic of the era he lived in, The Era of Modernity.

Modernity was all about, always, the dividing the world into two piles ---- those humans, beings and places worthy of continued life and succour and those unworthy of further life and support : in a word, Triage.

Think of all those medical doctors in jack boots, standing at the railway siding in places like Auschwitz, deciding in an instant if you were to die quickly in a shower or die slowly working too hard for too little food : Triage.

Triage had hit Dawson's hospital that Fall of 1940 : orders had gone out to focus resources on the diseases that affect front line 1A troops and to downplay devoting resources on diseases that only affect the useless 4Fs.

A wonderful time for medical political conservatives to gleefully call for a massive rollback of 1930s efforts to reduce the death rates among the poor, the minorities and the immigrants ("Social" Medicine) , under the guise that all resources were needed to keep our "boys" alive at the up-coming frontline : "War" Medicine.

Now if there ever was a Poster Child of a disease the war medicine hawks didn't want to treat, it was SBE and here is why.

Unlike Polio ( whose research efforts expanded during the war years) , the conservatives' own kids weren't likely to get RF and SBE.

And unfortunately both diseases were different from many other potentially fatal diseases like smallpox where if you got it once and survived, it would never hit you again.

Even 'curing' a bout of RF and SBE left behind permanent damage which made it not just likely you'd be hit again with new bouts, but hit harder each time as your delicate heart valves further weakened.

These were progressive, re-occuring, infectious diseases with a strong component of deadly auto-immunity to add to the mix.

Any success with SBE was going to be long and expensive in hospital resources, leave the cured patient still unable to serve in the military and do anything very arduous in a war plant - and a year later they be back in hospital again with another potentially fatal bout.

Neglect them and let them die quickly and quietly at home, at least until this war is over,  was the Allied medical establishment's decision worldwide.

Since this also was the Nazis' line, Dawson doubted we would really 'win' a war against them by taking up their horrific tactics.

This is why he deliberately choose to begin the new Age of Antibiotics on October 16 1940,  the first registration day for the
first ever peacetime draft, a day devoted to seeking out and celebrating the 1A youth of America.

He would mark that historical date by instead seeking out and celebrating the 4Fs of the 4Fs of America, celebrating the worthiness of  the least of these.

Cynical, clinical, trials

Conventionally having two (or more) patients suffering from the same disease under your medical wing at the moment when you are about to begin a new form of medical treatment was considered a godsend.

One half would get the old treatment and the other half the new treatment.

Officially and publicly the doctor(s) claimed to agnostic between the virtues of both treatments but that was rarely really true for the first pioneering medical teams.

Inside the privacy of their mind and conscience, they really didn't think the older treatment worked or at least didn't work very well.

This is because a strong belief in the likely success of a new drug was needed before any doctor is willing to do the extremely arduous work of being the first to try out a totally new treatment.

If the disease being treated was acute and had a high fatality rate, the trial would mean some would die who could have been saved , by the time good results came in.

The discussion of the early mass clinical trials of sulfa for dangerous diseases like pneumonia make extremely disturbing reading 75 years later.

Blithely it is - briefly - noted that hundreds died in these various trials.

Hundreds who could have lived if these pioneering true believers in the virtues of sulfa had consistently given their (abundant) supplies to everyone they felt might be saved by it.

The tiny amounts moral dilemma

The worst moral dilemma for many initial trials is that only a tiny amount of a potentially life-saving drug for an acute (rapid) disease has been made - because making this new drug is still hard and expensive and the pharma firm is unwilling to scale up production before there are good signs it might work.

(One drug in a thousand survives the normally long, long expensive trek from the first look at it, to mass production and mass use.)

Such new life-saving drugs tend to go to specialists in the disease it is judged best suited for and these doctors frequently have many
rapidly dying patients at hand who might live if they get it.

The only moral, ethical, solution is to grit one's teeth, stop up your tears and resolve to divide the limited supply among the healthiest/youngest/smallest patients, hoping in this way to get a few successes that will spur on greater production of the drug.

A dozen small children might use the same weight of limited drug as one elderly , weak, fat, adult ---- and get better results.

But with this very biased success could come more of the drug, to then humanely treat all the dying without selecting one over another.

Carefully applied, triage can be highly moral.

But there didn't seem any reason, in advance, to pick one of these young men over the other for the initial clinical trial.

The war medicine hawks had already put the 1As in one worthy pile and the 4Fs in another unworthy pile and Dawson did not want to divide 4Fs into further piles based on no morally fit grounds.

Dawson refused to pick and choose between Alston and Aronson : both got a few days treatment until the supply ran out.

As it turned out, Alston later got a more extensive penicillin treatment but still died. Aronson got no further penicillin but lived - because his particular strain turned out to respond well to massive sulfa doses given for months at a time.

He didn't get another bout of SBE for about three and a half years - a true cure by even exacting standards.

This is why I believe, despite the fact that both men both penicillin within minutes of each other, Aronson got the first needle.

Alston , I  feel certain, had been getting sulfa for weeks but it is known that Aronson didn't get any sulfa until a few more weeks after his first penicillin treatment.

If Alston was in fact the very first patient ever treated by penicillin , any success with penicillin would be quickly and loudly explained away by the many, many pioneers of sulfa --- all claiming it was really due to the use of their drug.

But if the first ever patient was Aronson, any success penicillin had with him would be due to penicillin alone and hard to refute.

Convincing scientists - and their egos - is harder than making major scientific discoveries

The sad fact is that success in science is based on facts and evidence and is relatively easy to achieve.

But convincing other scientists of that success in science really means reminding a lot of awfully big egos that their particular hobby horse isn't the right path to success after all - an extremely difficult process.

Rhetoric, not facts, is key here ----- it might seem ridiculous to highlight the success of one patient given a medication just moments before another , but to truthfully claim that my medicine cured the very first patient it treated was (and is) a potent bragging point.

Dawson's ego was small but he was not naive : I believe he did treat Aronson first, if only by mere moments, to help him win his rhetorical battle with his doubting bosses.

Dawson was extremely modest and truthful : he only ever claimed that Aronson lived through this first bout of SBE due to sulfa, not his penicillin.

 (Though Dawson later did cure him of a second bout in 1944 with enough penicillin to make a real difference.)

William Osler's take on the whole affair ?

But perhaps you believe, along with the world famous Dr William Osler and a boatload of distinguished clinicians ever since, that bedside moral support is at least as important as drugs in helping a body fight off an infection.

Then you might be forgiven in thinking that the compassion Dawson displayed to Charles Aronson, in not 'triaging' him out of the penicillin trial, was at least as important as the tiny amount of penicillin he did receive, in allowing him to live.

One way to look at Dawson's early penicillin was regard it as only .56 of one percent pure.

But alternatively - particularly if, like me,  you are a big fan of New York born  Eddie Rabbit - you could regard it as being made of "nighty nine and forty four one hundreds percent pure love".

Then you can rationally believe that Dawson's penicillin did at least help cure an invariably fatal disease in the very first person in history ever to be treated by an antibiotic ....

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