There is a potential flaw in Atul Gawande’s BetterBirth Project, which seeks to spread safer childbirth practices through neonatal intervention. In another initiative, in the nineteen-eighties, a group of Western mid worked in remote villages in Nepal to teach local birth attendants how to prevent neonatal tetanus, which was killing large numbers of infants. With immunization clinics, the group was able to achieve measurable improvements in neonatal survival. But the death rate of children under five years remained stubbornly high. Many of those who might have died as were doomed to die as toddlers. The innovations cannot stop with improved neonatal mortality statistics.
Mike Witte, M.D.
Point Reyes Station, Calif.
Gawande begins with an example of an innovation that spread rapidly after 1846: William Morton’s use of gas to render patients insensible to pain. This advance has been pondered elsewhere, however, as a discovery that surgeons were agonizingly slow to adopt. In 1800, the English chemist and inventor Humphry Davy, in his book «Researches» described the anesthetic properties of nitrous oxide, remarking, «As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage in surgical operations». This discovery caught the attention of Samuel Taylor Coleridge, to whom Daw’s publisher sent «Researches». Richard Holmes, who tells the story in some detail in his book «The Age of Wonder: How the Romantic Generation Discovered the Beauty and Terror of Science», relates that Coleridge wrote to Davy, pressing him to pursue the matter with Coleridge’s friend Sir Anthony Carlisle, a leading London surgeon. Yet nearly half a century of excruciating pain for surgical patients was to pass before the date when Gawande takes up the story. Holmes suggests that the best explanation for the failure to adopt anesthesia is that surgeons — who prided themselves on the speed with which they operated and on their psychological mastery of pain — were simply unable to conceive of the idea of painless surgery.
Daniel Mark Fogel Professor of English University of Vermont Burlington, Vt.
Gawande details the positive effects of community mobilization, and sending trained community health workers into the field certainly helps reduce neonatal and maternal mortality. However, if cultural influences are not also dealt with, these deaths will not be significantly reduced. The social mores include the need for women to get permission to seek health services from their husbands, low male-partner involvement, and lack of family planning and contraception counselling. Each country has its own unique context, and holistic strategies should be tailored to each one. Indeed, successful adoption of these «ideas» and their implementation cannot happen without strong political will, good governance, and stewardship.
Harry Strulovici, M.D.
New York City
In order to alter the preëxisting norms of a health-care environment, one must understand that certain protocols may not necessarily have been ignored but were instead «re-prioritized». It is entirely conceivable that the nurse in Gawande’s article who neglected to check a nowborn temperature properly, thus exposing the child to a cascade of risks, may have reevaluated its importance under institutional pressure, some of winch derives from limited personnel. Indeed, the U.S. health system is no stranger to the consequences of understaffing and budget cuts. In this country, health-care institutions have developed an affinity for patient-satisfaction scores that are seen as more potent leverage than basic safety measures like adequate staffing. After all, customer service, and the numbers it generates, correlates with funding. No idea occurs in a vacuum; innovation must compete against a myriad of standards, financial or otherwise, and this competition occurs on a daily basis in our own hospitals and clinics.
Jen Tung New York City
Gawande nicely contrasts medical acceptance of anesthesia, pioneered by William Morton, and medical resistance to prevention of sepsis, advocated by Joseph Lister. The contrast is even stronger with Lister’s predecessor Ignaz Semmelweis, who proposed in 1847 that childbed fever could be reduced if doctors washed their hands before seeing patients. His later publications, in 1858 and 1861, despite evidence of clinical success, were met with attack and ostracism, and Semmelweis died, insane, in 1865, the year that Lister began using carbolic acid as an antiseptic. One likely difference in reception is that Morton gave physicians something new, whereas Semmelweis faulted them for what they were already doing.
E. Bruce Brooks Amherst, Mass.
Gawande’s otherwise excellent piece dodges the hardest issue in health care in the developing world: how to stem explosive population growth. If birth-control teaching is omitted from rural health teams, the very methods Gawande espouses to decrease infant mortality, improve maternal health, and prevent diarrheal deaths will only contribute to the overgrowth of humanity. Yet Gawande does no more than mention in passing the «fifty-per-cent increase in the world’s population in the past three decades». Health efforts uncoupled from population control will exacerbate the ongoing anthropogenic environmental catastrophe.
Glenn Vanstrum, M.D.
San Diego, Calif.