CHAPTER 4

THE FIX IS IN-AND IT'S CHEAP AND SIMPLE

It is a fact of life that people love to complain, particularly about how terrible the modern world is compared with the past.

They are nearly always wrong. On just about any dimension you can think of-warfare, crime, income, education, transportation, worker safety, health-the twenty-first century is far more hospitable to the average human than any earlier time.

Consider childbirth. In industrialized nations, the current rate of maternal death during childbirth is 9 women per 100,000 births. Just one hundred years ago, the rate was more than fifty times higher.

One of the gravest threats of childbearing was a condition known as puerperal fever, which was often fatal to both mother and child. During the 1840s, some of the best hospitals in Europe-the London General Lying-in Hospital, the Paris Maternite, the Dresden Maternity Hospital-were plagued by it. Women would arrive healthy at the hospital to deliver a baby and then, shortly thereafter, contract a raging fever and die.

Perhaps the finest hospital at the time was the Allgemeine Krankenhaus, or General Hospital, in Vienna. Between 1841 and 1846, doctors there delivered more than 20,000 babies; nearly 2,000 of the mothers, or 1 of every 10, died. In 1847, the situation worsened: 1 of every 6 mothers died from puerperal fever.

That was the year Ignatz Semmelweis, a young Hungarian-born doctor, became a.s.sistant to the director of Vienna General's maternity clinic. Semmelweis was a sensitive man, very much attuned to the suffering of others, and he was so distraught by the rampant loss of life that he became obsessed with stopping it.

Unlike many sensitive people, Semmelweis was able to put aside emotion and focus on the facts, known and unknown.

The first smart thing he did was acknowledge that doctors really had no idea what caused puerperal fever. They might say they knew, but the exorbitant death rate argued otherwise. A look back at the suspected causes of the fever reveals an array of wild guesses:

"[M]isconduct in the early part of pregnancy, such as tight stays and petticoat bindings, which, together with the weight of the uterus, detain the faeces in the intestines, the thin putrid parts of which are taken up into the blood.""[A]n atmosphere, a miasma, or...by milk metastasis, lochial suppression, cosmo-telluric influences, personal predisposition..."Foul air in the delivery wards.The presence of male doctors, which perhaps "wounded the modesty of parturient mothers, leading to the pathological change.""Catching a chill, errors in diet, rising in the labor room too soon after delivery in order to walk back to bed."

It is interesting to note that the women were generally held to blame. This may have had something to do with the fact that all doctors at the time were male. Although nineteenth-century medicine may seem primitive today, doctors were considered nearly G.o.dlike in their wisdom and authority. And yet puerperal fever presented a troubling contradiction: when women delivered babies at home with a midwife, as was still common, they were at least sixty times less likely to die of puerperal fever than if they delivered in a hospital.

How could it be more dangerous to have a baby in a modern hospital with the best-trained doctors than on a lumpy mattress at home with a village midwife?

To solve this puzzle, Semmelweis became a data detective. Gathering statistics on the death rate at his own hospital, he discovered a bizarre pattern. The hospital had two separate wards, one staffed by male doctors and trainees, the other by female midwives and trainees. There was a huge gap between the two wards' death rates:

Why on earth was the death rate in the doctors' ward more than twice as high?

Semmelweis wondered if the women patients admitted to the doctors' ward were sicker, weaker, or in some other way compromised.

No, that couldn't be it. Patients were a.s.signed to the wards in alternating twenty-four-hour cycles, depending on the day of the week they arrived. Given the nature of pregnancy, an expectant mother came to the hospital when it was time to have the baby, not on a day that was convenient. This a.s.signment methodology wasn't quite as rigorous as a randomized, controlled trial, but for Semmelweis's purpose it did suggest that the divergent death rates weren't the result of a difference in patient populations.

So perhaps one of the wild guesses listed above was correct: did the very presence of men in such a delicate feminine enterprise somehow kill the mothers?

Semmelweis concluded that this too was improbable. After examining the death rate for newborns in the two wards, he again found that the doctors' ward was far more lethal than the midwives': 7.6 percent versus 3.7 percent. Nor was there any difference in the death rate of male babies versus females. As Semmelweis noted, it was unlikely that newborns would "be offended by having been delivered in the presence of men." So it was unreasonable to suspect that male presence was responsible for the mothers' deaths.

There was also a theory that patients admitted to the doctors' ward, having heard of its high death rate, were "so frightened that they contract the disease." Semmelweis didn't buy this explanation either: "We can a.s.sume that many soldiers engaged in murderous battle must also fear death. However, these soldiers do not contract childbed fever."

No, some other factor unique to the doctors' ward had to figure in the fever.

Semmelweis had by now established a few facts:

Even the poorest women who delivered their babies on the street and then came to the hospital did not get the fever.Women who were dilated for more than twenty-four hours "almost invariably became ill."Doctors did not contract the disease from the women or newborns, so it was almost certainly not contagious.

Still, he remained puzzled. "Everything was in question; everything seemed inexplicable; everything was doubtful," he wrote. "Only the large number of deaths was an unquestionable reality."

The answer finally came to him in the wake of a tragedy. An older professor whom Semmelweis admired died quite suddenly after a mishap. He had been leading a student through an autopsy when the student's knife slipped and cut the professor's finger. The maladies he suffered before dying-bilateral pleurisy, pericarditis, peritonitis, and meningitis-were, Semmelweis observed, "identical to that from which so many hundred maternity patients had also died."

The professor's case held little mystery. He died from "cadaverous particles that were introduced into his vascular system," Semmelweis noted. Were the dying women also getting such particles in their bloodstream?

Of course!

In recent years, Vienna General and other first-rate teaching hospitals had become increasingly devoted to understanding anatomy. The ultimate teaching tool was the autopsy. What better way for a medical student to limn the contours of illness than to hold in his hands the failed organs, to sift for clues in the blood and urine and bile? At Vienna General, every single deceased patient-including the women who died of puerperal fever-was taken directly to the autopsy room.

But doctors and students often went to the maternity ward straight from the autopsy table with, at best, a cursory cleansing of their hands. Although it would be another decade or two before the medical community accepted germ theory-which established that many diseases are caused by living microorganisms and not animal spirits or stale air or too-tight corsets-Semmelweis understood what was going on. It was the doctors who were responsible for puerperal fever, transferring "cadaverous particles" from the dead bodies to the women giving birth.

This explained why the death rate in the doctors' ward was so much higher than in the midwives' ward. It also explained why women in the doctors' ward died more often than women who gave birth at home or even in the streets, and why women in a longer state of dilation were more susceptible to the fever: the longer a woman lay in that state, the more often her uterus was poked and prodded by a gaggle of doctors and medical students, their hands still dripping with the remnants of their latest autopsy.

"None of us knew," as Semmelweis later lamented, "that we were causing the numerous deaths."

Thanks to him, the plague could finally be halted. He ordered all doctors and students to disinfect their hands in a chlorinated wash after performing autopsies. The death rate in the doctors' maternity ward fell to barely 1 percent. Over the next twelve months, Semmelweis's intervention saved the lives of 300 mothers and 250 babies-and that was just in a single maternity ward in a single hospital.

As we wrote earlier, the law of unintended consequences is among the most potent laws in existence. Governments, for instance, often enact legislation meant to protect their most vulnerable charges but that instead ends up hurting them.

Consider the Americans with Disabilities Act (ADA), which was intended to safeguard disabled workers from discrimination. A n.o.ble intention, yes? Absolutely-but the data convincingly show that the net result was fewer jobs for Americans with disabilities. Why? After the ADA became law, employers were so worried they wouldn't be able to discipline or fire bad workers who had a disability that they avoided hiring such workers in the first place.

The Endangered Species Act created a similarly perverse incentive. When landowners fear their property is an attractive habitat for an endangered animal, or even an animal that is being considered for such status, they rush to cut down trees to make it less attractive. Among the recent victims of such shenanigans are the cactus ferruginous pygmy owl and the red-c.o.c.kaded woodp.e.c.k.e.r. Some environmental economists have argued that "the Endangered Species Act is actually endangering, rather than protecting, species."

Politicians sometimes try to think like economists and use price to encourage good behavior. In recent years, many governments have started to base their trash-pickup fees on volume. If people have to pay for each extra bag of garbage, the thinking goes, they'll have a strong incentive to produce less of it.

But this new way of pricing also gives people an incentive to stuff their bags ever fuller (a tactic now known by trash officers the world around as the "Seattle Stomp") or just dump their trash in the woods (which is what happened in Charlottesville, Virginia). In Germany, trash-tax avoiders flushed so much uneaten food down the toilet that the sewers became infested with rats. A new garbage tax in Ireland generated a spike in backyard trash burning-which was bad not only for the environment but for public health too: St. James's Hospital in Dublin recorded a near tripling of patients who'd set themselves on fire while burning trash.

Well-intentioned laws have been backfiring for millennia. A Jewish statute recorded in the Bible required creditors to forgive all debts every sabbatical, or seventh year. For borrowers, the appeal of unilateral debt relief cannot be overstated, as the penalties for defaulting on a loan were severe: a creditor could even take a debtor's children into bondage.

If you were a creditor, however, you saw this debt-forgiveness program differently. Why loan money to some sandal maker if he could just tear up the note in Year Seven?

So creditors gamed the system by making loans in the years right after a sabbatical and pulling tight the purse strings in Years Five and Six. The result was a cyclical credit crunch that punished the very people the law was intended to help.

But in the history of unintended consequences, few match the one uncovered by Ignatz Semmelweis: medical doctors, while in pursuit of lifesaving knowledge, conducted thousands upon thousands of autopsies, which, in turn, led to the loss of thousands upon thousands of lives.

It is heartening, of course, that Semmelweis's brilliant data deduction showed how to end this scourge. But our larger point, and the point of this chapter, is that Semmelweis's solution-sprinkling a bit of chloride of lime in the doctors' hand-wash-was remarkably simple and remarkably cheap. In a prosperous world, simple and cheap fixes sometimes get a bad rap; we are here to defend them.

There is another powerful, if bittersweet, example from the realm of childbirth: the forceps. It used to be that when a baby presented itself feet-or derriere-first, there was a good chance it would get stuck in the uterus, endangering both mother and child. The forceps, a simple set of metal tongs, allowed a doctor or midwife to turn a baby inside the uterus and adroitly pluck it out, headfirst, like a roast suckling pig from the oven.

As effective as it was, the forceps did not save as many lives as it should have. It is thought to have been invented in the early seventeenth century by a London obstetrician named Peter Chamberlen. The forceps worked so well that Chamberlen kept it a secret, sharing it only with sons and grandsons who continued in the family business. It wasn't until the mideighteenth century that the forceps pa.s.sed into general use.

What was the cost of this technological h.o.a.rding? According to the surgeon and author Atul Gawande, "it had to have been millions of lives lost."

The most amazing thing about cheap and simple fixes is they often address problems that seem impervious to any solution. And yet almost invariably, a Semmelweis or a team of Semmelweises ride into view and save the day. History is studded with examples.

At the start of the Common Era, just over two thousand years ago, there were roughly 200 million people on earth. By the year 1000, that number had risen only to 300 million. Even by 1750, there were just 800 million people. Famine was a constant worry, and the smart money said the planet couldn't possibly support much more growth. The population in England had been decreasing-"essentially because," as one historian wrote, "agriculture could not respond to the pressure of feeding extra people."