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New Born Lambs, New Born Ideas October 29, 2010

Author: Beach Combing | in : Contemporary , trackback

The progress of a good idea depends not only on that idea’s quality, but also on the dress-code of its supporters and the mood swings of the establishment. For every good idea whose time has come: there are twenty or thirty who have to spend a generation kicking around in the bush before being welcomed up to the tribal fire. As someone with a conservative disposition Beachcombing can see the sense in treating new ideas – no matter how impressive – as lepers until society is absolutely positive that their legs or arms are not going to drop off. But he been particularly impressed/appalled – bad day with the doctors yesterday – at just how long medical science takes to embrace simple life-saving or life-improving innovations.

Beachcombing has put together several examples in a large viola envelope – specially converted for the purposes – he would be grateful for any others drbeachcombing AT yahoo DOT com. But for now he wants to offer just one particularly striking example, that of cortisol and premature babies.

In the late 1960s a pioneering New Zealand scientist, Graham Liggins showed that cortisol - a naturally occurring chemical – injected into foetal sheep led to amost immediate birth, establishing that the foetus not the mother triggered parturition. This was a remarkable discovery in itself, but Liggins’ real genius – and it is difficult to understand why he didn’t have a couple of Nobel prizes slapped on him – was to show that cortisol also improved the foetal lamb’s chance of survival after premature birth. It greatly increased the size of the baby lamb’s lungs.

Excited by his discovery Liggins began, with his colleague Ross Howie, a clinical trial using cortisol and human mothers and in 1972 they went public with their findings: ‘A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants’, Pediatrics 50, 515-25. They had proved that cortisol would also improve the chances (by a half) of survival in prematurely born human babies. They had also pleased hospital administrators by saving these lives for the price of  two to four tubes of synthetic cortisol.

Here then Beachcombing has his case-study. This was an important new discovery with straightforward, positive and cheap results. How long would it take to wing its way around the world? Six months, two years (this was before internet use), five years…

Incredibly, it took twenty years.

The first bad sign came even before publication when the Lancet turned the New Zealanders’ work down: the article that appeared in Pediatrics was precisely the same though with American spelling.  Then Ross Howie remembers the reaction of the UK’s Royal College of Obstetricians and Gynaecologists in 1972: ‘They didn’t want to know’.

By the 1980s when Liggins was welcomed into the Royal Society in London (1980) there had been some movement in some hospitals. One hospital in Cardiff (Wales), for example, had begun to use cortisol with dramatic effects: yet another hospital in the same city avoided the drug.

It was only in 1992 that guidelines published by the Royal College of Obstetricians and Gynaecologists – and based on an extensive review of the literature – included cortisol use in its recommendations and proved the tipping point: suddenly cortisol was being used everywhere and a heresy had become orthodoxy. Beachcombing suggests that you try and convince a doctor not to use cortisol next time you have a premature birth on.

But why did it take so long?

Depressingly one of the most important reasons was that the study had come out of New Zealand.  Liggins and Howie were clearly outstanding scientists – and individuals who created good will everywhere they went. But they were cast as amateurs from the colonies – one of the many anecdotes about Liggins revolves around an exploding sheep and a hospital incinerator, others are set in the abandoned, rotting wooden shed that Liggins employed as his laboratory in his younger years. Later studies on cortisol were carried out by others, but they were either badly done or threw up new problems - science tends to do that. Then there were the turf wars between obstetricians and paediatricians – paediatricians particularly resenting the invasion of ‘their’ territory. Finally, there was the refusal of many doctors to trust the ‘anecdotal’ evidence of their eyes – an all too common problem (sigh). Liggins (obit 2010) and Howie can ask themselves how many thousands baby lives they’ve saved with their revolutionary innovation: medical science, with the all too human qualities that animate it, might better ask how many lives were lost…