Alright. So I've broken the embargo. (But if e-mailing with my fellow doctors on the hospital network doesn't break the embargo, or for that matter in an Internet chat room, is this dialogue really so different? I suppose it's just a matter of critical mass, huh?) If you broke it in the Times, though, what happens? What is the penalty that gets extracted? So far, federal marshals have not come for me. But I'm ready and waiting.
Re gene therapy. Yes, I'm in complete agreement that it is far easier to contemplate fixing single gene defects, which tend to be rare, than fixing a disease with multiple genes playing in, like heart disease or incipient cancer. Gene therapy is not ready to fix everything. But no one was sure it was ready to fix anything. So now it seems it can. And once we are able to perfect these abilities, perhaps we'll then be able to move on to even more ambitious heights.
Now, I must confess I was a little surprised by the news that balloons are better than drugs at opening coronary arteries in heart attack patients. I myself don't do coronary angioplasties as part of my training. (I am in fact on my way to becoming a general surgeon instead—though the suspect academic, professorial kind.) But I can tell you that making an angioplasty go right is a hell of a lot harder than giving the right dose of a clot-busting drug. It takes teams of specially trained nurses and cardiologists and technologists and orderlies that have to be ready and able to come in from home on a moment's notice. They have to then be able to do what is still a dangerous and difficult procedure quickly, skillfully, and accurately. And the truth is that the people at hospitals have varying abilities and temperaments and commitments to pull this off. YET—and this is what seems most impressive about the study—the fabulous results were obtained not in fancy, well-endowed academic hospitals with lots of residents around to do the laborious grunt work but in 11 ordinary community hospitals. Can that be translated to a public health policy for the country as a whole? It won't be easy. The FDA can make sure that a clot-busting drug like TPA is the same wherever it's given. But no one has figured out how to make sure that a procedure like angioplasty is performed to the same standard everywhere.
Last, I think my favorite quote in today's papers comes from the Times' piece on the weed killer atrazine producing female frogs with six testicles and whatnot: "I'm not saying it's safe for humans," said Dr. Tyrone Hayes, the lead researcher on the study. "I'm not saying it's unsafe for humans. All I'm saying is it that it makes hermaphrodites of frogs."
It's hard to say much more, actually. One thing it seems important to find out is whether there are in fact lots of frog hermaphrodites bouncing around in the wild as opposed to in the laboratory where the research was done. And if there are, I suppose we would have to rethink our weed-killing ways. Back to DDT, anyone?
On the matter of hermaphrodites and people of ambiguous sex, however, there seems a lot to say. I remember during medical school helping with a delivery. The baby came out. And at one and the same time, the obstetrician said, "It's a boy!" and the nurse said, "It's a girl!" They both looked at each other. Then down at the baby. "What is it? What is it?" the mother asked. And finally the doctor confessed, "We don't know." We lifted the baby up to his/her mother to hold. But she was horrified and couldn't bring herself to even touch the child.
Maybe you have to be intelligent and resourceful to survive in this world without a clear gender. (In truth, I can't say that the intersex people I've met are actually that much smarter or more capable than others.) The traditional thing has always been to assign a gender to such a child. (Usually, they're assigned to be girls, since the body's default, in the absence of an effective testosterone system, is to have a clitoris instead of a penis, labia instead of testes, and a vagina, even if it is blind ending. If I remember correctly, the baby ended up being assigned female before going home.) But the compelling and fascinating notion that people with these conditions are increasingly pushing for is simply being allowed to be who they are—neither male nor female, or maybe a little bit of both. Can we handle it? Why shouldn't we?
Atul Gawande, a surgical resident in Boston, is a staff writer on medicine for The New Yorker and author of the new book Complications: A Surgeon's Notes on an Imperfect Science.