The great dream was to transplant a heart, but in many places it faced a seemingly insuperable obstacle: a person could not be declared dead until his heart had been stopped for a specified period, but that was all but certain to render the heart unusable for transplant. To remove a beating heart, no matter how far gone the owner was in all other respects, was to risk prosecution for murder. One place where that law did not apply was South Africa. In 1967, at exactly the time that René Favaloro was perfecting bypass surgery in Cleveland, Christiaan Barnard, a surgeon in Cape Town, attracted far more of the world’s attention by transplanting the heart of a young woman fatally injured in a car accident into the chest of a fifty-four-year-old man named Louis Washkansky. It was hailed as a great medical breakthrough, though in fact Washkansky died after just eighteen days. Barnard had much better luck with his second transplant patient, a retired dentist named Philip Blaiberg, who survived for nineteen months.*1
Following Barnard, other nations moved to let brain death be used as an alternative measure of irreversible lifelessness, and soon heart transplants were being attempted all over, though nearly always with discouraging results. The main issue was an absence of a wholly reliable immunosuppressive drug to deal with rejection. A drug called azathioprine worked sometimes but couldn’t be relied on. Then, in 1969, an employee of the Swiss pharmaceutical company Sandoz named H. P. Frey, while on holiday in Norway, collected soil samples to take back to the Sandoz labs. The company had asked employees to do so when traveling in the hope that they would find potential new antibiotics. Frey’s sample contained a fungus, Tolypocladium inflatum, which had no useful antibiotic properties but proved excellent at suppressing immune responses—just the thing needed to make organ transplants possible. Sandoz converted Herr Frey’s little bag of dirt, and a similar sample subsequently found in Wisconsin, into a best-selling medicine called cyclosporine. Thanks to it and some associated technical improvements, by the early 1980s heart transplant surgeons were managing success rates of 80 percent, an extraordinary achievement in a decade and a half. Today some four to five thousand heart transplants are performed globally each year, with an average survival time of fifteen years. The longest-surviving transplant patient so far was the Briton John McCafferty, who lived thirty-three years with a transplanted heart before dying in 2016 aged seventy-three.
Incidentally, brain death turned out to be not as straightforward as originally thought. Some peripheral parts of the brain, we now know, may live on after all the rest has grown still. At the time of this writing, that is the issue at the center of a long-running case involving a young woman in the United States who was declared brain-dead in 2013 but who has continued to menstruate, a process that requires a functioning hypothalamus—very much a key part of the brain. The young woman’s parents argue that anyone with even part of the brain functioning cannot reasonably be declared brain-dead.
As for Christiaan Barnard, the man who began it all, success rather went to his head. He traveled the world, dated movie stars (Sophia Loren and Gina Lollobrigida notably), and became, in the words of someone who knew him well, “one of the world’s great womanizers.” Even worse for his reputation, he made a fortune claiming rejuvenative benefits for a range of cosmetics that he most assuredly knew were bogus. He died in 2001, aged seventy-eight, of a heart attack while enjoying himself in Cyprus. His reputation was never again quite what it had been.
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Remarkably, even with all the improvements in care, you are 70 percent more likely to die from heart disease today than you were in 1900. That’s partly because other things used to kill people first, and partly because a hundred years ago people didn’t spend five or six hours an evening in front of a television with a big spoon and a tub of ice cream. Heart disease is far and away the Western world’s number one killer. As Michael Kinch has written, “Heart disease kills about the same number of Americans each year as cancer, influenza, pneumonia, and accidents combined. One in three Americans dies of heart disease and more than 1.5 million suffer a heart attack or stroke each year.”
Today the problem is as likely to be overtreatment as under, according to some authorities. Balloon angioplasties as a treatment for angina (or chest pains) are a case in point, it seems. With an angioplasty, a balloon is inflated inside a constricted coronary blood vessel to widen it, and a stent, or piece of tubular scaffolding, is left behind to keep the vessel permanently open.*2 The operation is unquestionably a lifesaver in emergencies, but it has also proven highly popular as an elective procedure. By 2000, a million precautionary angioplasties were being undertaken in the United States every year, but without any proof that they saved lives. When clinical trials were finally undertaken, the results were sobering. According to The New England Journal of Medicine, for every one thousand nonemergency angioplasties in America, two patients died on the operating table, twenty-eight suffered heart attacks brought on by the procedure, between sixty and ninety experienced a “transient” improvement in their health, and the rest—about eight hundred people—experienced neither benefit nor harm (unless of course you count the cost, the loss of time, and the anxiety of surgery as harm, in which case there was plenty).
Despite this, angioplasties remain extremely popular. In 2013, the former president George W. Bush had an angioplasty at the age of sixty-seven, even though he was in good shape and had no sign of heart problems. Surgeons don’t usually publicly criticize colleagues, but Dr. Steve Nissen, head of cardiology at the Cleveland Clinic, was scathing. “This is really American medicine at its worst,” he said. “It’s one of the reasons we spend so much on medicine and don’t get a lot for it.”
II
HOW MUCH BLOOD you have depends, as you might suppose, on how big you are. A newborn baby contains only about eight ounces, whereas a fully grown man will have more like five quarts. What is certain is that you are suffused with the stuff. Prick your skin anywhere and you will draw blood. Within your modest frame are some twenty-five thousand miles of blood vessels (mostly in the form of tiny capillaries), so no part of you is ever far from the refreshment of hemoglobin, the molecule that transports oxygen throughout your body.
We all know that blood carries oxygen to our cells—it is one of the few facts about the human body that everyone does seem to know—but it also does a whole lot more. It transports hormones and other vital chemicals, carries off wastes, tracks down and kills pathogens, makes sure oxygen is directed to the parts of the body where it is most needed, signals our emotions (as when we blush from embarrassment or grow red with fury), helps to regulate body temperature, and even enables the complicated hydraulics of the male erection. It is, in short, a complex material. By one estimate, a single drop of blood may contain four thousand different types of molecules. That’s why doctors are so fond of blood tests: your blood is positively packed with information.
Spin a test tube of blood in a centrifuge and it will separate into four layers: red cells, white cells, platelets, and plasma. Plasma is the most abundant, constituting a little over half of blood’s volume. It is more than 90 percent water with some salts, fats, and other chemicals suspended in it. That isn’t to say plasma is unimportant, however. It is anything but. Antibodies, clotting factors, and other constituent parts can be separated out and used in concentrated form to treat autoimmune diseases or hemophilia—and that is a huge business. In the United States, plasma sales make up 1.6 percent of all goods exported, more than America earns from the sale of airplanes.