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Telling the Stories Behind the Abortions
By CORNELIA DEAN, The New York Times, November 6, 2007
Dr. Susan Wicklund took her first step toward the front line of the abortion wars when she was in her early 20s, a high school graduate with a few community college credits, working dead-end jobs.
She became pregnant. She had an abortion. It was legal, but it was ghastly.
Her counseling, she recalls, was limited to instructions to pay in advance, in cash, and to go to the emergency room if she had a problem. During the procedure itself, her every question drew the same response: “Shut up!”
Determined that other women should have better reproductive care, she began work as an apprentice midwife and eventually finished college, earned a medical degree and started a practice in which she spends about 90 percent of her time on abortion services. Much of her work is in underserved regions on the Western plains, at clinics that she visits by plane.
In her forthcoming book “This Common Secret: My Journey as an Abortion Doctor” (Public Affairs), Dr. Wicklund describes her work, the circumstances that lead her patients to choose abortion, and the barriers — lack of money, lack of providers, violence in the home or protesters at clinics — that stand in their way.
But she said her main goal with the book was to encourage more open discussion of abortion and its prevalence.
“We don’t talk about it,” she said in a telephone interview. “People say, ‘Nobody I know has ever had an abortion,’ and that is just not true. Their sisters, their mothers have had abortions.”
Dr. Wicklund, 53, said that at current rates almost 40 percent of American women have an abortion during their child-bearing years, a figure supported by the Guttmacher Institute, which researches reproductive health policy. Abortion is one of the most common operations in the United States, she said, more common than tonsillectomy or removal of wisdom teeth. “Because it is such a secret,” she said, “we lose sight of how common it is.”
But Dr. Wicklund acknowledges that abortion is an issue fraught with dilemmas. In the book, she describes witnessing, as a medical student, the abortion of a 21-week fetus. She writes that at the sight of its tiny arm she decided she would perform abortions only in the first trimester of pregnancy. She says late-term abortions should be legal, but her decision means she occasionally sees desperate women she must refuse to help.
Dr. Wicklund describes her horror when she aborted the pregnancy of a woman who had been raped, only to discover, by examining the removed tissue, that the pregnancy was further along than she or the woman had thought — and that she had destroyed an embryo the woman and her husband had conceived together. And she describes the way she watches and listens as the women she treats tell why they want to end their pregnancies. If she detects uncertainty or thinks they may be responding to the wishes of anyone other than themselves, she says, she tells them to think it over a bit longer.
On the other hand, Dr. Wicklund has little use for requirements like 24-hour waiting periods, or for assertions like those of Justice Anthony M. Kennedy, who said in a recent Supreme Court decision on abortion that the government had an interest in protecting women from their own decisions in the matter.
“It’s so incredibly insulting,” Dr. Wicklund said in the interview. “The 24-hour waiting period implies that women don’t think about it on their own and have to have the government forcing it on them. To me a lot of the abortion restrictions are about control of women, about power, and it’s insulting.”
Dr. Wicklund said she would put more credence in opponents of abortion rights if they did more to help women prevent unwanted pregnancies. Instead, she said, many of the protesters she encounters “are against birth control, period.” That is unfortunate, she said, because her clinic experience confirms studies showing that emphasizing abstinence rather than contraception may cause girls to delay their first sexual experience for a few months, but “when they do have intercourse they are much less likely to protect themselves with birth control or a condom.”
According to the Guttmacher Institute, about a quarter of pregnancies in the United States end in abortion. Dr. Wicklund says that is why she believes far more people favor abortion rights than are willing to admit it in polls. For example, she said in the interview, an abortion ban that seemed to have wide support in South Dakota was put to a vote and “when people got behind those curtains and nobody was watching it was overwhelmingly defeated. Unfortunately, people are not willing to say what they really think.”
One of these people might be a woman she recognized as one of the protesters who regularly appeared, shouting, outside a clinic where she worked. Only now the woman was in the waiting room, desperate to end an unwanted pregnancy. Dr. Wicklund performed the procedure.
And then there is Dr. Wicklund’s maternal grandmother, a woman she was afraid would disapprove of her work. But it turned out that she had a story of her own. “When I was 16 years old, my best friend got pregnant,” is how the story began. Her friend turned to her and her sister for help. They did the only thing they could think of — putting “something long and sharp ‘up there,’ ” according to the book. The girl bled to death, and the cause of her death was kept secret.
“I know exactly what kind of work you do,” the grandmother told Dr. Wicklund, “and it is a good thing.” One question Dr. Wicklund hears “all the time,” she said, is how she can focus on abortion rather than on something more rewarding, like delivering babies.
“In fact, the women are so grateful,” Dr. Wicklund said in the interview. “Women are so grateful to know they can get through this safely, that they can still get pregnant again.
“It is one of the few areas of medicine where you are not working with a sick person, you are doing something for them that gives them back their life, their control,” she added. “It’s a very rewarding thing to be part of that.”
Rethinking What Caused the Last Mass Extinction
By JOHN NOBLE WILFORD, The New York Times, November 6, 2007
FREEHOLD, N.J. — Splashing through a shallow creek in suburban New Jersey, the paleontologists stepped back 65 million years to the time of the last mass extinction, the one notable for the demise of the dinosaurs.
The stream flows over sediment laid down toward the end of geology’s Cretaceous period. The clay at water level holds meaningful traces of iridium, the element more common in asteroids and other extraterrestrial objects than in the earth. No one could resist sticking a finger to the clay, treating it as a touchstone of their time travel.
Scientists associate the iridium anomaly with the asteroid impact or impacts thought to have set off the extinctions. The thin layer, which has been detected worldwide, is also considered the marker for the end of the Cretaceous and beginning of the Tertiary period, known as the K-T boundary.
At the time, sea levels were higher and New Jersey was warmer. The proto-Atlantic waters reached the center of the current boundaries of New Jersey, standing more than 60 feet deep here, where on a recent day the paleontologists were up to their ankles in a creek. They had their eyes on the sediments in the bank just above the iridium clay. They call this the Pinna layer.
On previous visits, they had found in the Pinna rock and soil a surprising number of marine fossils, including small clams, crabs and sea urchins. There was an abundance of ammonites, considered index organisms of the uppermost Cretaceous environment. Somehow, here at least, life appeared to have not only persisted but also flourished for tens, perhaps hundreds, of years after the putative asteroid impact.
“This is really putting New Jersey on the map of the K-T boundary,” said Neil H. Landman, an invertebrate paleontologist at the American Museum of Natural History who is directing the new research in the Manasquan River basin.
The discovery of thriving communities of survivors at the end of the Cretaceous is giving some scientists second thoughts about the extinction’s causes and effects. Some question the conventional explanation of a single large impact that enveloped Earth in a cloud of dust and almost instantaneously brought on a deadly global winter. They contend that this may be an oversimplification, and that the real story behind the dinosaur-ending disaster is more complicated and as yet unclear.
“It is undeniable that the iridium spike at the base of the Pinna layer was produced by the impact,” Dr. Landman said. “That’s amazing and makes it hard to explain the ammonite abundances we find above the iridium anomaly.”
Gerta Keller, a paleontologist and professor of geosciences at Princeton University, said the research by Dr. Landman’s group “shows the complexity of this extinction event and the difficulty explaining it by the currently popular impact theory.”
Dr. Keller, who had no part in the New Jersey discovery, has investigated the K-T boundary in Brazil, Mexico and Texas, finding evidence that she says indicates multiple asteroid impacts occurring at the end of the Cretaceous. She reported that the one that gouged out the Chicxulub crater at the tip of Mexico’s Yucatán Peninsula, which had been the prime suspect in the extinction, struck at least 300,000 years before the dinosaurs died out.
At a meeting of the Geological Society of America last week, Dr. Keller reported marine fossil evidence that she said linked the mass extinction to widespread volcanic eruptions that swept India at the end of the Cretaceous.
In other words, the world’s ecosystem was under widespread stress for an extended time. The extinctions might have had multiple causes, not the single asteroid impact and almost instant death as hypothesized in 1980 after the detection of the global iridium layer.
At first, the paleontologists treated the fossil discoveries in New Jersey with caution. Geologists who analyzed 37 samples of sediment from three sites at the creek and elsewhere in the basin concluded that they contained a telling concentration of iridium at the Pinna base. Still, Dr. Landman thought it possible that the iridium had shifted over time, confusing the chronology.
Dr. Landman said he had since become increasingly confident that the iridium layer at the creek remained where it was deposited. It is presumably a true marker of an asteroid impact with global repercussions, and this further complicates understanding of the mass extinction. Why is there no evidence at the creek for the almost immediate post-impact destruction, as assumed by the standard theory?
A construction project led scientists to the discovery. Excavations for a new bridge three years ago exposed a section of rock spanning the K-T boundary. In a report this year, Dr. Landman’s group wrote that the section contained “the most abundant and diverse invertebrate assemblage ever discovered from this interval in New Jersey.”
The first investigations, beginning with Ralph O. Johnson, a mostly self-educated but expert paleontologist who lives in West Long Branch, uncovered traces of the fossil-rich stratum reaching to the undisturbed outcrops along this creek. The stream has no name on maps, but the scientists, thinking of the prickling briars and entangling wild grape vines, call it Agony Creek.
“You don’t have to go to Mongolia to discover important fossils,” Mr. Johnson said. “These outcrops sit in the middle of the suburbs, two and a half miles from my home. How could they have been missed until now?”
Wading downstream, Dr. Landman, Mr. Johnson and Matthew P. Garb, a doctoral student in geology at Brooklyn College, came to a place that looked good for prospecting. Wet and dirty, they got to work — grown men squatting at the edge of a creek, making mud pies, or so it appeared.
In fact, they were cutting out wedges of the Pinna layer and, wielding picks, knives and brushes, were extracting and examining the remains of presumed survivors in the aftermath of the K-T mass extinction.
At least 110 species of near-shore marine organisms have been identified in the Pinna layer, Dr. Landman explained. This was a robust community that lived over a geologically short period of time, perhaps several tens of years. But the Pinna is truncated at the top, which the scientists said implied a still longer duration amounting to hundreds of years.
Later, back at his museum laboratory in Manhattan, Dr. Landman pulled out trays of ammonites, his scientific specialty. These organisms first appeared in the Devonian period, about 410 million years ago; there were 30 known species at the end of the Cretaceous, and after the extinctions, there were none. Their near-relative the nautilus survives, perhaps because it is a scavenger that will eat just about anything.
The trays held a collection of the creek specimens. Ten ammonite species were recovered from the presumably post-impact Pinna layer. One of them, Discoscaphites jerseyensis, is unique to New Jersey.
After the event producing the iridium residue, and the occurrence of any accompanying disasters, Dr. Landman said, the extinctions were not immediate everywhere, certainly not among marine organisms off New Jersey.
“This is what I imagine happening,” he said. “Storms of biblical proportions and a heavy discharge of river floods might have buried sediments rapidly. These marine communities may have flourished immediately afterward as a result of a lot of organic material, such as plankton, dying and settling to the depths for their consumption.”
A few other paleontologists have also cast doubt on the timing and single-impact suddenness of the mass extinction. The idea of a killer impact that became the standard theory was proposed in 1980 on the basis of iridium traces; it gained wide acceptance after the discovery in 1991 of the impact crater in Mexico. But in some places, the fossil record for dinosaurs seems to disappear a little before the iridium is deposited. Geologists have found several other crater remnants that could have been gouged out by asteroids and also the suspect volcanoes of India.
Dr. Landman said he was not sure how long the ammonites in New Jersey lived above the iridium marker, but they “could not possibly have survived 300,000 years,” as Dr. Heller of Princeton argues.
At the creek site, above the fossils of the Pinna layer, the Hornerstown Formation preserves a record of impoverished life, beginning a few hundred years after the extinction event or events. There were tiny oyster shells from a single species, and little else.
Shining Light on Diseases Often in the Shadows
By DONALD G. McNEIL Jr., The New York Times, November 6, 2007
When is a neglected disease no longer “neglected”?
A new online medical journal devoted to neglected tropical diseases was founded last week, and the first task its editors faced was choosing which ailments to snub.
By and large, germs were out, worms were in, and fungi and skin parasites had a shot.
For starters, the editors decided, AIDS, malaria and tuberculosis — which now have billion-dollar funds dedicated to fighting them — definitely received too much attention to qualify.
“If we opened it up to malaria, it would become a malaria journal,” said Dr. Peter J. Hotez, a worm disease specialist at George Washington University’s medical school and editor of the new journal, PLoS Neglected Tropical Diseases. “We want the most common diseases of the poor. Of the 2.7 billion people in the world who live on less than $2 a day, about half have one — or more — of these.”
Such diseases get less attention because they rarely kill.
“You hear a speech from someone in malaria, and they always say ‘In the time I’ve been talking, 200 kids have died of malaria’ — well, we don’t have that,” Dr. Hotez said.
But worms can leave a child anemic, urinating blood and too weak to walk to school. They can also blind adults or grotesquely swell legs or scrotums, leaving farmers doomed to starve and entire villages unable to climb out of poverty.
The first issue includes a report by Doctors Without Borders on a surge in visceral leishmaniasis in war-torn Somalia. (Among the troops in Iraq, leishmaniasis is known as “the Baghdad boil,” a weeping sore left by a sandfly bite. In the more dangerous visceral kind, the sores appear on internal organs.)
Another report describes how the spread of elephantiasis — the swollen leg and scrotum disease — can be stopped by drugs costing as little as 6 cents per year.
A third unriddles a perplexing leptospirosis outbreak in Thailand. It was caused by a bacterial clone hiding in the urine of a bandicoot rat.
The new journal — www.plosntds.org/home.action — is part of the Public Library of Science series and is being started with a $1 million grant from the Bill and Melinda Gates Foundation. Access is free, anyone can use the data, and ads from companies making drugs and medical devices are not accepted. The library is a challenge to the major medical journals, which charge hefty fees and usually sell ads to the same companies whose products they investigate, although they try to reveal any conflicts of interest that researchers have.
Instead, the journal on neglected diseases charges authors a $2,100 fee to publish. But the fee can be waived, no questions asked, for any researcher whose grants are too small to cover it, said Dr. Gavin Yamey, a senior PLoS editor overseeing the debut of the journal.
Scientist at Work | John Holcomb: Army’s Aggressive Surgeon Is Too Aggressive for Some
By ALEX BERENSON, The New York Times, November 6, 2007
SAN ANTONIO — Since the war in Iraq began, Col. John Holcomb has been working to change the way the military takes care of its wounded.
Along the way he has suffered a few dings himself.
A tall medical doctor with a Southern lilt and close-cropped gray hair, Colonel Holcomb, 48, has spent his entire 27-year career in the Army, earning a reputation as one of the military’s top trauma surgeons. Since 2001, he has headed the Army’s Institute of Surgical Research, based on the campus of the Brooke Army Medical Center here.
Under his watch, Army surgeons have become aggressive users of a controversial drug called Factor VII, which promotes clotting in cases of severe bleeding. He has also guided a redesign of the transport system for wounded soldiers, encouraging helicopter pilots to take the severely injured to the hospitals best able to treat them, even if they are not the closest.
Colonel Holcomb also strongly advocates conducting clinical trials to improve trauma care. It is an ethically tricky area, because trauma research can involve trying novel treatments on severely injured patients who cannot give informed consent. But he argues that any ethical problems pale in comparison to the toll that traumatic injuries take on civilians and soldiers every day.
He is fond of quoting a surprising statistic: trauma is the third-leading cause of death in the United States, taking 160,000 lives in 2004, more than any other cause except heart disease and cancer. Because it primarily affects the young, trauma leads all diseases in terms of life-years lost.
And besides the 4,000 American deaths in Iraq and Afghanistan, there have been 29,000 injuries from hostile fire, including 9,000 severe enough to require transport to hospitals outside the war zones.
In the face of that toll, Colonel Holcomb said, doctors must run clinical trials to ensure that patients are receiving the best treatments. Without those trials, even basic questions — which patients should be put on breathing tubes, for example — remain unanswered.
In an interview in his office at Brooke, Colonel Holcomb said he was determined to generate data that would help military and civilian surgeons answer those questions.
“We run a research institute,” he said. “Everything we do, we try to drive on data.”
Colonel Holcomb’s backers, who include surgeons both in and out of the military, say he is an exceptionally hard-working physician whose single-minded focus on wounded soldiers has led to improvements in the way the military treats its injured.
“John Holcomb is making a huge contribution to the advancement of trauma care in this country,” said Dr. Brent Eastman, the chairman of trauma for Scripps Health in San Diego and a regent of the American College of Surgeons.
But Colonel Holcomb is not without critics, who say his efforts, however well intended, may be doing more harm than good.
Dr. Andrew F. Schorr, a former military physician who is associate director of critical care medicine at Washington Hospital Center in Washington, said he believed that Colonel Holcomb had pushed military surgeons to use Factor VII despite a lack of data on its benefits — and some evidence that it can increase the risk of blood clots that cause strokes. Factor VII is a naturally occurring protein that helps the blood clot; an artificial version is produced by the Danish company Novo Nordisk under the name NovoSeven.
“I certainly disagree with his approach to Factor VII,” Dr. Schorr said.
Colonel Holcomb has also been criticized for his advocacy of an experimental blood substitute called PolyHeme, which recently failed a clinical trial in trauma patients. The trial, which ran from late 2003 until last year, was conducted on people who were severely injured and could not give consent to the experiment.
The trial followed an earlier failed test of PolyHeme in patients undergoing surgery for aneurysms. In the earlier trial, 54 percent of people who took it went on to suffer serious adverse events, compared with 28 percent who did not.
But the Brooke Army Medical Center and Colonel Holcomb did not disclose the results of the earlier trial to the public when they agreed to participate in the new trial. “Up to now, PolyHeme has not caused any clinically bad problems,” researchers for Brooke wrote in materials prepared for a public meeting, according to a 2006 article in The Wall Street Journal.
“He knew about this data, and he should never have approved the trial for his center and allowed the Army to participate in it,” said Keith Berman, a medical products consultant who specializes in research on blood substitutes. “Many, many centers declined to participate in this trial.”
Colonel Holcomb does not apologize for his advocacy of PolyHeme or Factor VII. Hemoglobin substitutes like PolyHeme, which enable the body to transport oxygen to its cells even after massive blood loss — could save lives, he said. And trials based on consultation with a public entity like a hospital review board, rather than individual informed consent, are necessary to improve the care of trauma patients.
In addition, the Food and Drug Administration approved the PolyHeme trial even though it saw the unreleased data from the earlier test, and many other medical centers participated in it, he said, adding, “We’re not irresponsible people going out and doing evil experiments on small groups of patients.”
As for Factor VII, Colonel Holcomb said he understood the concerns of the Army’s critics and agreed there was no strong evidence that the drug decreases mortality or other complications in trauma patients.
The F.D.A. has approved the drug to stanch bleeding only in hemophiliacs and people with a congenital deficiency of Factor VII, not in those whose blood is otherwise normal. And the label warns that the drug should be used “only under the supervision of a physician experienced in the treatment of bleeding disorders.”
But a 300-patient clinical trial showed that Factor VII reduced the need for transfusions in patients and showed a trend toward reducing mortality in patients who received it, though the difference was not statistically significant. A larger trial to confirm those findings is under way, but the results will not be available for several years.
With soldiers severely injured every day in Iraq, Colonel Holcomb said, the military cannot afford to wait for a definitive answer.
“You have a drug that you know is safe from the prospective randomized controlled clinical trials,” Colonel Holcomb said. “And you have to make a decision. It’s not something you can decide to talk about. It’s really yes or no. You have a lot of people bleeding to death in Iraq.”
Other trauma surgeons support that attitude.
Dr. John R. Hess, a professor of pathology and medicine at the University of Maryland and a physician at its Shock Trauma Center in Baltimore, said the Army was right to use Factor VII aggressively. Severe bleeding, he noted, quickly exhausts the natural resources of Factor VII.
In trauma patients, “hemorrhage is the second-leading cause of death,” behind only brain injuries. “But you can do something about it.”
Civilian hematologists rarely see injuries as severe as those the Army faces, Dr. Hess said, so they may not understand the need for the drug. He added that Colonel Holcomb, whom he has known for two decades, would never encourage the use of Factor VII if he thought it was endangering soldiers.
“He feels deeply concerned about the soldiers, he goes over there, he takes care of them,” Dr. Hess said. “If you were hurt, he’s the guy you’d want taking care of you.”
Colonel Holcomb has spent several months in Iraq since the war began. In addition to working as a surgeon, he has helped redesign the system that transports wounded soldiers to hospitals.
In previous conflicts, the wounded were evacuated to nearby forward operating stations, even if their injuries were so severe that doctors at those stations might not have been able to help them.
Now, helicopter pilots coordinate care more closely with the half-dozen large hospitals throughout Iraq, making sure that a soldier with head trauma, for example, is taken to a hospital that has a neurosurgeon available. The system is modeled on regional trauma systems in the United States, where patients with severe injuries go directly to regional trauma centers.
“Sometimes fast is slow and methodical is fast,” said Col. Stephen Flaherty, the chief of surgery at Landstuhl Regional Medical Center, an Army hospital in Germany that treats wounded soldiers from Iraq and Afghanistan. “And if you do things fast and take them to the wrong location with the wrong resources, you may not wind up giving them the best care.”
But changing the system required the notoriously bureaucratic Army to make significant changes in the way medical helicopters were positioned, as well as increasing coordination between hospitals, forward surgical teams and front-line units.
Colonel Holcomb drove those changes, said Colonel Flaherty, who added that the Army was willing to make them because both senior and junior officers trusted Colonel Holcomb to offer recommendations driven by hard data rather than untested assumptions.
“He does a great job of listening to us, getting multiple voices and multiple recommendations, and following the data,” he said.
Colonel Holcomb said his visits to Iraq had been invaluable in helping him understand how to change the system. “To understand the problem, you need to get yourself on the ground, talk to the guys,” he said.
At the same time, Colonel Holcomb has pressed the Army to develop a database to track the care of all wounded soldiers from the time of their initial injury to their discharge. The system, called the Joint Theater Trauma Registry, is designed to improve care by identifying the best practices and the problems in military hospitals. The registry may also help the military standardize soldiers’ care even as new nurses and doctors are rotated into the war zone.
Meanwhile, the war is never far from Brooke Army Medical Center, where young men and women with prostheses are a common sight. The hospital specializes in treating soldiers with severe burns and has a large, free-standing rehabilitation center for amputees called the Center for the Intrepid.
Since the war began, Brooke’s burn center has treated several hundred severely injured soldiers, while Colonel Holcomb has pressed it to find and test new treatments, like different dressings and continuous dialysis for patients with kidney failure, said Dr. Steven E. Wolf, a civilian who directs the burn unit. He quoted Colonel Holcomb’s philosophy:
“Why answer a question with another question? Just do the experiment.”
By CORNELIA DEAN, The New York Times, November 6, 2007
Dr. Susan Wicklund took her first step toward the front line of the abortion wars when she was in her early 20s, a high school graduate with a few community college credits, working dead-end jobs.
She became pregnant. She had an abortion. It was legal, but it was ghastly.
Her counseling, she recalls, was limited to instructions to pay in advance, in cash, and to go to the emergency room if she had a problem. During the procedure itself, her every question drew the same response: “Shut up!”
Determined that other women should have better reproductive care, she began work as an apprentice midwife and eventually finished college, earned a medical degree and started a practice in which she spends about 90 percent of her time on abortion services. Much of her work is in underserved regions on the Western plains, at clinics that she visits by plane.
In her forthcoming book “This Common Secret: My Journey as an Abortion Doctor” (Public Affairs), Dr. Wicklund describes her work, the circumstances that lead her patients to choose abortion, and the barriers — lack of money, lack of providers, violence in the home or protesters at clinics — that stand in their way.
But she said her main goal with the book was to encourage more open discussion of abortion and its prevalence.
“We don’t talk about it,” she said in a telephone interview. “People say, ‘Nobody I know has ever had an abortion,’ and that is just not true. Their sisters, their mothers have had abortions.”
Dr. Wicklund, 53, said that at current rates almost 40 percent of American women have an abortion during their child-bearing years, a figure supported by the Guttmacher Institute, which researches reproductive health policy. Abortion is one of the most common operations in the United States, she said, more common than tonsillectomy or removal of wisdom teeth. “Because it is such a secret,” she said, “we lose sight of how common it is.”
But Dr. Wicklund acknowledges that abortion is an issue fraught with dilemmas. In the book, she describes witnessing, as a medical student, the abortion of a 21-week fetus. She writes that at the sight of its tiny arm she decided she would perform abortions only in the first trimester of pregnancy. She says late-term abortions should be legal, but her decision means she occasionally sees desperate women she must refuse to help.
Dr. Wicklund describes her horror when she aborted the pregnancy of a woman who had been raped, only to discover, by examining the removed tissue, that the pregnancy was further along than she or the woman had thought — and that she had destroyed an embryo the woman and her husband had conceived together. And she describes the way she watches and listens as the women she treats tell why they want to end their pregnancies. If she detects uncertainty or thinks they may be responding to the wishes of anyone other than themselves, she says, she tells them to think it over a bit longer.
On the other hand, Dr. Wicklund has little use for requirements like 24-hour waiting periods, or for assertions like those of Justice Anthony M. Kennedy, who said in a recent Supreme Court decision on abortion that the government had an interest in protecting women from their own decisions in the matter.
“It’s so incredibly insulting,” Dr. Wicklund said in the interview. “The 24-hour waiting period implies that women don’t think about it on their own and have to have the government forcing it on them. To me a lot of the abortion restrictions are about control of women, about power, and it’s insulting.”
Dr. Wicklund said she would put more credence in opponents of abortion rights if they did more to help women prevent unwanted pregnancies. Instead, she said, many of the protesters she encounters “are against birth control, period.” That is unfortunate, she said, because her clinic experience confirms studies showing that emphasizing abstinence rather than contraception may cause girls to delay their first sexual experience for a few months, but “when they do have intercourse they are much less likely to protect themselves with birth control or a condom.”
According to the Guttmacher Institute, about a quarter of pregnancies in the United States end in abortion. Dr. Wicklund says that is why she believes far more people favor abortion rights than are willing to admit it in polls. For example, she said in the interview, an abortion ban that seemed to have wide support in South Dakota was put to a vote and “when people got behind those curtains and nobody was watching it was overwhelmingly defeated. Unfortunately, people are not willing to say what they really think.”
One of these people might be a woman she recognized as one of the protesters who regularly appeared, shouting, outside a clinic where she worked. Only now the woman was in the waiting room, desperate to end an unwanted pregnancy. Dr. Wicklund performed the procedure.
And then there is Dr. Wicklund’s maternal grandmother, a woman she was afraid would disapprove of her work. But it turned out that she had a story of her own. “When I was 16 years old, my best friend got pregnant,” is how the story began. Her friend turned to her and her sister for help. They did the only thing they could think of — putting “something long and sharp ‘up there,’ ” according to the book. The girl bled to death, and the cause of her death was kept secret.
“I know exactly what kind of work you do,” the grandmother told Dr. Wicklund, “and it is a good thing.” One question Dr. Wicklund hears “all the time,” she said, is how she can focus on abortion rather than on something more rewarding, like delivering babies.
“In fact, the women are so grateful,” Dr. Wicklund said in the interview. “Women are so grateful to know they can get through this safely, that they can still get pregnant again.
“It is one of the few areas of medicine where you are not working with a sick person, you are doing something for them that gives them back their life, their control,” she added. “It’s a very rewarding thing to be part of that.”
Rethinking What Caused the Last Mass Extinction
By JOHN NOBLE WILFORD, The New York Times, November 6, 2007
FREEHOLD, N.J. — Splashing through a shallow creek in suburban New Jersey, the paleontologists stepped back 65 million years to the time of the last mass extinction, the one notable for the demise of the dinosaurs.
The stream flows over sediment laid down toward the end of geology’s Cretaceous period. The clay at water level holds meaningful traces of iridium, the element more common in asteroids and other extraterrestrial objects than in the earth. No one could resist sticking a finger to the clay, treating it as a touchstone of their time travel.
Scientists associate the iridium anomaly with the asteroid impact or impacts thought to have set off the extinctions. The thin layer, which has been detected worldwide, is also considered the marker for the end of the Cretaceous and beginning of the Tertiary period, known as the K-T boundary.
At the time, sea levels were higher and New Jersey was warmer. The proto-Atlantic waters reached the center of the current boundaries of New Jersey, standing more than 60 feet deep here, where on a recent day the paleontologists were up to their ankles in a creek. They had their eyes on the sediments in the bank just above the iridium clay. They call this the Pinna layer.
On previous visits, they had found in the Pinna rock and soil a surprising number of marine fossils, including small clams, crabs and sea urchins. There was an abundance of ammonites, considered index organisms of the uppermost Cretaceous environment. Somehow, here at least, life appeared to have not only persisted but also flourished for tens, perhaps hundreds, of years after the putative asteroid impact.
“This is really putting New Jersey on the map of the K-T boundary,” said Neil H. Landman, an invertebrate paleontologist at the American Museum of Natural History who is directing the new research in the Manasquan River basin.
The discovery of thriving communities of survivors at the end of the Cretaceous is giving some scientists second thoughts about the extinction’s causes and effects. Some question the conventional explanation of a single large impact that enveloped Earth in a cloud of dust and almost instantaneously brought on a deadly global winter. They contend that this may be an oversimplification, and that the real story behind the dinosaur-ending disaster is more complicated and as yet unclear.
“It is undeniable that the iridium spike at the base of the Pinna layer was produced by the impact,” Dr. Landman said. “That’s amazing and makes it hard to explain the ammonite abundances we find above the iridium anomaly.”
Gerta Keller, a paleontologist and professor of geosciences at Princeton University, said the research by Dr. Landman’s group “shows the complexity of this extinction event and the difficulty explaining it by the currently popular impact theory.”
Dr. Keller, who had no part in the New Jersey discovery, has investigated the K-T boundary in Brazil, Mexico and Texas, finding evidence that she says indicates multiple asteroid impacts occurring at the end of the Cretaceous. She reported that the one that gouged out the Chicxulub crater at the tip of Mexico’s Yucatán Peninsula, which had been the prime suspect in the extinction, struck at least 300,000 years before the dinosaurs died out.
At a meeting of the Geological Society of America last week, Dr. Keller reported marine fossil evidence that she said linked the mass extinction to widespread volcanic eruptions that swept India at the end of the Cretaceous.
In other words, the world’s ecosystem was under widespread stress for an extended time. The extinctions might have had multiple causes, not the single asteroid impact and almost instant death as hypothesized in 1980 after the detection of the global iridium layer.
At first, the paleontologists treated the fossil discoveries in New Jersey with caution. Geologists who analyzed 37 samples of sediment from three sites at the creek and elsewhere in the basin concluded that they contained a telling concentration of iridium at the Pinna base. Still, Dr. Landman thought it possible that the iridium had shifted over time, confusing the chronology.
Dr. Landman said he had since become increasingly confident that the iridium layer at the creek remained where it was deposited. It is presumably a true marker of an asteroid impact with global repercussions, and this further complicates understanding of the mass extinction. Why is there no evidence at the creek for the almost immediate post-impact destruction, as assumed by the standard theory?
A construction project led scientists to the discovery. Excavations for a new bridge three years ago exposed a section of rock spanning the K-T boundary. In a report this year, Dr. Landman’s group wrote that the section contained “the most abundant and diverse invertebrate assemblage ever discovered from this interval in New Jersey.”
The first investigations, beginning with Ralph O. Johnson, a mostly self-educated but expert paleontologist who lives in West Long Branch, uncovered traces of the fossil-rich stratum reaching to the undisturbed outcrops along this creek. The stream has no name on maps, but the scientists, thinking of the prickling briars and entangling wild grape vines, call it Agony Creek.
“You don’t have to go to Mongolia to discover important fossils,” Mr. Johnson said. “These outcrops sit in the middle of the suburbs, two and a half miles from my home. How could they have been missed until now?”
Wading downstream, Dr. Landman, Mr. Johnson and Matthew P. Garb, a doctoral student in geology at Brooklyn College, came to a place that looked good for prospecting. Wet and dirty, they got to work — grown men squatting at the edge of a creek, making mud pies, or so it appeared.
In fact, they were cutting out wedges of the Pinna layer and, wielding picks, knives and brushes, were extracting and examining the remains of presumed survivors in the aftermath of the K-T mass extinction.
At least 110 species of near-shore marine organisms have been identified in the Pinna layer, Dr. Landman explained. This was a robust community that lived over a geologically short period of time, perhaps several tens of years. But the Pinna is truncated at the top, which the scientists said implied a still longer duration amounting to hundreds of years.
Later, back at his museum laboratory in Manhattan, Dr. Landman pulled out trays of ammonites, his scientific specialty. These organisms first appeared in the Devonian period, about 410 million years ago; there were 30 known species at the end of the Cretaceous, and after the extinctions, there were none. Their near-relative the nautilus survives, perhaps because it is a scavenger that will eat just about anything.
The trays held a collection of the creek specimens. Ten ammonite species were recovered from the presumably post-impact Pinna layer. One of them, Discoscaphites jerseyensis, is unique to New Jersey.
After the event producing the iridium residue, and the occurrence of any accompanying disasters, Dr. Landman said, the extinctions were not immediate everywhere, certainly not among marine organisms off New Jersey.
“This is what I imagine happening,” he said. “Storms of biblical proportions and a heavy discharge of river floods might have buried sediments rapidly. These marine communities may have flourished immediately afterward as a result of a lot of organic material, such as plankton, dying and settling to the depths for their consumption.”
A few other paleontologists have also cast doubt on the timing and single-impact suddenness of the mass extinction. The idea of a killer impact that became the standard theory was proposed in 1980 on the basis of iridium traces; it gained wide acceptance after the discovery in 1991 of the impact crater in Mexico. But in some places, the fossil record for dinosaurs seems to disappear a little before the iridium is deposited. Geologists have found several other crater remnants that could have been gouged out by asteroids and also the suspect volcanoes of India.
Dr. Landman said he was not sure how long the ammonites in New Jersey lived above the iridium marker, but they “could not possibly have survived 300,000 years,” as Dr. Heller of Princeton argues.
At the creek site, above the fossils of the Pinna layer, the Hornerstown Formation preserves a record of impoverished life, beginning a few hundred years after the extinction event or events. There were tiny oyster shells from a single species, and little else.
Shining Light on Diseases Often in the Shadows
By DONALD G. McNEIL Jr., The New York Times, November 6, 2007
When is a neglected disease no longer “neglected”?
A new online medical journal devoted to neglected tropical diseases was founded last week, and the first task its editors faced was choosing which ailments to snub.
By and large, germs were out, worms were in, and fungi and skin parasites had a shot.
For starters, the editors decided, AIDS, malaria and tuberculosis — which now have billion-dollar funds dedicated to fighting them — definitely received too much attention to qualify.
“If we opened it up to malaria, it would become a malaria journal,” said Dr. Peter J. Hotez, a worm disease specialist at George Washington University’s medical school and editor of the new journal, PLoS Neglected Tropical Diseases. “We want the most common diseases of the poor. Of the 2.7 billion people in the world who live on less than $2 a day, about half have one — or more — of these.”
Such diseases get less attention because they rarely kill.
“You hear a speech from someone in malaria, and they always say ‘In the time I’ve been talking, 200 kids have died of malaria’ — well, we don’t have that,” Dr. Hotez said.
But worms can leave a child anemic, urinating blood and too weak to walk to school. They can also blind adults or grotesquely swell legs or scrotums, leaving farmers doomed to starve and entire villages unable to climb out of poverty.
The first issue includes a report by Doctors Without Borders on a surge in visceral leishmaniasis in war-torn Somalia. (Among the troops in Iraq, leishmaniasis is known as “the Baghdad boil,” a weeping sore left by a sandfly bite. In the more dangerous visceral kind, the sores appear on internal organs.)
Another report describes how the spread of elephantiasis — the swollen leg and scrotum disease — can be stopped by drugs costing as little as 6 cents per year.
A third unriddles a perplexing leptospirosis outbreak in Thailand. It was caused by a bacterial clone hiding in the urine of a bandicoot rat.
The new journal — www.plosntds.org/home.action — is part of the Public Library of Science series and is being started with a $1 million grant from the Bill and Melinda Gates Foundation. Access is free, anyone can use the data, and ads from companies making drugs and medical devices are not accepted. The library is a challenge to the major medical journals, which charge hefty fees and usually sell ads to the same companies whose products they investigate, although they try to reveal any conflicts of interest that researchers have.
Instead, the journal on neglected diseases charges authors a $2,100 fee to publish. But the fee can be waived, no questions asked, for any researcher whose grants are too small to cover it, said Dr. Gavin Yamey, a senior PLoS editor overseeing the debut of the journal.
Scientist at Work | John Holcomb: Army’s Aggressive Surgeon Is Too Aggressive for Some
By ALEX BERENSON, The New York Times, November 6, 2007
SAN ANTONIO — Since the war in Iraq began, Col. John Holcomb has been working to change the way the military takes care of its wounded.
Along the way he has suffered a few dings himself.
A tall medical doctor with a Southern lilt and close-cropped gray hair, Colonel Holcomb, 48, has spent his entire 27-year career in the Army, earning a reputation as one of the military’s top trauma surgeons. Since 2001, he has headed the Army’s Institute of Surgical Research, based on the campus of the Brooke Army Medical Center here.
Under his watch, Army surgeons have become aggressive users of a controversial drug called Factor VII, which promotes clotting in cases of severe bleeding. He has also guided a redesign of the transport system for wounded soldiers, encouraging helicopter pilots to take the severely injured to the hospitals best able to treat them, even if they are not the closest.
Colonel Holcomb also strongly advocates conducting clinical trials to improve trauma care. It is an ethically tricky area, because trauma research can involve trying novel treatments on severely injured patients who cannot give informed consent. But he argues that any ethical problems pale in comparison to the toll that traumatic injuries take on civilians and soldiers every day.
He is fond of quoting a surprising statistic: trauma is the third-leading cause of death in the United States, taking 160,000 lives in 2004, more than any other cause except heart disease and cancer. Because it primarily affects the young, trauma leads all diseases in terms of life-years lost.
And besides the 4,000 American deaths in Iraq and Afghanistan, there have been 29,000 injuries from hostile fire, including 9,000 severe enough to require transport to hospitals outside the war zones.
In the face of that toll, Colonel Holcomb said, doctors must run clinical trials to ensure that patients are receiving the best treatments. Without those trials, even basic questions — which patients should be put on breathing tubes, for example — remain unanswered.
In an interview in his office at Brooke, Colonel Holcomb said he was determined to generate data that would help military and civilian surgeons answer those questions.
“We run a research institute,” he said. “Everything we do, we try to drive on data.”
Colonel Holcomb’s backers, who include surgeons both in and out of the military, say he is an exceptionally hard-working physician whose single-minded focus on wounded soldiers has led to improvements in the way the military treats its injured.
“John Holcomb is making a huge contribution to the advancement of trauma care in this country,” said Dr. Brent Eastman, the chairman of trauma for Scripps Health in San Diego and a regent of the American College of Surgeons.
But Colonel Holcomb is not without critics, who say his efforts, however well intended, may be doing more harm than good.
Dr. Andrew F. Schorr, a former military physician who is associate director of critical care medicine at Washington Hospital Center in Washington, said he believed that Colonel Holcomb had pushed military surgeons to use Factor VII despite a lack of data on its benefits — and some evidence that it can increase the risk of blood clots that cause strokes. Factor VII is a naturally occurring protein that helps the blood clot; an artificial version is produced by the Danish company Novo Nordisk under the name NovoSeven.
“I certainly disagree with his approach to Factor VII,” Dr. Schorr said.
Colonel Holcomb has also been criticized for his advocacy of an experimental blood substitute called PolyHeme, which recently failed a clinical trial in trauma patients. The trial, which ran from late 2003 until last year, was conducted on people who were severely injured and could not give consent to the experiment.
The trial followed an earlier failed test of PolyHeme in patients undergoing surgery for aneurysms. In the earlier trial, 54 percent of people who took it went on to suffer serious adverse events, compared with 28 percent who did not.
But the Brooke Army Medical Center and Colonel Holcomb did not disclose the results of the earlier trial to the public when they agreed to participate in the new trial. “Up to now, PolyHeme has not caused any clinically bad problems,” researchers for Brooke wrote in materials prepared for a public meeting, according to a 2006 article in The Wall Street Journal.
“He knew about this data, and he should never have approved the trial for his center and allowed the Army to participate in it,” said Keith Berman, a medical products consultant who specializes in research on blood substitutes. “Many, many centers declined to participate in this trial.”
Colonel Holcomb does not apologize for his advocacy of PolyHeme or Factor VII. Hemoglobin substitutes like PolyHeme, which enable the body to transport oxygen to its cells even after massive blood loss — could save lives, he said. And trials based on consultation with a public entity like a hospital review board, rather than individual informed consent, are necessary to improve the care of trauma patients.
In addition, the Food and Drug Administration approved the PolyHeme trial even though it saw the unreleased data from the earlier test, and many other medical centers participated in it, he said, adding, “We’re not irresponsible people going out and doing evil experiments on small groups of patients.”
As for Factor VII, Colonel Holcomb said he understood the concerns of the Army’s critics and agreed there was no strong evidence that the drug decreases mortality or other complications in trauma patients.
The F.D.A. has approved the drug to stanch bleeding only in hemophiliacs and people with a congenital deficiency of Factor VII, not in those whose blood is otherwise normal. And the label warns that the drug should be used “only under the supervision of a physician experienced in the treatment of bleeding disorders.”
But a 300-patient clinical trial showed that Factor VII reduced the need for transfusions in patients and showed a trend toward reducing mortality in patients who received it, though the difference was not statistically significant. A larger trial to confirm those findings is under way, but the results will not be available for several years.
With soldiers severely injured every day in Iraq, Colonel Holcomb said, the military cannot afford to wait for a definitive answer.
“You have a drug that you know is safe from the prospective randomized controlled clinical trials,” Colonel Holcomb said. “And you have to make a decision. It’s not something you can decide to talk about. It’s really yes or no. You have a lot of people bleeding to death in Iraq.”
Other trauma surgeons support that attitude.
Dr. John R. Hess, a professor of pathology and medicine at the University of Maryland and a physician at its Shock Trauma Center in Baltimore, said the Army was right to use Factor VII aggressively. Severe bleeding, he noted, quickly exhausts the natural resources of Factor VII.
In trauma patients, “hemorrhage is the second-leading cause of death,” behind only brain injuries. “But you can do something about it.”
Civilian hematologists rarely see injuries as severe as those the Army faces, Dr. Hess said, so they may not understand the need for the drug. He added that Colonel Holcomb, whom he has known for two decades, would never encourage the use of Factor VII if he thought it was endangering soldiers.
“He feels deeply concerned about the soldiers, he goes over there, he takes care of them,” Dr. Hess said. “If you were hurt, he’s the guy you’d want taking care of you.”
Colonel Holcomb has spent several months in Iraq since the war began. In addition to working as a surgeon, he has helped redesign the system that transports wounded soldiers to hospitals.
In previous conflicts, the wounded were evacuated to nearby forward operating stations, even if their injuries were so severe that doctors at those stations might not have been able to help them.
Now, helicopter pilots coordinate care more closely with the half-dozen large hospitals throughout Iraq, making sure that a soldier with head trauma, for example, is taken to a hospital that has a neurosurgeon available. The system is modeled on regional trauma systems in the United States, where patients with severe injuries go directly to regional trauma centers.
“Sometimes fast is slow and methodical is fast,” said Col. Stephen Flaherty, the chief of surgery at Landstuhl Regional Medical Center, an Army hospital in Germany that treats wounded soldiers from Iraq and Afghanistan. “And if you do things fast and take them to the wrong location with the wrong resources, you may not wind up giving them the best care.”
But changing the system required the notoriously bureaucratic Army to make significant changes in the way medical helicopters were positioned, as well as increasing coordination between hospitals, forward surgical teams and front-line units.
Colonel Holcomb drove those changes, said Colonel Flaherty, who added that the Army was willing to make them because both senior and junior officers trusted Colonel Holcomb to offer recommendations driven by hard data rather than untested assumptions.
“He does a great job of listening to us, getting multiple voices and multiple recommendations, and following the data,” he said.
Colonel Holcomb said his visits to Iraq had been invaluable in helping him understand how to change the system. “To understand the problem, you need to get yourself on the ground, talk to the guys,” he said.
At the same time, Colonel Holcomb has pressed the Army to develop a database to track the care of all wounded soldiers from the time of their initial injury to their discharge. The system, called the Joint Theater Trauma Registry, is designed to improve care by identifying the best practices and the problems in military hospitals. The registry may also help the military standardize soldiers’ care even as new nurses and doctors are rotated into the war zone.
Meanwhile, the war is never far from Brooke Army Medical Center, where young men and women with prostheses are a common sight. The hospital specializes in treating soldiers with severe burns and has a large, free-standing rehabilitation center for amputees called the Center for the Intrepid.
Since the war began, Brooke’s burn center has treated several hundred severely injured soldiers, while Colonel Holcomb has pressed it to find and test new treatments, like different dressings and continuous dialysis for patients with kidney failure, said Dr. Steven E. Wolf, a civilian who directs the burn unit. He quoted Colonel Holcomb’s philosophy:
“Why answer a question with another question? Just do the experiment.”
