Physician and historian David S. Jones offers a finely tuned balance of medical details and pathophysiology in order to tell a history of advanced cardiac care in the United States. Many of the technologies he examines in Broken Hearts — angiograms, bypass surgery, stents, and statins — seem to be almost ubiquitous in the contemporary West. As a result, their shaky rise to prominence and persistent ambiguities about their efficacy and effects seem somewhat astonishing. How could therapies that are so common and seemingly effective have such disorderly histories that, to a surprising degree, have not yet been fully resolved? This is one of the overarching questions that Jones seeks to answer.
The treatment of heart disease serves as the pivot for this book; the first half examines the reciprocal relationships between what physicians thought about the causes of heart disease and how it should be treated, while the second half concerns itself with how physicians understand and study a treatment's safety and side effects. Part I lays out a central, stubborn mystery: what causes heart attacks? To those of us who have been drawn pictures of clogged arteries by our physicians, or seen media coverage of the parade of US presidents who have had cardiac procedures (for others, a quick internet search for images of ‘heart disease’ should suffice), it will come as a surprise that until quite recently, there was no clear scientific consensus on the causes of heart attacks. Jones traces how until the 1980s, medical opinion was split: some thought they were caused by clots coating plaques in the coronary arteries cutting off blood and oxygen to the heart, or by the spontaneous bursting of capillaries carrying blood to growing plaques. Others believed that abscesses in the coronary arteries ruptured (‘plaque rupture’) to release toxins that triggered clotting then occlusion, or that spontaneous spasms in the coronary arteries led to attacks. Jones touches on the pivotal importance during these decades of debate of research tools and materials — electrocardiograms, angiography, electron microscopy, laboratory animal experiments, the bodies of humans who ostensibly died from heart attacks (on which researchers could perform autopsies), and human labour — in redirecting, coloring, and prolonging this causal debate.
But as Jones details, the 1980s through the 2000s eventually brought consensus, not because medical research alone was able to settle the question, but because physicians decided to try ‘learning by doing.’ In the absence of certainty about the causes of heart attacks, cardiologists decided nonetheless to proceed with treatments like bypass surgery, clot-busting drugs, statins, and most notably, angiography (the use of injected dye and special x-rays to visualise blood flow through the coronary arteries). In the process, they found that much of the therapeutic evidence weighed in favour of the plaque rupture hypothesis, as did also the intuitive appeal of the hypothesis itself, and the institutional prestige of its proponents. But ‘therapeutic feedback’ raises, as Jones points out, questions about the rigour and credibility of therapeutic evidence: It was only after physicians had drugs such as statins and platelet inhibitors that proved both effective and highly profitable that the plaque rupture hypothesis also became widely accepted.
In Part II, Jones turns to the question of why it is easier for physicians to generate knowledge about the efficacy of treatment than about its risks, using historical concerns about the safety of cardiac surgery and cerebral side effects as a case study. By the 1960s, surgical mortality rates fell below 5%, ushering in a decades-long boom of cardiac surgery. All the while medicine selectively disregarded cerebral complications. Jones attributes this to the demands on the time and attention of clinicians, and to their decisions regarding the relevance of the heart over the brain. That is, surgeons were simply too busy participating in the cardiac surgical boom to conduct sufficient research on its complications. For neurologists and psychiatrists who in theory were disciplinarily equipped to study the effects of surgery on the brain were not rewarded in terms of academic prestige for conducting such research. Even as the 1990s brought renewed awareness of the problem of cognitive complications, multiple arguments were used to minimise it, including constructions of the continuing uncertainty about the incidence and severity of complications; the resilience of the brain; the transience of most cognitive deficits; and the known benefits of surgery outweighing the uncertain risks. As Jones' last chapter of Part II details, these questions of the nature, magnitude, and incidence of cognitive complications, how they could be mitigated, and who is responsible for the marked asymmetry in knowledge and communication about cardiac surgery's benefits and risks continue to dog us to this day. Larger questions of accountability and responsibility for the problem of cerebral complications — who should study them, fund research on them, and otherwise work to mitigate them — remain.
As the concluding chapter points out, these questions have taken on even greater significance in an era of evidence-based medicine and persistent demands for rationality in health care. Yet, as Jones adroitly argues, the global maldistribution of advanced cardiac care is acutely at odds with the global distribution of heart disease, which kills more people than HIV, malaria, and tuberculosis combined. Jones juxtaposes these epidemiologic facts against concerns about unwarranted variations in treatment to ask how we might craft a morally tenable stance regarding global access to cardiac interventions. These are consequential biopolitics indeed; thus a history that incorporates the politics of and power relations in contestations over efficacy, safety, rationality, and knowledge could have enriched the analysis as much as Jones' careful attention to the social and technical conditions and cultural values in cardiac care already does.
Wide-ranging, full of interesting and telling historical details, steadily paced yet thorough in its making sense of complex medicine, Broken Hearts exposes cardiac care as neither mundane nor settled. As another case study in the social construction of medical facts and technological certainty, it invites further dialogue about how we can interrogate, question, and challenge if need be, seemingly foregone and naturalised ‘facts’ about medicine's efficacy, safety, and distribution.