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By Jim Barrett
Many Americans had enough money to buy their first house. Cancer killed famous people. Actor Humphrey Bogart died at 57. Nobel laureate atomic physicist Enrico Fermi died at 53.
The nation enjoyed unparalleled prosperity in the '50s, a decade that opened a brief, shining period of Camelot as it was envisioned in the '60s by the young new president John F. Kennedy. In the ensuing half century, science and medicine have produced breakthroughs that are now taken for granted -- antibiotics, organ transplants, polio vaccines.
Advances are so numerous that historians can't help but wonder: What would the '50s have been like if we knew then what we know today?
President Kennedy's second son, Patrick Bouvier Kennedy, probably would have lived, for example. Born prematurely, baby Patrick died two days after his birth in 1963.
Drug trials at the Health Science Center and other institutions in the '80s tested a synthesized "replacement" surfactant, which proved to prevent the lungs of premature babies from collapsing.
"If Patrick Kennedy were born today, most people would consider his complications very routine, almost unremarkable," said Marilyn Escobedo, MD, professor of pediatrics and head of neonatology.
Patrick's death underscored a national tragedy: Half of the underweight babies born in the '50s and '60s died. Today, 90 percent survive.
"When Patrick Kennedy was born, all the medical expertise in the country was called upon to save the child of the president of the United States," Dr. Escobedo said. "Today, a child doesn't have to be the son or daughter of the president to receive the best neonatal care. Every baby in America, even those living in the most impoverished counties in South Texas, has access to modern intensive care."
The drug is a credit to microbiologists, physiologists and pathologists who were the first to define the substance, which occurs naturally in the body but is deficient in premature babies. Testing with laboratory animals yielded encouraging results. Trials with humans established synthesized surfactant's efficacy, and it was approved for use in 1990.
Emergency medicine
The automobile became the emblem of the '50s, and most everyone could afford one. Ragtops. Dynaflow transmissions. Rakish fins. Our cars set us free.
Then teen idol James Dean died in a chilling highway accident in 1955. His acting career just blooming, Dean was only 24. His mangled racing Porsche became the symbol of a scandal on the nation's roadways. Too many people were dying. Detroit began to make safer cars. Engineers devised safer highways. And the field of emergency medicine took shape.
In 1974, San Antonio founded one of the nation's first paramedic EMS systems with the help of physicians from the Health Science Center. The team literally wrote the book on emergency medical technology (EMT). Called Emergency Care and Treatment of the Sick and Injured, it was the first and only EMT textbook until the '90s. The Health Science Center's EMT program became Texas' first to be accredited by the American Medical Association. More than 1,600 people have completed the paramedic training.
Highway travel is much safer today. James Dean was among 25,000 people who died on the roadways in 1955. Back then, the traffic death rate was 2.7 deaths per 100 million passenger miles. Last year it was 1.7 deaths, the lowest on record.
A key factor in safer highway travel is the emergence of emergency medical services, the 911 era.
"My paramedics know more today, technically, than the doctors did in the '50s," said Donald J. Gordon, MD, PhD, medical director of Bexar County Emergency Medical Services and chairman of the Health Science Center's emergency medical technology department.
"Back then, ambulance attendants had only as much training as their ambulance company felt they needed. The training might have been eight hours of Boy Scout or Red Cross first aid," Dr. Gordon said.
In San Antonio, and now in many U.S. cities, the mobile intensive care unit, or MICU, has replaced the ambulance. MICUs are equipped to monitor heart rhythms and oxygen levels, provide automated ventilation, determine blood sugar levels and even provide computer transmitted patient case information. Paramedics can start IVs, administer drugs to prevent cardiac disrhythmia and immobilize the body to prevent further patient injury in transit.
Open-heart surgery
Heart ailments took a tremendous toll in the '50s. Silver-screen icon Clark Gable died at age 59. There were others. Jazz musician Charlie Parker, singer Billie Holiday, and actor Ward Bond.
"The patient who may have required open-heart surgery in the '50s had no access to it and simply died," said surgeon Carlos Pestana, MD, PhD, associate dean for academic affairs in the Medical School.
Dr. Pestana completed his training amid the excitement and glamour of the early years of open-heart surgery. A resident at the Mayo Clinic in the early '60s, Dr. Pestana said the procedure captured nearly every doctor's attention.
"We did the operations in a big amphitheater with a gallery of visitors from all over the world," he said.
Open-heart surgery and heart, lung and kidney transplants soon became common. Health Science Center surgeons, led by J. Bradley Aust, MD, PhD, chairman of surgery, performed their first transplant, a kidney, in 1970, two years after the university opened. Since then, they have performed 430 transplants involving the heart, lungs, liver and kidneys.
An innovative new generation of transplant surgeons on the Health Science Center faculty now is pushing back other frontiers. Examples:
Tuberculosis was the great pretender of the '50s. We almost beat it with antibiotics and a public health campaign that identified and treated TB carriers. In our enthusiasm, we mistakenly claimed victory.
The statistics looked good. The number of cases had been falling for 40 years. So had the number of infections. In 1900, about 85 percent of Americans tested positive for TB exposure. By 1960, the rate had fallen to 5 percent. Today it is less than 0.5 percent.
But no one seemed to notice that TB remained the No. 1 killer among the nation's infectious diseases. Even small reminders seemed to be overlooked, such as the death of Vivien Leigh, Gable's co-star in "Gone with the Wind," in 1967. She died from complications of TB.
Until 1985, the number of cases kept declining. Alfonso H. Holguin, MD, assistant dean of the School of Public Health, who headed the TB division of the U.S. Public Health Service from 1965 to 1969, remembers the situation well.
"This continuing decline gave us a good feeling," Dr. Holguin said. "Gosh, we had tuberculosis on the run!"
Starting in the '60s, policy decisionmakers shifted money to other public health threats that seemed more menacing. Dr. Holguin said the nation's system to identify and treat TB carriers deteriorated.
"Things will look pretty good if the number of cases seems to be declining, but is it reality you see or the failure of your own surveillance system?" he said.
TB cases in the nation rose 12 percent between 1987 and 1993. Last year, there were 25,300 known cases. In San Antonio, cases are up 30 percent since 1984. TB has spread fastest at the gateways for immigrants -- California, New York, and Texas.
"People are becoming alarmed. We are finding pockets of TB in some major cities such as Dallas and Houston and along the Mexican border," said Bess Stewart, PhD, of the Texas Statewide Tuberculosis Coalition, formed earlier this year under state auspices to draft a counteroffensive. She also is an associate professor and assistant dean in the School of Nursing. The coalition intends to press for a tougher campaign against TB.
Discovery of the antibiotic streptomycin in 1944 helped in the fight against TB. Doctors discovered that antibiotics stopped a patient from being contagious and killed the TB. "Prior to those drugs, all we had going against tuberculosis was bed rest and you could be hospitalized for as long as two years," said Malcolm C. Lancaster, MD, clinical professor of family practice. He completed his internship and residency at Fitzsimons Army Hospital in Denver, the Army's center for chest research and treatment, from 1956 to 1960.
Antibiotics
Success with antibiotics led to a new problem -- drug resistance. A growing number of patients have forms of TB that are immune to many antibiotics.
"There is no doubt that antibiotics represented a major advance in the '50s, but we are suffering now from the misuse of them," said Alexander M. M. Shepherd, MD, PhD, professor of pharmacology.
Patients have insisted that their physicians give them antibiotics, even when they were unnecessary, and the physicians themselves have overprescribed them, Dr. Shepherd said.
Humans receive a number of antibiotics in their diet, particularly in meat, poultry and dairy products, because the drugs are given to farm and ranch animals. Antibiotics also are available without prescription in Mexico, contributing to overuse on both sides of the border. Bacteria have built a resistance to many common antibiotics, leaving scientists to wonder about their next step.
With a limited number of new antibiotics on the horizon, Dr. Shepherd said, medicine will look to biotechnology for weapons against disease.
Cancer
The more we knew about cancer, the more frightened we became. We could identify cancer better, and so more deaths were attributed to it, especially among famous actors. There was Bogey and then Charles Laughton and Dick Powell. All this was probably sheer coincidence, but people began to wonder whether cancer was contagious.
"Even to this day," said one of the nation's leading oncologists, Daniel D. Von Hoff, MD, "people are still a little afraid that they can catch cancer."
Cancer actually describes abnormal cell growth that is fatal if untreated. Unlike in the '50s, today's victims have a good chance of surviving.
"Some people say that cancer is the most curable chronic disease, because, for example, you can't cure arthritis or diabetes," said Dr. Von Hoff, professor of medicine. "Overall, 51 percent of the 1 million people who are diagnosed with cancer every year are cured."
Dr. Von Hoff said cancer care has advanced dramatically since the '50s. He cited better surgery, radiation therapy, chemotherapy and supportive care.
In those days, cancer patients commonly underwent "commando surgery" that removed large parts of an affected organ. For example, a surgeon attacking breast cancer would remove a woman's breast and the underlying muscle and lymph tissue. Surgery alone seldom stopped the cancer's spread.
"We know now that if you have a tumor, even a small one, it is already shedding off tumor cells," said Dr. Von Hoff.
Oncologists discovered a more effective strategy. By the '70s, radiation therapy and chemotherapy became as important as surgery and the surgical procedures became more conservative. Faculty surgeons helped develop ways to minimize surgery, particularly the dreaded laryngectomy, removal of the larynx, Dr. Von Hoff said. And with breast cancer, surgeons aim to remove only the lump from the breast and use other therapies to "clean up" residual cancer cells.
Dr. Von Hoff has led a group of specialists from the Health Science Center and its affiliated institutions in San Antonio in a campaign to develop new anti- cancer medicines.
In the '80s, they helped test and produce three important and now widely used anti-cancer drugs: mitoxantrone for leukemia, breast cancer and lymphoma, a disease of the lymph glands; Taxotere for breast cancer; and taxol for ovarian and breast cancer.
Two other drugs are expected to receive approval in 1995 from the U.S. Food and Drug Administration: CPT-11 for colon, lung and cervical cancer; and gemcitabine, the first chemotherapeutic agent for pancreatic cancer.
San Antonio is unusual in that it is home to a consortium of cancer research and treatment partners. Dr. Von Hoff himself not only teaches at the Health Science Center, he is research director of the affiliated Cancer Therapy & Research Center, a non-profit outpatient treatment facility. He also has ties to other parts of the consortium, known as the San Antonio Cancer Institute. It is one of six in the nation funded by the National Cancer Institute to conduct initial human trials of new anti-cancer drugs. Several of the drug tests have been run with the Southwest Oncology Group, St. Luke's Lutheran Hospital, the Institute for Drug Development (where Dr. Von Hoff is director), Brooke Army Medical Center and Audie L. Murphy Memorial Veterans Hospital.
The group has developed drugs to counter the ill-effects of chemotherapy, such as nausea, hair loss and diminished appetite. Dr. Von Hoff said the goal is to remove the discomfort of treatment so oncologists can do their utmost to seek a cure. "Our philosophy is to treat the patient the way he or she wants to be treated," he said. "If they want a full-court press, that's our responsibility and we had better do it for them."
Strokes
Cigarette ads from the '50s featured celebrities smoking. Stylish at the time, they seem misplaced in the '90s. Models in the ads, such as Gable, Bogart and singer Nat "King" Cole, died from strokes, heart attacks, lung cancer and other conditions associated with smoking.
Rates for heart attack, hypertension, rheumatic heart disease and stroke have dropped dramatically in the past 40 years, according to the American Heart Association. For example, deaths from stroke, the third-largest cause of death in North America, are down sharply. In 1950, there were 89 stroke deaths per 100,000 Americans. By 1990, the rate had declined to 28 deaths.
Experts attribute the change to Americans kicking the cigarette habit, and to better awareness and treatment of vascular problems such as high blood pressure.
Faculty members at the Health Science Center played a key role. They have improved preventive methods, making important contributions in changing patient lifestyles and producing new therapies and surgical techniques to open blocked arteries, which cause strokes.
A Health Science Center professor, for example, has designed an expandable tubular device that opens the site of a blockage. The Palmaz-Schatz stent, designed by radiologist Julio C. Palmaz, MD, was the first such device approved by the U.S. Food and Drug Administration for use in cardiac vessels. Approval came in August.
Faculty members Robert G. Hart, MD, and David G. Sherman, MD, have led several landmark national studies on how to prevent strokes. They have personally enrolled and treated hundreds of patients in San Antonio clinical trials, and have supervised drug and other trials across the nation.
One of their studies yielded a regimen of preventive steps for patients with atrial fibrillation, an irregular heart rhythm. They believe the measures will prevent 30,000 strokes a year.
More than 2 million people in the United States have atrial fibrillation and most of them are over 75. "With our expanding senior population," Dr. Sherman said, "it is extremely important to define how best to prevent strokes in these individuals."
Minority health
"People under 30 may not remember that many blacks, Hispanics and other minorities, including women, living in this country in the 1950s and earlier had difficulty getting health care at all in some cases, let alone top quality care," said Leonard E. Lawrence, MD, associate dean for student affairs in the Medical and Dental schools and past president of the National Medical Association. "And the health status of these population groups was often not even known."
Today, as many of those minorities increase in numbers, the federal government has recognized the need for special focus on their health. For example, the National Institutes of Health has created special offices focusing on minority and women's health. New demographic data from researchers, including those at the university's South Texas Health Research Center, are revealing discrepancies and ethnic differences that can be addressed.
The center is applying comparison data from other parts of the country for Hispanic subgroups including those of Cuban, Mexican and Puerto Rican descent.
"Two issues that have been priorities of ours are now emerging as national priorities -- bridging the academic health centers with the community, and increasing awareness about Hispanic health issues," said the center's director, Amelie Ramirez, DrPH.
What's ahead
The future? Genetics appears to be the medical frontier for the double-aught decade of the 21st century. Gene makeup seems to predispose individuals to illness and disease. Someday, a person may receive an outline of his or her particular health risks much like an investor receives a prospectus before putting money into a mutual stock fund.
Phenomenal, almost unbelievable developments since the '50s have made medicine a captive of its own success. The public becomes impatient if the pace of progress seems to lag. Americans wonder if research is worth the price.
None of the progress since the '50s has come easily nor has it come without expense. Research, which sowed the breakthroughs, is more highly organized and produces sharper conclusions than ever before. But those in the scientific and medical fields worry about a possible retreat from research, if only in the name of cost efficiency.
"Research is expensive and it's a calculated gamble, but research is necessary to keep making medical care more effective and less costly," said Dr. Halff, the transplant surgeon. "We still need to be willing to take a risk, and to be curious and adventuresome."
Andrea Corbett and Mike Lawrence contributed to this story.