A conversation with Mary Ellen Avery, MD
Mary Ellen Avery, MD, is best known for her discovery, in 1959, that respiratory distress syndrome in premature newborns is caused by a lack of surfactant, the foamy coating that helps lungs expand. Her work has saved countless babies' lives and earned her a National Medal of Science in 1991. As Children's Hospital Boston's physician-in-chief from 1974 to 1985, she established the Joint Program in Neonatology with Beth Israel and Peter Bent Brigham Hospitals. Previously, Avery was pediatrician-in-charge of Newborn Nurseries at Johns Hopkins and physician-in-chief at Montreal Children's Hospital. She was the 2003 president of the American Association for the Advancement of Science, the first pediatrician in that post, and its 2004 board chairman. Avery's many scientific publications include several classic textbooks in pediatric and newborn medicine.
Avery spoke with Children's News on the occasion of receiving two important honors—the John Howland Medal, which is the American Pediatric Society's highest award, and an honorary doctor of science degree from Harvard University.
How did the surfactant discovery come about?
I was a fellow at the Harvard School of Public Health, and was asked to find out more about the foam that formed in the lungs of people with pulmonary edema—they literally foam at the mouth. At night, I worked in the delivery room at the Boston Lying-In Hospital where I could see the babies take their first breaths. There were many premature babies with hyaline membrane disease, now called respiratory distress syndrome, who were struggling to breathe.
I had access to lungs from babies who had died, and I found there was something wrong with their capacity for gas exchange. The babies couldn't keep the air spaces in their lungs open—they closed when the babies exhaled. The material that was important—the foam—was missing, and they were struggling to re-inflate their lungs. Nature put this foam, or surfactant, in the lung to lower surface tension. You cannot keep air spaces inflated without it; the lung becomes airless. In the autopsies, surfactant was present in all the babies that survived and in none of those that died.
Your discovery came out in 1959,
yet surfactant replacement wasn't licensed for babies until 1991. Why?
The early response was ho-hum. Everybody had their own theory about hyaline membrane disease. Some thought the pulmonary circulation must be critical. It changed the scenery to think about surface tension. People couldn't see why it mattered. I heard things like, "Mel's playing with soap bubbles again." Then, it took a lot of time to do the experiments, ascertain the chemical composition of surfactant and show what molecular changes take place. People were also asking what cells in the lung make the surfactant.
In the 1970s, I presented my work to the most famous pulmonary group in the country, headed by Julius Comroe at the University of California in San Francisco. Comroe said, "This is exciting," and his team switched immediately to studying surfactant. That was an important step.
How did your finding get translated to clinical practice?
Part of the fallout of my visit to San Francisco was that a pediatrician from Japan, Tetsuro Fujiwara, spent years reproducing everything we'd done and adding to it. He demonstrated that he could instill artificial surfactant in a living baby, and within minutes, the baby would be able to breathe.
He said to me, "How can I explain this to the world? I'm an unknown Japanese researcher." And I said, "I've been through something similar." He paid my way, and I visited his lab at the Akita University School of Medicine, with great ceremony, and he showed me his notebooks and his X-ray films. In one film, the tube that delivered surfactant was in one bronchus of the lung but not the other. And you could see that the first lung was normal, while the other had no air. That was the absolutely definitive experiment. It was published in The Lancet in 1980.
What was your agenda as physician-in-chief at Children's?
I was keen to keep excellence up front. The strength of this place was marvelously talented interns and residents. I learned the importance of recruiting good people with the things one likes in a doctor—sensitivity to mothers and babies and being a good citizen.
A major focus was the Joint Program in Neonatology. Neonatal medicine was Children's weakness at the time. Because of my research, I could get funding for my training grants and was blessed with a number of talented people who wanted to learn more about the lung. My trainees have all left to do great things—there are at least 60 department heads or chiefs among them in the U.S. alone.
Tell me about your international work.
James Grant, UNICEF director from 1980 to 1995, wanted to get developing countries to adopt polio vaccination and oral rehydration therapy for diarrhea. He would have to sell the program to the head of each country, and he needed a physician to add credibility to his message.
I went with Jim to Cuba at a time when a diplomatic passport was required. At Cuba's institute of health, they wanted to make their own surfactant, because it was expensive to purchase. So I gave them the recipe. I got a note the following Christmas: "By the way, our neonatal mortality is lower than yours." When a dictator wants something done, it gets done!
I've also been to many countries as an invited speaker and visiting professor. It wouldn't have happened if I hadn't been physician-in-chief of this hospital.
Has being a woman been a help, an obstacle or a neutral force in your career?
All of the above. Sometimes it's opened doors, other time it's been a hindrance. At Hopkins, I was not appointed chief resident. There were those who thought women were incapable of leading a group. And it was hard for some at Children's to have a woman as chief. But I did get into medical school, I did get promoted, I've traveled the world and I'm now trying to figure out what to do with the rest of my life. I have more choices now than I can handle.
