Good surgeons know that they have better outcomes if their patients are not too sick. Medical doctors think of surgery only when all other options have failed. A heart transplant surgeon wants to operate before the patient gets can’t live without it. Cardiologists, meanwhile, tend to hold on to their patients until they are at death’s door. Unfortunately, the sickest patients, the ones that need a transplant the most, tend to die even when we do operate, leaving the family asking why we didn't do something sooner. On the other end of the spectrum, somewhat paradoxically, the hypothetical best candidate for a transplant in terms of outcomes is a patient who is perfectly healthy. However, if the patient is not sick enough, he won’t feel any benefit from the procedure, leaving him justifiably asking if he needed it at all.

Soon after the French army sacked Naples in 1495, a never before seen venereal epidemic swept through the ranks. The illness presented as a painless genital ulcer that manifested a few day after sexual intercourse. It quickly spread to the Italian population and within a few years had reached all of Europe and everywhere in the world that Europeans travelled. As the world would soon learn, the disease, known now as syphilis, progressed past its initial presentation and caused a wide range of debilitating and disfiguring sequelae. Initially, the disease was named by each population for the group it thought was responsible for the epidemic. In far away Tahiti, it was called “the British disease”. The British, agreeing with the Italians, called it “the French disease”. The French called it “the Spanish disease”. The spaniard were through to have brought it with them when returning with Columbus from the New World. There, the Aztec deity Nanahuatzin (“the little pustule covered one”) was depicted bearing characteristically syphilitic deformities. The deity is patient zero in the long chain of attribution of blame for the disease.

When confronted with a poor patient prognosis in an ICU, it is not uncommon for an intensivist to blame the surgeon for a botched operation. The surgeon, for his part, can blame the medical specialist who failed to refer the patient soon enough. The specialist points to the GP for not understanding the disease who points to the patient for not coming in until it was too late. Like Nanahuatzin, the patient finds himself at the beginning of a long chain where ultimately he is to blame.

New evidence suggests that some strains of the bacteria responsible for syphilis were present in Europe even before the Columbian Exchange. Perhaps Europe had syphilis all along. Perhaps the doctors werepowerless to help their patients all along, too.

The limit of our mechanistic thinking is that we never find ourselves at time zero. We observe the consequences of our interventions on a system whose various pathologies may have been developing long before we came on the scene. If we fail to remember this simple fact, we are biased into thinking that all of our observations are direct effects of our actions. Instead, we should remember that we are stepping into an ever moving stream whose source we cannot see. Likewise, we are unlikely to ever see its full downstream course. The best we can hope for is to look far enough up- and down-river to accurately place ourselves in the rush and to understand the transience of our presence and interventions.