IELTS Academic Reading Practice Test 342

Virginia Apgar was born in Westfield, New Jersey, in 1909 and studied zoology at Mount Holyoke College before entering the College of Physicians and Surgeons at Columbia University in New York. She qualified as a physician in 1933 intending to become a surgeon, but surgical posts were scarce during the Depression, and the head of surgery at Columbia, impressed by her ability, urged her to take up the new specialty of anaesthesia instead. She trained in it, and in 1938 returned to Columbia to lead its new division of anaesthesia.

Her attention soon turned to childbirth. Anaesthesia for women in labour was then given in a variety of ways, and little was known about how the drugs used reached the fetus or what they did to it. Much of Apgar's time in the operating theatre was spent on such cases, and she began to study the condition of newborn babies systematically, recording what she observed. In 1949 she became the first woman to hold a full professorship at Columbia's medical school.

The problem she faced was one of language as much as of medicine. A midwife or a junior doctor might describe a baby as blue or as limp, but such words meant different things to different people, and there was no way of comparing the babies delivered in one hospital with those delivered in another, or of judging whether a drug given to the mother had harmed her child. A well-known account holds that the idea of a score came over breakfast in the hospital cafeteria, when a medical student asked Apgar how she decided whether a newborn was well. She is said to have taken a piece of paper and asked him to list the signs he would look for.

The list that emerged contained five signs: the heart rate, the effort of breathing, the tone of the muscles, the response to stimulation such as a flick on the sole of the foot, and the colour of the skin. Each was given a value of nought, one or two, and the five values were added together to give a total between nought and ten. Her original scheme assessed the baby at one minute after birth, when its condition is most critical; a second assessment at five minutes became standard later. Each of the five signs can be assessed in seconds, so the whole score takes under a minute to complete. Apgar published the scheme in 1953 in a journal of anaesthesia; her surname was attached to it by others, and it soon became known as the Apgar score.

Reception was cautious. Some paediatricians doubted that a number could replace clinical judgement, or objected that a score of seven in one hospital would not mean the same as a score of seven in another. Nurses, by contrast, took to it readily, because it gave them a recognised way of recording what they observed and of calling a doctor when a baby's condition deteriorated. Its spread through maternity units in the United States was gradual, but by the early 1960s the score was being taught in medical schools in Europe and Australasia as well.

The score acquired a second life when someone noticed that the letters of Apgar's name could be arranged to stand for Appearance, Pulse, Grimace, Activity and Respiration. This mnemonic, invented some years after the score itself, is probably better known to medical students than the woman behind it, though it fits the five signs loosely: Grimace stands for the response to stimulation and Appearance for colour.

What the score measures, and what it does not, is often misunderstood. It records a baby's condition at a particular moment and how well the baby responds to any resuscitation that is needed; it was never designed as a forecast of a child's future. Professional bodies have repeatedly stressed that a low score does not in itself indicate that a baby has been deprived of oxygen, still less that the child will develop a disability such as cerebral palsy. A baby born prematurely, for example, may score low because of immaturity rather than because of anything that happened at birth.

Apgar's later career took her away from the delivery room. She left Columbia in the late 1950s, took a master's degree in public health at Johns Hopkins University, and joined a national foundation concerned with birth defects, where she became a senior figure and travelled widely to raise money. There she campaigned for the vaccination of children against rubella, a virus that can cause severe defects when a woman is infected in early pregnancy. Although the score had made her name familiar to generations of doctors, much of her energy in these years went into fundraising and public education. With the journalist Joan Beck she also wrote a book for parents about the health of babies and young children.

She died in New York in 1974. The score she devised has proved remarkably durable: it is still recorded in delivery rooms around the world, and the assessments at one and five minutes remain part of the routine record of a birth. It has been criticised, revised and defended, but no one has proposed a simpler alternative that works better. Its survival owes something to its simplicity, since it can be taught in minutes and applied without equipment, and something to its author's insistence that it was a tool for observing babies rather than a verdict on them.

For nine months the lungs of a fetus do not breathe. They are filled with liquid and are supplied with oxygen by the placenta, which passes it into the fetal blood. Yet the fetus is not entirely passive: from early in pregnancy it makes regular breathing movements, drawing the fluid in and out of the developing airways. These movements are thought to be essential to the growth of the lung tissue and to the development of the muscles that will later be needed for breathing. Babies born very prematurely, who have had little chance to practise, often struggle to breathe.

The fluid itself is produced by the lung. Cells lining the airways secrete chloride and with it water, so that the lungs gradually fill; the liquid also contains proteins and surfactant, the substance that will later keep the air sacs open. Because the lung is full of fluid, its tissue develops in a distended state, and the pressure of the fluid helps to shape the branching airways. Towards the end of pregnancy production slows and the composition of the fluid changes, as hormones released before labour begin to prepare the lung for air.

Some of that fluid is removed during labour. As a baby is squeezed through the birth canal, the chest is compressed and a quantity of liquid is pushed out through the nose and mouth. The amount is disputed, and much of what remains must be cleared in other ways. The walls of the airways absorb it into the blood and lymph vessels, a process that begins before birth and accelerates sharply once the baby is delivered. Any fluid left in the upper airways is usually coughed out or swallowed in the first minutes of life.

The first breath is an extraordinary effort. The newborn must open air sacs that have never contained air, overcoming both the resistance of fluid-filled airways and the surface tension of the film that lines them. Measurements suggest that the pressure required for that first breath is several times greater than the pressure needed for any later one, which is why a newborn's first cries are so vigorous. Once the sacs open they tend to close again with each exhalation until surfactant spreads across their inner surfaces and holds them open.

Surfactant is made by one of the specialised cells that line the air sacs, and its production matures late in pregnancy. A baby born before about 34 weeks may have too little of it, and the sacs then collapse with every breath; this is the essential problem in respiratory distress syndrome, the condition that once made premature birth so dangerous. From the late 1980s doctors were able to give premature babies replacement surfactant through a tube into the windpipe, and this treatment, with better ventilators and steroids given to the mother before delivery, transformed the survival of the smallest infants.

Breathing also reshapes the circulation. In the fetus most blood bypasses the lungs, which are collapsed and full of fluid, and passes instead through two openings, one between the upper chambers of the heart and one joining the pulmonary artery to the aorta. The first breaths cause the blood vessels of the lung to relax and widen, so that blood flow through the lungs rises steeply. The opening between the atria normally closes within minutes to days, while the ductus arteriosus usually shuts within the first day or two of life, though in some babies it takes longer or fails to close at all.

Labour appears to help. Babies delivered by caesarean section before labour has begun are more likely than others to develop transient tachypnoea of the newborn, in which breathing is abnormally fast because fluid lingers in the lungs; most recover within a few days. The hormones of labour, including adrenaline and cortisol, are thought to reduce the secretion of lung fluid and to speed its absorption, which is one reason why elective caesarean sections are usually delayed until 39 weeks unless there is a medical reason.

Much remains uncertain. How much fluid is expelled by squeezing and how much is absorbed, and how important each route is, are still debated. Researchers are also trying to explain why some babies born at term, and not only those delivered by caesarean section, retain fluid and breathe rapidly for a day or two. Surfactant has been studied for more than sixty years, yet the best way to deliver it to a very small baby is still being refined: newer methods pass a thin catheter into the windpipe while the infant breathes spontaneously, avoiding a ventilator.

The change from liquid to air is therefore neither instant nor simple. It depends on a sequence of events that must occur in the right order at the right time: the clearance of fluid, the opening of the air sacs, the release of surfactant, the fall in the resistance of the lung's blood vessels and the closure of the openings that served the fetus. When the sequence is interrupted the consequences appear within minutes, which is why the first breath of a newborn is watched so closely.

Walk into almost any pharmacy in a wealthy country and you will find a wall of vitamin pills. Surveys suggest that around half of adults in the United States take some kind of dietary supplement, and the global market is worth many billions of dollars a year. The appeal is easy to understand: a tablet is cheap, requires no effort and seems to make up for a poor diet.

The most careful reviews have been sobering. In 2022 the US Preventive Services Task Force, a panel of American preventive-medicine specialists, examined randomised trials of vitamins and minerals taken to ward off heart disease and cancer and concluded that there was little or no benefit. On two supplements it was firmer still: it advised against beta-carotene, which was found to raise the risk of lung cancer in people who smoked or had been exposed to asbestos, and recommended against vitamin E as well. Both are widely sold.

The most famous claim for a vitamin was made by Linus Pauling, a chemist who won two Nobel prizes and who argued from 1970 that large daily doses of vitamin C could prevent the common cold. His advocacy was enormously influential, and megadoses became fashionable. Later trials were less kind. A review coordinated by the Cochrane Collaboration found that regular vitamin C did not reduce the number of colds caught by people in general, although it slightly shortened those they did catch; only in people under extreme physical stress, such as soldiers in sub-Arctic conditions, did it appear to reduce the risk at all.

Nor is the only risk that of wasting money. Edgar Miller and his colleagues at Johns Hopkins University pooled trials of high-dose vitamin E and reported in 2005 that doses of 400 international units a day or more were associated with a small increase in the risk of death. The finding was contested and the absolute risk to an individual was tiny, but it undermined the assumption that a vitamin, being natural, must be harmless.

Yet the blanket conclusion that nobody needs supplements is wrong. Women who are pregnant or may become pregnant are advised to take folic acid, which reduces the risk of severe defects of the baby's brain and spine. Vitamin D is needed for the absorption of calcium and is made in the skin only in sunlight; in 2016 the Scientific Advisory Committee on Nutrition, which advises the British government, concluded that everyone in the country over the age of four needs ten micrograms a day, an amount that in autumn and winter can realistically be obtained only from a supplement. People who eat no animal products need vitamin B12 from a supplement or fortified food, and some patients with diseases of the gut cannot absorb nutrients and depend on supplements for life.

Why, then, do trials of multivitamins show so little? One reason is that the people who take them tend to be health-conscious already. Studies comparing people with high blood levels of a vitamin with those who have low levels are confounded by this: those with high levels may differ in income, diet, exercise, smoking and a hundred other ways. Nutrients also work together: an orange contains vitamin C but also fibre, potassium and hundreds of other compounds, and a diet rich in fruit and vegetables is consistently associated with better health in a way that no pill has been shown to be.

Regulation also deserves scrutiny. In the United States, dietary supplements are treated as a category of food rather than as medicines, and they may be sold without the pre-market testing of safety and effectiveness that a drug requires. In the European Union, claims printed on a label must be authorised, but the product itself is not individually assessed. Analyses of herbal products have repeatedly found that the contents did not match the label, and contamination has been reported. A shopper is thus relying on the manufacturer's honesty to a degree that would be unacceptable for any medicine.

Vitamins A, D, E and K dissolve in fat and are stored in the body, so very large doses accumulate; vitamin A taken in high doses during pregnancy can harm the developing fetus, so official advice tells pregnant women to avoid supplements containing it. Supplements can also interact with prescribed medicines, and taking a pill may delay a proper diagnosis when symptoms are serious.

My own view is that the question has been asked in the wrong way. The honest answer to whether a healthy person needs a multivitamin is usually no, and the money would be better spent on vegetables or on a pair of running shoes. But the same answer to whether supplements matter would be badly wrong, for folic acid, vitamin D, B12 and vitamin A in deficiency are among the cheapest and most effective interventions in medicine. The sensible policy is not to dismiss supplements but to target them: to supplement those who need it, to fortify staple foods where the need is widespread, and to require that what is sold matches what is claimed.

The supplement industry thrives on a confusion between two quite different things: the value of a vitamin to a person who lacks it, and the value of a capsule to a person who does not. Advertising blurs the distinction, and the public pays for the blurring. Clearer information and stricter labelling would not put an end to the market, but they would ensure that the pills people buy do something worth paying for.