The chemist knew everything, which is a dreadful handicap to carry through life.
‘The guy who invented these CPAP machines is a genius,’ he said. ‘Did you hear the story? His name is Colin O’Sullivan. Or Sullivan. Yes, Sullivan. See, it’s written here on the machine. He’s a multi-millionaire and a total recluse. Lives in a mansion and never sees anybody. Doesn’t need to. He has a swimming pool he could fill with cash. All because he had one good idea in his life. You know how he thought of it? It’s amazing. Everyone was trying to discover what to do about sleep apnoea. One night, this Sullivan or O’Sullivan was sitting in a Chinese restaurant in Marrickville. He was the last to leave and they began to clean up the restaurant before he was finished. He noticed that the restaurant owner didn’t sweep up the grains of rice off the floor. Instead, he had reverse-wired a vacuum cleaner, which he used to blow the rice out the back door. That was when Col O’Sullivan had his Archimedes moment. He went ah-ha. A million bucks, right there. What he came up with was basically a reverse-wired vacuum cleaner to push air down your throat all night to let you breathe. That’s the little beauty you’re about to buy right here. It comes with its own little travel bag. It’s brilliant. Getting the right mask usually takes people a while. That’s normally the hard part. I wish I could have an idea like that. Just one. Ten minutes’ work. No worries, mate. Actually, I have got an idea of my own. It’s a secret. I’m working on it at home. I don’t want to say what it is because I don’t want anyone to steal it. If I tell you, you have to promise me you won’t steal it. It’s for disposable dentures, just like disposable contact lenses.’
‘Or disposable nappies.’
‘That’s exactly right.’
I met Professor Colin Sullivan in September 2004. He had never been in a Chinese restaurant in Marrickville in his life and was so much the multi-millionaire recluse that it took a masterful campaign of subterfuge and stealth on my part to run him to ground: I rang up Sydney University and asked to be put through. He picked up the phone and started telling me the best place to park when I came to see him. He was still in the same unassuming room in the same uninspiring item of architecture, the Blackburn Building, where he had devised the first CPAP machine almost twenty-five years before. By the time we met, a million people around the world were using his invention and it had become Australia’s second-largest medical export after the cochlear implant for hearing. But Sullivan’s room in the old Blackburn Building in the medical precinct of Sydney University still didn’t have airconditioning and, when I arrived, Sullivan was struggling to get the window open.
‘It gets difficult to breathe in here,’ he said.
It was breathing that brought Colin Sullivan into the area of sleep medicine, which in the 1970s was very much in its infancy. In many respects it still is. Sullivan was drawn to medicine through physiology, the study of the more mechanical aspects of the human person, because it was the closest branch of medicine to engineering. His two elder brothers had both been engineers and it seemed to be the family default position. His father had been an electrical fitter.
‘My wife calls me a human engineer rather than a doctor because I tend to think mechanically. It’s only recently that I have begun to think of myself as an inventor.’
In the early seventies, Colin Sullivan embarked on study under the supervision of Dr David Read, after whom the centre for sleep research in which we were sitting is named. Read became interested in the sad phenomenon of Sudden Infant Death Syndrome (SIDS) after friends had lost a baby in this way; SIDS had only been named as a distinct condition in 1969. Read began to explore the nature of breathing and sleep in infants. Over time, Sullivan moved on to asking separate questions about sleep in adults. He went to Canada and did research on what happens to the breathing of adults during sleep, using dogs fitted with masks to help him.
‘We are pretty sure now that, in children, sleep drives the entire process of development,’ he said. ‘In adults, it has more a function of maintenance.’
Ironically, after thirty years in the field, Sullivan was now more interested in childhood sleep and especially fetal sleep than ever before, developing techniques for studying it. He was trying to ascertain if there were clues in childhood, especially in childhood breathing and snoring, which might provide pointers for the later onset of serious conditions such as sleep apnoea. He wondered if they could be headed off before they developed and did damage. He points out that it was once common to remove large tonsils from children.
‘These kids often presented as sickly and we used to rip out their tonsils at the drop of a hat. Their snoring was interrupting their sleep and suppressing their growth hormone. After the procedure, they’d often have a growth spurt.’
He went on. ‘A baby can spend eighteen to twenty hours a day asleep.’
This was news to me.
‘Most of that sleep is REM sleep, which is that part of sleep where the brain stimulates itself. But fetal sleep is even more predominately REM sleep. So what’s going on? We know that by eighteen weeks, the fetus starts to perform the motions of breathing, even though it doesn’t need to. It gets all the oxygen and nutrients it needs through the placenta. In its last four or five months, the fetus looks like it is breathing a lot of the time and this requires a good deal of energy, so there must be some point. What we know is that the fetus learns and practises three key activities while it is asleep: breathing, sucking and swallowing. These are critical to survival at birth. They are learned during fetal sleep. So, like adult sleep, it isn’t exactly down time. It is key learning time.’
Colin stood up and reached to the top shelf of a bulging cupboard and pulled down a box in which he started rummaging, picking over pieces like it was a box of oddments in a garage sale. These were the first masks that had ever been used for CPAP machines; it was a little box of medical history. They were ugly and cumbersome. There were plaster-of-Paris moulds in the box as well, masks taken from the faces of early patients. They had all been made by hand and fitted to each patient like a dentist fits a plate. In the early days, they had to be stuck on every night with glue, and then prised off in the morning. It was a hell of a business. But the people who were prepared to sleep with these hideous gadgets stuck to their faces were in dire straits. They were people for whom the most natural thing in the world, breathing, did not come naturally, at least not in bed.
To a young science graduate, Lucy Costas, Sullivan was an entertaining lecturer and ‘a bit of an iconoclast’ who ‘didn’t kowtow to the medical hierarchy’. When Costas began working with Sullivan and his team in 1979 she had newly returned from overseas with her husband. Not sure of life’s next direction, her eye happened to fall on a job advertisement in the paper that wasn’t quite what she was looking for but which she thought might do for now. She soon found herself in a new world.
Costas recalled, from when she first arrived in the Blackburn Building, discussions about one particular patient with whom the laboratory had made contact a few years earlier. Let’s call him Andy Chappell.
‘He was in his fifties and I think he’d been a bookmaker. He’d certainly been a heavy smoker and he was overweight.’
Andy suffered from being what is sometimes known as a blue bloater, a condition in which the body, faced with little choice in the matter, begins to tolerate low blood oxygen levels and high levels of CO2. As a result, Andy had developed a blue physical appearance. But studies showed that there was actually nothing wrong with his diaphragm; his rib cage was expanding and contracting as it was supposed to, so his breathing apparatus ought to have been doing a better job. Yet there was little airflow at his nose and mouth during sleep. Up to this point, medical science had believed that such a problem must be neurological; in other words, that the brain wasn’t communicating properly. Sullivan and his team, with help from poor Andy, clarified the issue. The problem was really the collapse of the upper airway; the mine shaft was blocked near the surface.
‘Up until that point,’ said Costas, ‘respiratory medicine didn’t involve the throat, it basically ended at the neck.’
Then, by 1980, Elliot Weitzman and Christian Guilleminault from Stanford had used fibre optic scopes and produced vivid pictures of the upper airway closing during sleep. Initially, Colin Sullivan thought that patients with this condition were few and far between and that he’d have to go looking for them; he wondered if he’d find five a year.
But they came looking for him.
Just as he had done in Canada, Sullivan used dogs fitted with masks to help him understand breathing and sleep. He used German Pointers because they were placid, easy to train and had short hair which made life easier when it came to keeping equipment clean. One day in 1980, he was visited by a man who had been scheduled to undergo a tracheostomy to enable him to survive. The man was in his early forties, had a young family and had reached such a level of dysfunction, scarcely able to stay awake at all, that he was willing to undergo the extreme procedure; needless to say, he was not looking forward to it. He was volunteering some before and after studies to measure the procedure’s effectiveness but kept asking Sullivan if there was any alternative at all to having a pipe stuck out of his throat.
For some reason, Sullivan thought of the German Pointers and an idea popped into his head.
Well, it didn’t just pop. Creativity is a form of intimacy. It happens when you are so close to an issue or problem that you wear it like a second skin, move around in it, sometimes even stop noticing how much it shares your space. Sullivan had been living for a long time with deep questions about the nature of lethal sleep.
Ten or twelve years earlier, Sullivan’s own mother had died at the age of fifty-nine as a result of a thyroid condition known as myxoedema, which involves a large weight gain and often causes the victim to develop enormous legs.
‘All people with myxoedema get obstructive sleep apnoea,’ he said. ‘They are also prone to vascular disease. I can remember Mum snoring, but I had no idea what it was really all about. It was terrible. My father ended up sleeping in another room; normally it’s the other way around. She was falling asleep the whole time. This is what killed her. She died in her sleep.’
Who knows how or why the necessary forces coalesce at any given moment – but it so happened on this day that, in the middle of the afternoon in Sydney, Sullivan found himself saying to Andy, a patient who was prepared to try anything, that he supposed he could fit a mask to him and hook it up to a machine that looked like a reverse vacuum cleaner, similar to one which had been used on babies considered in danger of SIDS.
By 4 am the next morning, Sullivan could hardly believe what he had seen.
‘It was incredible. The first experiment just worked like a charm. We turned on the blower and this guy went straight into REM sleep and stayed there for two and a half hours. You never see that. A REM cycle might be forty-five minutes.’
Lucy Costas said she remembers the excitement the following day; Sullivan was already telling people that they needed to have their findings published as soon as possible. Before long, five patients had similar experiences and were reporting dramatically improved daytime alertness.
So it was that on page 862 of the Lancet of 18 April 1981, written by the team of Colin Sullivan, Faiq Issa, Michael Berthon-Jones and Lorraine Eves, there appeared an article modestly entitled ‘Reversal of Obstructive Sleep Apnoea by Continuous Positive Airway Pressure Applied Through the Nares.’ The nares are nostrils. The Lancet expects you to know that already.
The Lancet, it must be said, is an acquired literary taste, especially compared to publications which can make medical history out of a footballer’s strained groin. The Lancet goes to the other extreme; it uses inverse sensationalism. The bigger the news, the smaller the print. If the Lancet had been breaking the news to the world of the death of Princess Diana it would have described:
the reversal of vital signs of intoxicated tourist in consequence of change of velocity without regard to suitable deployment of seatbelt.
And if someone found a way to bring the dead back to life, the Lancet could make it sound as exciting as burnt toast. You have to credit such hardy resolve.
The biggest news in sleep since the observation of REM in 1953 got the same dour treatment:
Continuous positive airway pressure applied in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive sleep apnoea syndrome.
The article pointed out that five patients who, without CPAP, had virtually no stage three or stage four sleep improved instantly once they tried it. It concluded:
the inherent simplicity and safety suggest that home use will be possible.
That last line should have been lit up with dollar signs. The publication in the open forum of the Lancet meant that it was now possible for anyone to turn the reverse vacuum cleaner into cash. The Lancet has an assiduous readership of both medicos and business people, two groups which are by no means mutually exclusive.
There were hurdles to get over yet. One was getting the medical fraternity to accept a simple solution, especially one emanating from Australia. Another was creating a machine that was user-friendly; the early ones were so big and loud that they had to be installed outside the bedroom and pipes brought in, a bit like what happens with split-system airconditioners. Other issues involved finding a way for the airflow to increase gradually to the desired level, so the patient could get to sleep before it reached full force. But far and away the biggest challenge was to be designing a mask that people could use comfortably.
Twenty-five years later, the company that began from Sullivan’s work, ResMed, occupies a vast site on the side of a freeway in Bella Vista, one of the western suburbs of Sydney, not far from Tuscan Waters and other places whose names reflect a desire to really be someplace else. It is a part of the urban sprawl which believes fervently in two propositions. The first is that that every bed must have its own bedroom. So it builds enormous houses. The second is that nobody should ever look at the night sky. So it puts those enormous houses on tiny scraps of land where they almost touch each other and you can hear your neighbours snoring and imagine that you’re in the jungle.
The ResMed plant, where I joined a tour in late 2006 not long after it opened, looks more like a university than a factory. This is fine because the medical part of Sydney University looks like a factory. Near the entrance of ResMed is the Healthy Sleep Centre, outside which lie beds of lavender, an ancient ally of sleep; their presence lends a slight air of the esoteric to a place with a business edge. Any mysticism here is created with silicon, plastic and computer boards. At the bottom of a gentle slope you come to the Innovations Building which, our tour group is informed, will house 300 engineers. Every room has access to the balcony which overlooks the Stream of Ideas, an artificial river that runs through the centre of the site; the time-and-motion people clearly overlooked the cost of this gurgling brook to the company in terms of extra comfort stops.
Many of the battalion of engineers at ResMed are involved in creating the perfect sleep mask, a task which must be more complicated than it sounds; such a small thing seems hardly to deserve such avid attention. On the other side is the factory itself. Here they make 2,000 CPAP machines and 15,000 masks every day, mostly for export, mostly to the United States, where ResMed competes fiercely with another company called Respironics which does much the same thing for a similar share of the market. Only three per cent of ResMed’s trade is in Australia. Indeed, it appears that the company works hard in the United States to make itself look like an American company with a base in Delaware. One of the visitors on the tour pipes up and tells everyone that the cheapest way to buy one of these machines is to go online, buy it in America and have it shipped back home. The guide smiles inscrutably.
The factory is designed like a cloister, so we can peer into places where the action happens. The company’s ‘core competency’, whatever that means, is making masks from Silastic, a word which was manufactured by gluing together silicon and plastic. It’s not quite as fetching as nylon, which was made from putting together New York and London, but who wants to go to bed with nylon over their head. Twenty-six moulding machines, soon to be thirty, churn out masks day and night. Every few months, a new development in mask technology comes into effect, usually a precise refinement making them quieter or less obtrusive or more flexible. I have a collection of my own discarded masks from the last decade: each one a small advance on the previous model, each one a bit more expensive. Masks cost between $200 and $300 and need to be replaced regularly.
When I mention that I can make a mask survive for two or three years, the guide tut tuts that I would be so foolish. He soon gets onto exports and global expansion. The company does best in countries with lots of food but poor diets.
‘You might say that where McDonald’s goes, we soon follow.’
So is the company helping people accommodate to an unhealthy lifestyle? Wouldn’t it be better if people just lost a bit of weight?
‘Well,’ he says, ‘sleep apnoea is more complicated than that. You can be thin and still have it, although it’s less common. Perhaps by giving overweight people a good night’s sleep we are giving them the energy to do some exercise and lose some weight. It’s hard to be motivated about anything when you haven’t slept. Everything is hard when you haven’t slept.’
After thirty years, Colin Sullivan says that he still spends half his time thinking about the meaning and purpose of sleep.
‘So why do we sleep?’
‘It’s hard to know. We would have a better idea if we could observe what happened to people who didn’t sleep. But it’s hardly an ethical thing to deprive people of sleep.’
‘You must have some idea why we sleep?’
‘It’s like asking why we eat. The answer goes in so many directions all at the same time.’
A pioneer in the area of sleep medicine, William Dement, is famous for his response to the same question.
Question: What is sleep?
Dement’s answer: What is wakefulness?
Waking, of course, can have traumas of its own. The fairytales never tell you that: Little Brier Rose (if you like the brothers Grimm) or Sleeping Beauty (if you prefer either Charles Perrault or Walt Disney) wakes after one hundred years and everything’s gorgeous. The prince finds his way through the thicket of thorns, plants the kiss we’ve been waiting for and everyone in the castle rises and shines and gets on with life as if nothing has happened. Even the cook, who fell asleep as he was about to hit the scullery boy, gets to land his punch. The only misgiving is in Perrault’s eighteenth-century version, where the prince notices that Sleeping Beauty is wearing the fashion of his great-grandmother’s era and that her collar is too high – but she is so beautiful, and no doubt well rested, that he loves her anyway. The people who are not in love feel peckish after a hundred years of fasting. But the princess desires only her prince.
Lucy Costas still works in the area of sleep apnoea, patiently fitting mostly jowly men to the masks that put the wind back in their sails. She thinks back to one of the very first CPAP patients and recalls that he found waking from his long years of slumber a difficult experience. He awoke in a world that was not the world in which he had fallen asleep. Things had changed. It was years since he’d been alert enough to notice.
‘I often wonder what became of him,’ says Lucy. ‘He didn’t continue with his treatment.’
Apparently, the journey back from his long hibernation was too hard.
‘As far as I recall, he chose to go back to sleep.’