The BioEthics Cafe of Philadelphia

Gene testing?

2009-05-06T09:24:00.003-04:00

As a society, we have evolved in many fields, before, we had no way of knowing who would have what disease and how we can avoid passing it onto our children. Now through gene testing becoming more common with the population, it’s revealing those hidden factors. They don’t have gene testing for a lot of diseases because there are too many genetic variations such as in chronic diseases (diabetes), that you can’t pinpoint one marker. Some of the gene testing is probabilities that you might or might not get it, meaning that some people have the strain, but it’s not active until some outside factor such as disease or other environmental factors influence it. Physicians use the few genetic tests that we have to target illnesses and prescribe the appropriate medications.

Most scientists question gene testing because there are too many genetic variations which we don’t have the medicine to treat it yet, even if found. Errors in testing can also have an impact on you. Gene testing is not regulated by the Food and Drug Administration. It is costly and it is not covered by insurance. Even if insurances are going to cover it, they’ll ask for the results of your genetic tests to keep on file. We are so big on privacy that we get angry if someone sees your medicine bottle, but you are going to let a bunch of people look at your genetic results, I don’t think so.

In this article, they mention that Medicare doesn’t pay for gene test. The Center for Medicare and Medicaid services believe that there isn’t enough evidence showing that these tests improve patient’s illness. Insurances can’t cover everything especially government provided insurances, so they have to be carefully in what they find applicable to cover. In this article, they wanted to give precise warfarin doses to each individual based on their genetic makeup. Warfarin, a blood thinner is hard to dose and any slight variations in it, will either cause blood clots or hemorrhages. We’re still far away from personalizing medicine with genetic testing such as to tailoring it to individuals and their needs. Maybe when we have more solid evidence and more participation in genetic testing, we can think about it being covered under an insurance plan.

Pandemics and Politics - A Recipe for Pandemonium

2009-05-03T22:53:00.002-04:00

The very nature of influenza virus makes prediction difficult. New strains of influenza for which populations are not immune in combination with increased global travel, urbanization, and overcrowding make pandemic conditions inevitable (see WHO Pandemic Preparedness strategy)(1). Also, seasonal epidemics heavily influence the impact of pandemics. Although the World Health Organization (WHO) and the Centers for Disease Control (CDC) have strategies for outbreak response (global outbreak/pandemic response) that includes communicating real and potential risks at the earlier phases;(2) unfortunately communications are filtered through sources with alternate agendas that do not account for the public’s short or long-term health.

The so-called swine flu provided the perfect mix of mystery and intrigue political mud slingers salivate over. From the first news reports the number of deaths was just as inflated as its origins. Turns out, swine flu doesn’t even come from swine – imagine that! Instead, swine flu is a strain of influenza virus - influenza A (H1N1) - isolated and reported to originate from a confined area in Mexico. Suddenly, suggestions of bioterroism and border closings ran through the media like California-wild fires through the canyons. Bioterroism from a flu virus? Border closings? Outbreaks do call for quarantine to complete epidemiologic investigations as well as treatment to avoid spread (when possible); however, no responsible medical authority made this declaration or even insinuated locking out an entire country as the option. So why did “the media” jump so quickly to this type of conclusion?

Politics. Throughout history disease has been used as an agent of power and politics (see Sheldon Watts for an excellent account on epidemics in history-3). Since a minority (about 20% according to a recent Washington Post poll) of disgruntled Americans (you can see a lot of them on Fox News) are beside themselves with anger about the last election and the perceived success of the First 100 Days, nearly any excuse for political posturing seems justified even in situations of extreme health. The paranoia that the news media has spread to elementary school children(4) who, yes, should be aware of ways to thwart human-to-human transmission but should not be afraid that they are going to die because someone sneezes on them. In fact, the precautions for this strain of flu are like precautions for any other strain of flu which should be taught outside of the confines of a pandemic alert.

Furthermore, what is not discussed nearly enough in the media is the link between very poor health and susceptibility to every day occurrences. The reality is, the American diet does not prepare American’s for epidemic catastrophes let alone pandemics. Furthermore, endemic flu continues to immobilize us as a nation because we have yet to confront the medical and social variants that propagate disease (see Holly Tomlin’s BW706 Final Project). This does not mean that pandemics or warnings should be ignored but the information should be communicated responsibly.

To panic people by combining basic fears of “terror” (thanks to the previous administration) with diseases that will become more commonplace with globalization is not only irresponsible but should be considered an act of treason; especially when the act is for political gain and not the public’s health.

Holly Tomlin
Blog 12

References
1. WHO. Pandemic Preparedness 2009. http://www.who.int/csr/disease/influenza/pandemic/en/index.html. Accessed 03 May 2009.
2. WHO. Global influenza programme: WHO pandemic descriptions and main actions. http://www.who.int/csr/disease/influenza/GIPA3AideMemoire.pdf. Accessed 03 May 2009.
3. Watts S. Epidemics and History: Disease, Power, and Imperialism. 1997
4. A personal account – my friend’s 8 year-old daughter called me with questions about the swine flu because of the stories she saw on the news and the information she received at school.

Opulence and Insecurity and the outmoded 40-hour Work Week – A Personal Rant

2009-05-02T03:27:00.006-04:00

How insecurity develops is a matter of psychology – quite frankly I don’t care where it comes from. What concerns me is the impact personal insecurities have on innovation, development, and progression. In a time when technology affords us the opportunity to exchange basic and complex information from seconds to minutes from one continent to the next as well as physically travel to those same regions within less than a day, for the life of me, I cannot understand why big businesses do not consider optimizing productivity potential beyond physical presence at a desk, behind a computer monitor, sipping gallons of coffee each day.

Part of the blessings (yes – I mean blessings) of technology is that it should free up people’s time to allow neurons and synapses to fire in different directions, expand brain capacity, and encourage creativity. Technology (laptops, iPhone®, Blackberries®, cars, buses, trains) should instill confidence in our capacities as human beings. Instead, people’s fear of technology has held the rest of us hostage to their insecurities and made us slaves (no disrespect) to an establishment that is afraid to embrace … dare I say it… yes – I will… embrace change. It’s like being an extra in your own reality t.v. show, a riddle wrapped in a Twinky®, Bizzaro to Superman – it doesn’t make sense!

Even more senseless are the salaries corporate fat cats make to keep the illusion going – particularly middle managers. They compound the insanity by celebrating mediocrity with big bonuses while utter stupidity is perversely excused and accepted. Do I really need to be chained to a desk listening to an earning’s call reiterating the same bleak economic forecasts of days before? Wouldn’t my time be better spent engaging in real scientific exchange that requires hours of research and contemplation that produces results? Perhaps such an exchange would add a little sunshine to the next forecasts…? But because I’m surrounded (quite literally) by the hypocrisy of an antiquated philosophy that impedes real work and progress (as well as an uncertain economy) I’m stuck between a rock and a hard place in a glass house built on quick sand.

Yet, I’m not giving up nor will I be fooled by misguided attempts to buy my personal ethic that craves intellectual challenge without being micromanaged.

Holly Tomlin
Blog 11

Beans (A Poem for Organ Donation)

2009-05-02T02:10:00.003-04:00

Beans

Because they fail to work properly on their own

A catheter was inserted into her abdomen

For easy access to the machine she uses daily

To help her kidneys balance the minerals that flow

In and out of her blood stream

The process is intricately connected to her fluid and food-intake

As well as the money she makes

The support she has from friends and fam

That worries about the fragility visible in her face

As she recants tales of fighting her landlord

Who doesn’t care about her handicap placard

Or the government that sits on the hill counting kidney transplants,

Comparing them to dollars and cents

As if they were beans in a jar

For years she’s struggled with doctors

Trying to make sense of the disease they cannot fully explain

- It causes swelling, bone loss, brain damage, and severe joint pain

She was taken off the transplant list, put back on… then taken off again

No one understands the agony she’s in

Not even I – her sister-friend

Although weak from frustration, mineral imbalance, and poverty

She writes letters to congress, speaks at rallies, and talks to anyone willing to listen

To God she prays for a kidney that works

As hard as she does to make life meaningful and whole

Like two kidney beans in concert

It is for KH that I write

In hopes that others will get to know the miracle of organ donation

And know that life…your life amounts to more than a hill of beans…

Holly Tomlin

Blog 10

End of Life Health Care is Our Biggest Health Care Problem, both Financially and Morally

2009-05-01T23:59:00.007-04:00

These are horrible questions, but these questions must be asked. I do not claim to know the answers, but I do know that what we are doing now does not make sense.

The truth is that an extremely disproportionate percentage of health care costs are incurred in the last year of a person’s life. Over ¼ of Medicare expenditures (27%) are made on patients in their last year. ( http://www.usatoday.com/money/industries/health/2006-10-18-end-of-life-costs_x.htm ) Roughly, $2000.00 to $3000.00 dollars are spent in a patient's last week of life.( http://archinte.ama-assn.org/cgi/content/short/169/5/480 ) As the baby boomers age, unpleasant choices are going to have to be made.

However, no one (understandably) wants to say, “Sorry, now that your best years are behind you and your utility to us has ended, you are more of a burden than you are worth, so if you wouldn’t mind too terribly, would you please die now?” “Broke your arm? Here is some morphine. These casts are getting expensive.”

Of course, the above is absurd, but it begs the question: Where do we draw the line? To what degree do we care for the health of the elderly before we decide it is not worth it? Is it moral to ask that question at all? Is it a sliding scale? Starting at the age of 70, is a person entitled to less care with each passing year? Do we draw the line according to condition, as in a broken finger is treated but a stroke is not? Do we draw the line according to prognosis, as in once the doctor decides that a person will not last a year, the morphine drip is wheeled in? If you thought insurance companies were tough on claims before, what happens when this Pandora’s Box is opened? Once it is considered reasonable for insurance companies to deny claims for terminal patients, what happens when the patients do not die as quickly as predicted? What if the doctor was wrong and the patient has 10 years left?

Our success with medical technology is ironically a part of the problem. It sounds horrible to ask, but in some twisted way, are we a little too good at keeping people alive?

This issue makes me upset, because my parents are in their mid-to-late 60’s.

We can not fix this problem by rationing care and deciding who gets what. This is not an issue that politicians can fix or bureaucrats can manage. The only way this problem will be alleviated is if our opinions about death and our opinions about our life cycle change.

In the meantime, I guess it all needs to come back to what is best for the patient.

The Terms "Right to Die" and "Assisted Suicide" Won't Do

2009-05-01T23:08:00.009-04:00

As I write this posting about end of life issues, I am well aware that I am not an expert on this topic. Thus, I am writing more in the spirit of asking questions rather than making statements. Even the statements that I make here will be along the lines of “thinking out loud.”

I consider life precious. It is a gift. We have been admitted into the club of human existence. Regardless of the quality or circumstances of one’s life, just being born makes one fortunate. I am not naive. Some lives turn out badly. However, to be given a shot at life makes a person one of the elite entities in the history of (as far as we know) the universe. While the following sayings are not valid when taken to extremes, there is an element of truth when people say “I never had a bad day in my life” and “I’m great just as long as I’m on the right side of the grass.”

I think that suicide by an otherwise healthy person is an unnatural act brought about by mental illness. However, if a person is physically (not mentally) suffering and that person’s best days are definitely chronologically behind him or her, then it is understandable why one may want to end their lives.

The term “assisted suicide” is one of those “b.s.” semantic terms used to place a spin on a philosophy, like “pro-life,” “pro-choice,” and the agenda-laden “anti-choice.” Besides, “assisted suicide” does not account for the terminal nature of the lives of those who choose to end things. I know I just criticized re-naming things for “spin” reasons, but I think in the context of end-of-life issues, it might be warranted. Euthanasia, while a legitimate term, has become such a loaded word that it seems no longer appropriate. Besides, we euthanize cats, dogs, and horses, and those animals do not choose to end their lives. Humans need their own term, one that reflects the choice one has made to end their own suffering on their own terms. I am not sure what term to suggest. I have some mind, but I will refrain from writing them here.

Though I never was passionate about the issue, I had always considered ‘assisted suicide” wrong. Dr Kevorkian seemed a little creepy to me, like he was a little too into it. He was turning what otherwise should have been the ultimate moment of dignity for a person into a circus.

My mind changed on the subject when I had surgery a few years ago to try to correct my sleep apnea. The surgery involved trying to open up my nasal passages. I then understood why suffering, terminally ill patients would want to end it all. My suffering was so great that if I did not know that I would get better, I would have wanted to die.

What is a better way? Have the person sign a do not resuscitate (DNR), no breathing assistance and no feeding tube letter then fill them with morphine to ease their last days?

Somehow, I think that might be the way to go. Unless I am mistaken, that is what we are doing now. Maybe we need to let more people know they have that option.

I do not know the answers here. I am just asking questions.

Another aspect of this issue is the cost of end-of life care. I will cover that in my next posting.

I am Beginning Consider "Comitting a Gaffe" Laudable

2009-05-01T18:37:00.002-04:00

I applaud the Vice President’s candor recently with regard to the swine flu. He said that right now he would advise his family to avoid planes and trains and any tight spaces. I am sure the airline and rail industries were not happy, but they are not the Vice President’s first obligation. His first obligation is to protect the health and safety of Americans. Lest one think that we have completely entered a new era of openness and responsibility in Washington, the attempted corrective spin on the part of president Obama’s press secretary was beneath comical. Robert Gibbs’ attempt to make things “right” (i.e. politically correct) was so pathetic that it elicited laughter from the otherwise Obama-phile press corps. They were not laughing with him. They were laughing AT him. You can see the video here: http://www.realclearpolitics.com/video/2009/04/30/gibbs_on_what_biden_meant_to_say.html

This reinforces the issue I raised in an earlier post. Just how responsible should our government be when it comes to protecting the lives of our citizens? We cannot just shut down the society, especially at this point. Restricting trade and travel right now is not warranted. However, the population should know the risks and decide for itself. The key is the authorities providing accurate and complete information. Accurate and complete information should not be held back just to avoid a “panic” or to avoid dampening the economy. Staying out of airplanes or trains is not a panic. That is a conscious, measured decision that one makes based on what is best for that person and his or her family. Our government owes the common person honesty. We can decide for ourselves what risks we want to take with our own personal lives.

Hospitals are seeing up to a 50% increase in emergency room visits by people who are afraid they have swine flu. Is that not a good thing? Does increased overall vigilance make it more likely that we will be able to contain the problem and avoid a pandemic?

To smoke or not?

2009-05-01T16:13:00.001-04:00

I don’t get it. They get so happy to tackle a smoking problem in this article. I wonder who they surveyed. They should come and survey the kids in the cities. Half of the kids quit because they want to and I don’t think it’s inaccessibility to smoking paraphernalia that is the cause of the decline. If you want to smoke, you’ll find away to get around it. I worked in a store and older kids just buy it for the younger kids. In the Pennsylvania smoking law, no where does it say that minors are restricted from smoking, just says that they can’t purchase it. You can get arrested for selling cigarettes to minors but police can’t arrest the minors who are smoking, if they catch them smoking. That’s a twisted way of putting things into perspective. It’s like saying something but doing something else which defeats the whole purpose.
I live by a busy road, with a high school on its side and police cars driving by left and right. All the stores are near there, and the high school, middle school, and elementary schools are near to each other. So when the school lets out all the “should be” role models for the younger kids are smoking and they give it to them as they pass by. You see smoking groups by each store. Then you see the police, just ignoring them. I think if you use reverse psychology, you have more of a chance to make kids stop smoking, by allowing them to purchase it legally. They’ll get tired of it once it becomes readily available. I mean, the whole thrill other than the addiction of smoking is because you are doing something against what society deems you can’t. So kids are at the age where they like breaking the rules. If there is no rule, they have nothing to break and it’s not fun anymore. Smoking will not be cool anymore. In certain areas, sometimes having no rules is more effective than having rules to follow. I mean who follows rules anyway, if we fully abide by them, we’ll all be at the bottom of the social ladder. It comes down to that whether to smoke or not, it’s their choice.

Restrict late term abortion: A law?

2009-05-01T16:10:00.003-04:00

My opinions are neutral in the abortion area. I think no one should suffer whether it is the baby, the mother, the healthcare personnel, or the families. However, abortion is needed if carrying the baby to term will jeopardize the physical and mental health of the patient. If the family has no means to provide for the baby and putting the baby up for adoption, in most cases, not a good idea. The kid would suffer through the system as sad as that sounds. This doesn’t mean I condone reckless behavior beforehand of the caused problem. Sometimes, a person’s irresponsibility shouldn’t be the cause of death of a life. I mean having a baby should be a joyous occasion; a lot of abortions are proving that feeling wrong. All these anti-abortion people, it’s funny that the most statements I read are from the men, I mean what do they know and don’t tell me it’s that someone who was close to them had an abortion and that changed their life. If you had an abortion, I would think that would change anyone's life. I think they stay by the idea without knowing anything else. I get why they are against it, not killing a life, personal morals, and for religious reasons. However, are they willing to endanger one’s life to save another?
Nowadays people are jumping to sue everyone left and right, and passing this bill would have added more to that list. No wonder some of the best doctors avoid practicing certain areas, because they are inhibited in the care that they can give, by the same people that they cared for. I think if they passed the bill, it wouldn’t change things, everything runs its course. Restricting certain laws in late term abortions just so you could sue, I mean doesn’t that defeat the whole purpose about saving a life. Most of the time, it ends up that obtaining money is the true face of abortion. People are still going to do abortions. The person who has the money will do it silently and the person who doesn’t have the money will find other means. Restricting abortion will result in more people dying. I think being more open about sex, will help decline the rate of abortion. If you want to prevent abortion, put your energy in educating people on prevention, be more open about sex education and hopefully make them realize the value of life. Sometimes, the causes for abortion are ridiculous such as for career reasons.

Artificial insemination:Natural process or not?

2009-05-01T16:08:00.002-04:00

Some women get pregnant and they abort due to various reasons. The women who want to have a child can’t but now through artificial insemination women can get pregnant. However, the negative side of this is that with artificial insemination, you never know how many babies you will conceive. This results in having too many babies that won’t survive or sometimes the women get reduction done, meaning they kill off the number of babies conceived. Reduction most of the time is done for health reasons, because with more babies, the women and the fetus have a higher chance of being in danger. Even if 9 fetuses are carried to term, the woman needs a caesarian to get the babies out which will lead to complications. The babies who are born are weak and need extra care, some of them might not survive. In both cases having artificial insemination causes you to choose to have abortion. There is also the factor that with artificial insemination you are choosing the characteristics of your baby, it’s not naturally conceived.
Religious groups and anti-abortionists have a field day with this. Just from one procedure, there are too many deaths, not to mention the unnatural process to pick what characterisitcs you want in your child. What if someone wants to create a superior race as many as they want?Hopefully in the future they find a way to select how many you can conceive at a time. People don’t like surprises when they have to take care of nine kids all at once. For the people who are against abortion, they’ll risk it and carry the babies to term, which might put a strain on them. As with the case of the octuplet’s mom, Suleman, the healthcare professionals also have a duty to care for the health of the patient. In this case, the doctors were at fault because they let her follow through with a dangerous pregnancy. They shouldn’t even have let her have IVF if she already had six other children. I thought they underwent psychological evaluation before choosing these fertility options. Personally, I wouldn’t resort to artificial insemination on the basis that it is not natural, no matter how modern the world gets, there are some things you shouldn’t do. There are plenty of kids, who are not wanted out there, help them before you help yourselves. However, as much as artificial insemination is against my beliefs, other people may have that much desire to create a child by any means. It’s their choice in the end, and whatever is comfortable for them.

Congress, the Food and Drug Administration (FDA), and Dietary Supplements

2009-05-01T16:06:00.004-04:00

The dietary supplement industry (vitamins, herbs) has bought off Congress to keep the FDA from regulating products that in reality are sold as drugs.

The dietary supplement industry is huge in the United States. A 2002 FDA survey concluded that 75% of Americans used dietary supplements (vitamin or herbal) within the previous year. That survey also concluded that 14.5 of Americans (a different survey said 20%) used herbal (non-vitamin/non-mineral, NVNM) supplements within the previous year. About 6% of Americans used NVNM supplements every day. The most used NVNM supplements were Echinacea, ginkgo balboa, garlic pills, ginseng and saw palmetto.

Before Congress got involved in 1994, the FDA regulated dietary supplements under The Federal Pure Food and Drugs Act (1906) and The Federal Food, Drug, and Cosmetic Act (FD&C Act) (1938). Under these laws, supplements were treated as food, and the FDA emphasized truth in labeling and safety.

In 1958, the FD&C Act New Food Additive Amendments added supplements to the items under FDA control. With these laws, all new food additives needed prior approval.

Everything changed in 1994, when Congress passed the Dietary Supplement Health and Education Act (DSHEA). The new law removed dietary supplements from food category and created a new, separate, and essentially unregulated “dietary supplement” category. The DSHEA defined dietary supplements as “a concentrate, metabolite, constituent, extract, or combination of vitamins, minerals, herbs (or other botanicals), or amino acids used to supplement the diet by increasing the total dietary intake.”

“Dietary Supplement” implies nutritional content though many have none.

The Dietary Supplement Health and Education Act of 1994 created a facade of regulation but essentially stripped the FDA of all authority in regulating the claims these products. The FDA lost its ability to insure that these products actually are what they say they are. An example of this “regulation facade” is the requirement that the supplement industry “evaluate” pill composition. However, the industry is not required to report that evaluation to the FDA. The FDA also cannot require submission of efficacy and safety information prior to the pill going on the market. New supplements do not require FDA approval. The FDA can act only after a dietary supplement has been on the market and there is a problem. The law mandated only voluntary adverse event reporting. Prescription drug companies are required to tell the FDA about any problems possibly related to their drugs, but the supplement companies were not required to do so. The law also stipulated that the supplements could not claim to “diagnose, cure, mitigate, treat, or prevent illness.” However, the supplements do just that, along with a disclaimer that says, “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.” Supplement labels make claims on the front of the label while showing the disclaimer less prominently on the rear of the label. Even worse, the Federal Trade Commission (which regulates all drug advertising outside of the control of the FDA) does not require the disclaimer in dietary supplement advertising.

Do you remember Ephedra? Between 1993 and 1997, over 800 Ephedra adverse event reports were made by doctors. As a result, in 1997, the FDA proposed a ban on ephedra but could not get supporting evidence. The FDA was not allowed to demand adverse event information or product samples. In 2000, the FDA finally bowed to Congressional pressure and dropped the ban proposal. In 2002, the government ordered a safety study. In 2003, some states banned Ephedra. After a 2003 high-profile pro-athlete death (a pitcher for the Baltimore Orioles), Congress finally was forced to allow the FDA to ban Ephedra in 2004.

In 2006, there was growing pressure from the public to regulate the dietary supplement industry. Therefore, Congress passed another law that was designed to give the appearance of protecting the American people but in reality was designed to help the dietary supplement industry. It was “the Dietary Supplement and Nonprescription
Drug Consumer Protection Act.” In this law, the supplement industry gave an inch and took a mile. The new law said companies must report serious adverse events (a government term loosely defined here as a health problem resulting in death or hospitalization) along with a copy of the product label. The supplement companies were also required to keep records of (but not report) all non-serious adverse events for six years. The new law also required product labels to include contact information.

All of this sounds good on the surface, but the supplement industries got a lot more than they gave up. Companies were still not required to provide any information to the FDA before selling a supplement. The adverse event reporting rules result in only about 1% of all adverse events being reported to the FDA. If there is a serious adverse event, the supplement company does not have to send a sample of the product along with the report. The law also (and this is the biggie) prohibited states from regulating supplements in any way whatsoever. The companies still did not have to prove that their products were good, but the FDA still (if it wanted to act) had to prove the supplements were bad AFTER something happened. In the first year of serious adverse event reporting, 608 serious adverse events were reported (368 required reports from supplement companies and 236 from private citizens and healthcare workers). Previously, before the reporting requirement, the supplement industry said they never received any adverse event complaints against any of their products.

Still, the FDA is doing what it can. In 2007, the FDA issued “Dietary Supplement Current Good Manufacturing Practices.” While prohibited from going any further by law, the guidance covered design and construction of physical plants, manufacturing operations, quality control procedures, testing materials, consumer complaints handling, and records maintenance. However, the FDA cannot enforce these practices, and nothing still need be submitted prior to a supplement going on the market.

Because the FDA is not allowed to require it, there is little clinical evidence that these supplements are effective or safe. Some clinical trials have been done on dietary supplements, but lack of standardization leaves results inconclusive at best and meaningless at worst. A given herb has varying potency depending on where and how it was grown (weather, altitude, soil quality, sunlight exposure, etc.) and prepared. The National Institutes of Health said, “Most of the studies we examined do not provide strong evidence for beneficial health-related effects of supplements taken singly, in pairs, or in combinations of three or more....However, several other studies also provide disturbing evidence of risk, such as increased lung cancer risk with β-carotene use among smokers.”

The problem of the FDA’s lack of authority over the supplement industry is made worse by the public’s perception that the supplement industry is subject to FDA authority. The vast majority of Americans believe that supplements are approved by the FDA and are thus effective and safe. Further, the conflicting claims and disclaimers on product labels result in people believing what they want to believe. Studies that show a lack of effectiveness do not cause a nationwide decrease in supplement use. Only well publicized incidents relating to safety result in decreased use.

For the future, the U.S. General Accounting Office recommends that supplement companies be required to 1) Register as dietary supplement companies, 2) provide all supplement names with labels and 3) report all adverse events related to dietary supplements. The General Accounting Office also recommends that the FDA “educate consumers that it does not analyze and approve dietary supplements and seek more authority over supplements sold in U.S.”

I do not expect it to happen anytime soon. Money talks.

References
Sadovsky R, Collins N, Tighe A, Brunton S, Safeer R. Patient use of dietary supplements: a clinician’s perspective. Current Medical Research and Opinion. Vol. 24, No. 4, 2008, 1209–1216

Dietary Supplement Health and Education Act of 1994, Public Law 103-417, 103rd Congress. Available at: http://www.fda.gov/opacom/laws/dshea.html [accessed March 3, 2006]

U.S. Food and Drug Administration. Dietary Supplements Overview. http://www.cfsan.fda.gov/~DMS/supplmnt.html Accessed 4/21/09

Dietary Supplements: FDA Should Take Further Actions to Improve Oversight and Consumer Understanding. The U.S. Government Accountability Office http://www.gao.gov/products/GAO-09-250 Accessed 4/21/09

Public Law 109–462—Dec. 22, 2006 http://www.fda.gov/cder/regulatory/public_law_109462.pdf Accessed 4/21/06

AJ Perez. (2008, September 23). Dietary supplements cause 600 'adverse events' :First data since reporting law. USA TODAY,p. D.7. Retrieved April 22, 2009, from National Newspaper Abstracts (3) database. (Document ID: 1560768251).

Katherine Wong. (2007). New Mandatory Reporting Requirements for Dietary Supplements and Nonprescription Drugs Solve Very Little. The Journal of Law, Medicine & Ethics, 35(2), 336-339. Retrieved April 22, 2009, from Research Library database. (Document ID: 1334834441).

Sarah Lueck and Anna Wilde Mathews. (2003, December 30). FDA Is Expected to Ban Ephedra, Citing Supplement's Health Risks. Wall Street Journal (Eastern Edition), p. A.1. Retrieved April 22, 2009, from ABI/INFORM Complete database. (Document ID: 517744241).

Metabolife Praises FDA Withdraw of Proposed Ephedra Restrictions. (3 April). PR Newswire,1. Retrieved April 22, 2009, from ABI/INFORM Complete database. (Document ID: 52164278).
References

Timbo BB, Ross MP, McCarthy PV, Lin CT. Dietary supplements in a national survey: prevalence of use and reports of adverse events. J Am Diet Assoc 2006;106:1966-74

Dietary Supplement Current Good Manufacturing Practices (CGMPs) and Interim Final Rule (IFR) Facts. U.S. Food and Drug Administration. http://www.foodsafety.gov/~dms/dscgmps6.html Accessed 4/22/09

Report: FDA lacks authority over supplements – Without necessary resources, 'it's like the Wild West' USA TODAY (Arlington, VA) - Wednesday, March 4, 2009 Author: Elizabeth Weise: (c) USA TODAY

Bent S. Herbal Medicine in the United States: Review of Efficacy, Safety,
and Regulation J Gen Intern Med 23(6):854–9. 2008

Foote, J. Protecting Consumers in the Wake of the U.S. Dietary Supplement Health and Education Act. Journal of Allied Health , Spring 2007

Bent S, Ko R. Commonly Used Herbal Medicines in the United States: A Review
Am J Med. 2004 ;116:478–485.

NIH State-of-the-Science Conference Statement on Multivitamin/Mineral Supplements
and Chronic Disease Prevention. The National Institutes of Health. NIH Consensus and State-of-the-Science Statements Volume 23, Number 2. 2006

Tilburt J, Emanuel E. Does the Evidence Make a Difference in Consumer Behavior? Sales of Supplements Before and After Publication of Negative Research Results. J Gen Intern Med 23(9):1495–8 2008.

Plan A or B?

2009-05-01T16:06:00.003-04:00

All this controversy surrounding two pills called Plan B, I wonder what happens to the rest of the population who have sex and don’t have access to Plan B. So now they made it readily available to women and men 17 years of age and over, so what, it is only going to be effective if you take it. It’s like other contraceptive methods; everything is there for you in plain sight, to protect yourself from an unwanted pregnancy but what’s the point if you are not going to utilize it. Teenagers severely lack the sexual education and most of them are not mature enough to make a decision or maybe they just don’t plain care. Parents are part of this too, encouraging kids too much by showing their lack of care in their kids’ activities and not restricting them in some cases. So far, kid’s decision making skills are poor.

We all went through that phase that we know everything and because the parents are providing for you, life is a breeze. It’s when the wind propelling that breeze cuts off, and you finally feel the weight known as reality. There has to be a better way to prevent teen pregnancies, and abortions. We just need to be more open about it and have to get through the barrier that the kids somehow can’t see through. The more you restrict the more challenging or wild it’s for teenagers. Kids think that having sex is the next step to adulthood, and when you’re hormones are running wild, it might be too addictive for some to control it. Also, why would you want to burden yourself with an extra person to care for when you can’t even take care of yourself?

Got milk?

2009-05-01T16:04:00.002-04:00

I’ve been drinking milk all my life but never delved into what really goes into the process of store bought milk. If you are in most countries they don’t go through the whole food safety process that milks go through such as pasteurization and homogenized milk. They drink raw milk. I drank cow and goat milk before which didn’t go through any extra processes. The taste is different and according to experts, it contains better nutritional properties because you are not messing with its natural process. There is no injecting the cow with hormones, antibiotics, or putting them on a certain diet to increase the quality or the quantity of the milk produced. In this news story, they are trying to restrict raw milk from being in stores for health reasons. Some people got a bad case of raw milk that sent them to the hospital and now the agriculture police don’t want any in stores. I mean, any food handled without proper care is going to be poisonous to the body, doesn’t matter whether it passes through many safety processes or you just plain drink it straight from a cow.

It is the people’s choice whether they want to drink raw milk or not. You can get bacteria or diseases from anyone, don’t matter if they drink raw milk or not. Raw milk has more nutritional value than processed milk. It does have less of a shelf life. However, whether to consume it or not is up to the people. I mean not everyone can drive to a farm for fresh milk and if they are so worried, put a label on it to indicate a person’s right to drink the raw milk knowing that it might be hazardous to their health. They should be aware, I am assuming many people drink it based on having knowledge of what it is they are consuming. Restricting raw milk to certain places can hurt the people economically and take away their right to choose.

Mandating ultrasounds before abortion…

2009-05-01T16:02:00.001-04:00

Abortion is a controversial topic for a lot of people. Some people see it as killing a living being. Others see it as a means to improve the health of the woman. As long as abortion is therapeutic meaning it is performed to save the life of a woman mentally or physically, for terminating pregnancies if the baby is going to be born with congenital disorders and who’s health is fatal or will lead to morbidity, and to prevent multiple births, if those births will be harmful to the woman and child.
Although many people yearly have abortions, more than a million according to the Alan Guttmacher Institute Statistics (AGI) in 2006-2007, it is their choice to make. Now, some states want to enforce viewing of ultrasounds before abortion even if the patient doesn’t want to see it. If they are comfortable with the abortion, there is no need to enforce ultrasound images on them when they don’t want to view it. Medical personnel can give them the choice to view ultrasounds to make sure they are making the right decision. However, it shouldn’t be mandatory. It would be uncomfortable for both the doctor and the patient. A person has the right to view or not view what they want. When they made the decision, they thought it through to prevent future complications. However, a life is a life, and anyone will preserve it even if it is against their better judgment. So if they view an ultrasound when they don’t want to see it, their judgment might be impaired due to wanting to keeps the life growing inside of them.
Instead of preventing abortions, they should educate people beforehand about the consequences of getting pregnant. Most of the reports from the Center for Disease prevention and control (CDC) indicate most of the abortions are done to girls less than fifteen years of age. There is something wrong with that number. Either people aren’t educating these kids or their parents just don’t care and it results in them getting an abortion. Instead of mandating ultrasounds for abortion after the cause, mandate educational approaches for prevention of the cause.

To live or let go?

2009-05-01T15:58:00.003-04:00

Nowadays, we can’t even die peacefully without someone arguing over your life or death, mentally or physically. We all have a time to go, some sooner than others. Yes, you should die of natural causes, not by the help of something or someone else. In hospitals, you’re being kept alive by machines, so is it that you are on the brink of death, but something is keeping you here. Personally, I don’ think it is our decision to argue whether a person should live or die, especially a person who is immobile for 17 years. I don’t get why the government and other people related to this force this issue, maybe for political reasons. There are too many questions surrounding this, that I myself don’t even half an opinion. I mean other people who are alive and well are starving to death without any help from anyone. But the one who is dead mentally and physically are being force fed to live. I don’t see the logic in this. Yes, everyone should live, but let go, if someone who is related to them made a decision or themselves made a decision before their vegetative state to let them survive on their own without machines. It is much harder for the family than for the public to let go. It's not like they are making an irrational judgement. Each case is different and unique, what applies to one may not apply to the other. We don’t know how long someone might be in a coma. After a period of time, if you think to let go, let go. There are miracles out there of people waking up after spending years in a coma. That miracle might not be for everyone.

How tight is Airline Security in 2009?

2009-05-01T11:09:00.002-04:00

Boca Raton, FL is home to Kenton Weaver, a 13 year old boy who suffers from autism. Kenton has always loved airplanes and dreams for one day becoming a pilot.

Kenton has been known to escape from home and attempt to travel to the airport. However, on a beautiful day in April Kenton finally made it to the airport. Only this time he was driving his father’s car. Kenton not only made it to the airport without putting a scratch on the car, he also flew all the way to San Jose, California with a couple of connecting flights. The worst part of this entire debacle is that Kenton never had an id only his report card that he used as his id.

According to Southwest Airlines, the boy “presented a valid ticket for travel and underwent security to board his flight”. In addition, the Transportation Security Administrations Web site states that under federal law, “only travelers 18 and older are required to show identification”. Southwest continued to state that minors are allowed to travel alone as long as an “Unaccompanied Minor” is completed. It was not confirmed whether or not this form was completed.

When you hear a story like this you wonder if people that work at airport really pay attention to what they are doing. If you were working for the airport, wouldn’t you find it a little strange that a 13 year old child is purchasing his own plane ticket, has no luggage and no one to fill out the “Unaccompanied Minor” form? It’s a little scary that airport staff does not use their instincts to realize when things don’t seem right. If a 13 year old boy fooled the system anyone with a good plan could fool the system.

Coloring Book Helps to Teach Kids About Tragedy

2009-05-01T11:09:00.001-04:00

A coloring book with burnt out cars, buildings on fire and tornadoes does not sound like a coloring book that many parents would give to their children to color. However, this coloring book was posted on the Federal Emergency Management Agency’s web site.

The coloring book was posted on FEMA’s web site after the 9/11 attacks. The purpose of the coloring book was to help children cope with anxiety and fears that they may have had from their experiences of 9/11. However, the coloring book was removed from the website last week from FEMA’s web site.

The coloring book was created in Minnesota, by the Freeborn County Crisis Response Team. According to Rose Olmsted, a representative from the response team, “I’ve never received any criticism of the book until yesterday. “Everything we’ve heard in terms of feedback had been positive”.

This coloring book and others like it have been used for other disasters. In 2007, after the Minnesota bridge collapse a coloring book was used to help children. Australia also used a coloring book for their children after the wildfires.

Art therapy is often used to help children that have gone through traumatic events in their life. The therapy helps child to express their feelings that they often suppress after a scary experience such as 9/11.

However, a L.A. based psychologist stated that “while she does see coloring as an effective coping mechanism for children who have experienced traumatic events, she warns against one tool being used too broadly”.

If your child experienced 9/11, as a parent you would have to decide what you felt was the best method of therapy for your child. I believe that art therapy can be extremely effective in children. However, I am not sure whether or not I would want my child coloring pictures of burning buildings or burnt out cars. All children are different and all children cope with traumatic events differently. Therefore, I agree that the coloring book should not be used to help treat all children. I feel as though the help of a professional art therapist would be the best solution to the problem.

Insurance Company Denies Claim After a Woman’s Husband is Murdered

2009-05-01T11:07:00.000-04:00

Last year, Curtis McCraw was gunned down and murdered. The insurance company in which he has a $25,000 life insurance policy with is denying the claim which would be paid to his widow Stephanie McCraw.

Stephanie McCraw filed a suit against the Insurance Company stating the reason they denied the claim was because her husband had Hepatitis C. According to McCraw’s lawyer, “The policy is not specific as to whether there is a difference as to how you die. It does not event say you won’t get paid if you have a pre-existing condition”.

Curtis McCraw was gunned down last April outside of a housing project. The police declared his death a case of murder and was declared dead at the scene. Even though the police declared his death a murder the Insurance Company continues to fight the claim.

President, Michael Lowe of the company stated that “The law in Tennessee is clear that the cause of death is not relevant. What is relevant is whether the insured truthfully informed the company of his health at the time of his death”. The president continued to explain that under law the company has two years to contest the information that was provided to the company from the insured. If the company finds that the insured did not fully disclose his health history, the company has the right to rescind the policy.

At my previous job, I worked for The Hartford Insurance Company. The Hartford Insurance Company is a very ethical and trustworthy company whose best interest is their customers. Therefore, it blows my mind that a company would try and weasel there way out of this claim. It is clear that the man was gunned down and murdered. That was his cause of death not hepatitis. The actions of the insurance company could severely affect their reputation, especially in this type of economic climate. I would suggest that the insurance company pony up and pay the poor woman. If the company suspected that the customer was lying about his health, the company should have requested a blood test to be completed.

Post Marketing Surveillance…No wonder doctors are skeptical to the point of confusion

2009-04-30T00:46:00.001-04:00

For another class, I had to write a paper on the safety of statins (you’ll see why in the second paragraph). (But for now – a little background)…Statins are well established first-line drugs for the treatment of hypercholesterolaemia and dyslipidaemia implicated in the pathogenesis of coronary heart disease and atherosclerosis.1 Stains lower cholesterol levels by blocking the enzyme HMG CoA (don’t worry about the acronym for now) in the liver involved in the synthesis of cholesterol.2 There are five drugs (use to be 6 – again, second paragraph) in this drug class – each associated with certain toxicities (particularly myopathy) which may lead to a debilitating condition called rhabdomyolysis.3-5 One problem is, statin-induced myopathy is not well understood.1, 6-8 The other problem is, rhabdomyolysis is a rare muscle wasting disorder that results in muscle cell breakdown and release of the contents of muscle cells into the bloodstream. If unchecked, this could lead to renal (kidney) damage. Symptoms of rhabdomyolysis include muscle pain, weakness, tenderness, malaise, fever, dark urine, nausea, and vomiting. The muscle groups involved most frequently are the calves and lower back; however, some patients report no symptoms of muscle injury. The FDA states “in rare cases” (this probably came from the product information or package insert – can’t remember what they are calling it these days – you know, the PI) the muscle injury is so severe that patients develop fatal organ damage, including renal failure.9

The controversy (here we go) over statin use stems from Bayer Pharmaceutical’s voluntary withdrawal of Baycol®/Lipobay® (cerivastatin) in August 2001.10 Bayer received numerous reports of side effects involving muscular weakness, particularly in patients treated concurrently with gemfibrozil. Subsequently the FDA reported 31 deaths associated with cerivastatin use; 12 were associated with concurrent use with gemfibrozil.9 (What happened?) In 1997 the FDA approved cerivastatin labeling for 0.2 – 0.3 mg/day; in 1998 0.4 mg/day; and in 2000 0.8 mg/day was approved without recommendations for a maximum dose.5, 11 However, reports indicate that many physicians prescribed cerivastatin at 0.8 mg/day instead of starting at the lower dose then titrating up.5 Furthermore according to an FDA report, the rate of fatal rhabdomyolosis associated with cerivastatin is up to 80 times as high as the rates for any other statin.5 Also, concomitant medications are pervasive in statin-patient populations with high-risk factors for cardiovascular mortality. Therefore, the risk of drug-drug interactions (DDI) is quite high.

What caught my attention was a report by Psaty et al (2004) who stated that internal company reports from Bayer, specifically case reports, suggested cerivastatin-gemfibrozil DDI data was available within 100 days of the 1998 drug launch; yet the company did not add contraindications about concomitant use to the product information until 18 months after launch.11 (Okay – they knew there was a potential problem but they waited for…what to report it)? According to a 2003 European news report, Bayer fought back (of course they did!) against “claims that it was aware of possible dangers long before the drug was voluntarily withdrawn…”12 Yet, Bayer paid out $125 million to 450 individuals who experienced “serious side effects” and was in negotiations with another 500 cases through 2005.10

Ultimately, who is responsible for post-marketing surveillance? Drug companies! Pharmaceutical companies are responsible for conducting their own post-marketing trials but this is usually more beneficial to the company than it is for the safety of patients. Post-marketing trials are usually conducted to expand the label: new indications, new patient populations (e.g., children), and voila patent extension. Physicians are also responsible to report adverse drug events to the FDA – however, this is voluntary. In collaboration with the FDA’s, CDER, division of pharmacoepidemiology, safety data is gathered and shared with the product firm and an agreement is reached with the firm to determine the next step. In essence, the responsibility to pull a drug lies with the company in question; the FDA may “support” the decision and in some cases engage in litigation when companies do not comply with specific FDA recommendations. Confusing?

How must doctors feel? One minute a drug is on the market and being marketed aggressively then the next its being recalled. One minute a drug is deemed safe and “well tolerated” by patients and the next it could be a lethal weapon. Let’s face it, drugs (I do mean drugs, plural) are a necessary part of life (so is food and yes, cosmetics, too for many of us). But who is ultimately accountable for ensuring, beyond a shadow of doubt, that what we put in and on our bodies will not cause harm (including death)? Surely, drug companies cannot be the sole bearers of responsibility – for reasons, shall we call it, conflict of interest…! Then the government needs to do its job and be allowed to do its job by expanding resources which means more money more money more money…! Less we forever ride the roller-coaster of post-marketing surveillance.

Holly Tomlin
Blog 9

References

1. Tiwari A, Bansal V, Chugh A, Mookhtiar K. Statins and myotoxicity: a therapeutic limitation. Expert Opin Drug Saf. 2006;5(5):651-666.
2. Evans M, Rees A. Effects of HMG-CoA reductase inhibitors on skeletal muscle: are all statins the same? Drug Saf. 2002;25(9):649-663.
3. Kashani A, Phillips CO, Foody JM, et al. Risks associated with statin therapy: a systematic overview of randomized clinical trials. Circulation. 2006;114(25):2788-2797. Epub 2006 Dec 2711.
4. Moride Y, Hegele RA, Langer A, McPherson R, Miller DB, Rinfret S. Clinical and public health assessment of benefits and risks of statins in primary prevention of coronary events: resolved and unresolved issues. Can J Cardiol. 2008;24(4):293-300.
5. Staffa JA, Chang J, Green L. Cerivastatin and reports of fatal rhabdomyolysis. N Engl J Med. 2002;346(7):539-540.
6. Smogorzewski M. The myopathy of statins. J Ren Nutr. 2005;15(1):87-93.
7. Jamal SM, Eisenberg MJ, Christopoulos S. Rhabdomyolysis associated with hydroxymethylglutaryl-coenzyme A reductase inhibitors. Am Heart J. 2004;147(6):956-965.
8. Strippoli G, Navaneethan S, Johnson D, et al. Effects of statins in patients with chronic kidney disease: meta-analysis and meta-regression of randomised controlled trials. BMJ. 2008;336:645-651.
9. FDA. http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01095.html; 2001.
10. Bayer Withdraws Baycol/Lipobay. PR Newswire; 2001.
11. Psaty BM, Furberg CD, Ray WA, Weiss NS. Potential for conflict of interest in the evaluation of suspected adverse drug reactions: use of cerivastatin and risk of rhabdomyolysis. Jama. 2004;292(21):2622-2631. Epub 2004 Nov 2622.
12. Milmo S. Bayer Defends Itself on Baycol. Chemical Market Reporter. 2003;263(9).

Red Wine and Heart Disease: A Riddle Wrapped in an Association – Not Causation

2009-04-29T23:17:00.001-04:00

In 1991, the widely popular CBS television news show, 60 Minutes, featured a story that attributed the lower risk of heart disease in France to drinking red wine. Since the original story aired, red wine sales skyrocketed1 along with the public’s consumption of the beverage and thirst for evidence about this proposed cardioprotective effect. Seemingly everyone attempted to “cash in” on the phenomenon, particularly red wine producers2 and nutrition “experts” who marketed the nutritional value in books like the New York Times Bestseller, French Women Don’t Get Fat by Mireille Guiliano (2004 hardcover; 2007 paperback). Earlier this year CBS followed-up on the 1991 story with additional information about the so-called French Paradox.3 The “French Paradox” refers to the low rate of cardiovascular mortality in France compared to the United States despite a high fat diet.4-6 The term “French Paradox” comes from the work of an Irish physician, Dr. Samuel Black (1891), interested in the observed differences in angina pectoris in Irish patients compared to the lack of discussion about coronary diseases in French patients.7 More than a century after Dr. Black’s query, evidence of biological mechanisms for cardioprotective effects continues to emerge – slowly; yet, the momentum has not died down in the popular media where the focus is primarily the medium of ethyl alcohol (ethanol) and red wine.

The truth is epidemiologic data demonstrates an association between heart disease, health and nutritional benefits, and alcohol and red wine consumption5, 6 but the association has been misinterpreted as causally related to heart disease. While biomedical research systematically explores the relationship between red wine and heart disease by exploring the biological pathways associated with cardiovascular risk factors (e.g., obesity, diabetes, blood pressure) as well as outcomes (e.g., heart attack or myocardial infarction, death), conclusive evidence for human benefit is lacking. Yet, a lack of evidence has not stopped the paucity of marketing campaigns postulating the benefits of red wine or the benefits of resveratrol (as a nutritional supplement or pharmacologic agent) for a healthy heart, anti-aging, or to combat cancer (all types of cancer).5, 8

Resveratrol is a polyphenol found on the skin of red grapes which protects the grape from bacteria and fungi. The compound is available in detectable quantities of red wine because skins of grapes are not fermented in the production process. In vitro data for resveratrol in human tissue and in vivo mice models of obesity, cardiovascular disease, and anti-aging effects is positive;9 however, its effects are the subject of ongoing clinical investigation in humans (see clinical trials.gov for a list of 10 active trials studying resveratrol). Numerous academic institutions and pharmaceutical companies such as Sitris, a Glaxo-Smith Kline (GSK) company, have jumped on the resveratrol-anti-aging/anti-cancer/anti-obesity/decreased-heart-disease-band wagon. As such, resveratrol has been isolated and marketed as a dietary constituent despite repeated warnings from the FDA to cease selling the product as a pharmacologic agent since there are no definitive results from clinical trials.8 In fact, there are warnings against purchasing resveratrol on many sites linked to Google.

Although alcohol has a well documented cardiovascular pathway, its pathway is independent of beverage type (i.e., wine, beer, or other alcoholic spirit).10, 11 The cardioprotective effects of alcohol includes increased high-density lipoprotein (HDL), antithrombotic effects, improved endolethial function, and decreased insulin resistance.5, 6, 10, 11 These effects, however, are confounded by individual characteristics such as gender, race, age, quantity, and type of alcohol (e.g., beer may be more beneficial for men while wine or a distilled spirit may be more beneficial for women).

Established risk factors for heart diseases include smoking, systemic hypertension, type II diabetes, blood lipids, atherogenic lesions, and thrombosis damage.6, 7 Both alcohol and red wine polyphenols antioxidant properties have antithrombotic and antiatherogenic action as well as significant impact on blood lipids (HDL and LDL); however, their association to other risk factors is confounded by intake and lifestyle variables. Alcohols’ positive impact on acute physiologic events (such as high blood pressure and heart rate) is a plausible explanation for the heightened interest in the association between alcohol, red wine, and heart disease. These findings excite nutrition proponents who fail to understand that red wine and alcohol independently impact heart disease risk factors; in fact, the non-alcohol related benefits (e.g., resveratrol) can be found in non-alcoholic beverages such as grape juice, other fruits and vegetables. Furthermore, the amount of property relates significantly to the benefit such that alcohol in large quantities has equally harmful consequences.

Fortunately, biomedical researchers, pharmaceutical companies, and legitimate organizations such as the American Heart Association are not marketing red wine or alcohol as beneficial mechanisms to decrease heart disease. In fact, it appears that only independently owned organizations such as Nutra-Smart.net by Stuart Adams or Bio-Medicine.org use evidence of an association between moderate alcohol consumption and acute cardioprotective benefit as explanations for the French Paradox while purporting causal relationships. Therefore, in light of the complex evidence for mechanisms of heart disease as well as the multiple pathways for alcohol and non-alcohol benefits people should be leery of the hypothesis that red wine decreases heart disease. Since alcohol consumption to the point of abuse represents a problem for a significant portion of American adults,12 it is not wise for popular news to continue promoting red wine consumption as a legitimate benefit for a healthy heart. Instead, promoting a low-fat diet with fruits and vegetables and exercise is a much more responsible message.

Holly Tomlin
Blog 8

References

1. McGraw A. Wine drinkers spark up sales. Central Penn Business Journal. 1995;11(5).
2. Dolan C. Marketing: Wineries and Government Clash over Ads that Toast Health Benefits of Drinking. The Wall Street Journal, 1992.
3. Fountain of Youth in Wine Rx. Jan 25, 2009, 2009.
4. Opie LH, Lecour S. The red wine hypothesis: from concepts to protective signalling molecules. Eur Heart J. 2007;28(14):1683-1693. Epub 2007 Jun 1687.
5. Saiko P, Szakmary A, Jaeger W, Szekeres T. Resveratrol and its analogs: defense against cancer, coronary disease and neurodegenerative maladies or just a fad? Mutat Res. 2008;658(1-2):68-94. Epub 2007 Aug 2017.
6. Saremi A, Arora R. The cardiovascular implications of alcohol and red wine. Am J Ther. 2008;15(3):265-277.
7. Klatsky AL. Alcohol, wine, and vascular diseases: an abundance of paradoxes. Am J Physiol Heart Circ Physiol. 2008;294(2):H582-583. Epub 2007 Dec 2014.
8. FDA. Warning Letter (09-ATL-01). In: Services DoHaH, ed; 2008.
9. Baur JA, Sinclair DA. Therapeutic potential of resveratrol: the in vivo evidence. Nat Rev Drug Discov. 2006;5(6):493-506. Epub 2006 May 2026.
10. Pearson TA. Alcohol and heart disease. Circulation. 1996;94(11):3023-3025.
11. Sato M, Maulik N, Das DK. Cardioprotection with alcohol: role of both alcohol and polyphenolic antioxidants. Ann N Y Acad Sci. 2002;957:122-135.
12. CDC/NCHS, Survey NHI. Figure 31. Cigarette smoking and alcohol use among young adults 18-29 years of age, by sex: United States, 1997-2006. In: Health US, ed: CDC; 2008.

Health in the News is not the Health News

2009-04-27T12:08:00.009-04:00

The media distorts the nature of our country’s challenges, especially those pertaining to our public health. One of those challenges is what the government calls “homicide by discharge of firearms.” While it is a more prevalent cause of death for certain demographic groups (I will use age as an example), firearms homicide is far from the predominant cause of death in society as a whole. When it comes to protecting the life and health of our citizens, several other health issues are much more important than firearms homicide. My intention here is not to defend guns as much as shed light on how the media emphases different public health issues disproportionately to the issues' true effects on society.

Here is the CDC’s list of the leading American causes of death for 2005 (all statistics in this article are from 2005):

Top Death Causes (Actual #) (% of Total)
All causes (2,448,017) (100.0)
Cardiovascular disease (856,030) (35.0)
Cancer (559,312) (22.8)
Cerebrovascular diseases (143,579) (5.9)
Chronic lower respiratory diseases (130,933) (5.3)
Diabetes mellitus (75,119) (3.1)
Alzheimer's disease (71,599) (2.9)
Non-transportation accidents (69,368) (2.8)
Influenza and pneumonia (63,001) (2.6)
Motor vehicle accidents (45,343) (1.9)
Kidney failure (42,868) (1.8)
Infection (34,136) (1.4)
Suicide (32,637) (1.3)
Chronic liver disease and cirrhosis (27,530) (1.1)
Hypertension / hypertensive renal disease (24,902) (1.0)
Parkinson's disease (19,544) (0.8)
Lung Tissue Inflammation (17,129) (0.7)
Human immunodeficiency virus (12,543) (0.5)
Homicide by discharge of firearms (12,352) (0.5)

Granted, the above data is for the entire population and is skewed toward natural causes and disease because of the inclusion of the elderly.

However, if we isolate the age group with the highest number of firearms homicide victims, firearms homicide is still far from the number one cause of death. Just as the general population numbers are skewed by the elderly against firearms homicide, the numbers for ages 15-24 are skewed in favor of firearms homicide (plus auto and other accidents) because of this group’s superior overall physical health and lack of world experience. In plain language, when people between the ages of 15 and 24 die, it is least likely from natural causes and most likely from their own stupidity.

Top Death Causes Ages 15-24 (Actual #) (% of Group)
All causes (34,234) (100)
Motor vehicle accidents (10,908) (31.9)
Homicide by discharge of firearms (4,499) (13.1)
Non-transportation accidents (4,465) (13.0)
Suicide (4,212) (12.3)
Cancer (1,717) (5.0)

This 15-24 age group is an extreme example. While the number of firearm homicides is unacceptably high for this age group, where is the outcry over the number of deaths from motor vehicle accidents? While a discussion about outlawing cars would be absurd, why is there not a similar (let alone a greater)media lust for traffic safety as there is for gun control? Why is it that motor vehicle accidents kill twice as many people as firearm homicide, yet the latter is hyped up in the news while the former is not?

To put it in perspective, let us look at an age group that 1) eliminates the very young and very old outliers and 2) has the firearm homicide death rate (4.6 per 100,000) closest to the firearm homicide death rate for the entire population (4.2 per 100,000). That age group is 35-44.

Top Death Causes Ages 35-44 (Actual #) (% of Group)
All causes (84,785) (100)
Cardiovascular disease (15,852) (18.7)
Cancer (14,566) (17.2)
Non-transportation accidents (9,624) (11.3)
Motor vehicle accidents (6,748) (8.0)
Suicide (6,550) (7.7)
Human immunodeficiency virus (4,363) (5.2)
Chronic liver disease and cirrhosis (2,688) (3.2)
Diabetes mellitus (2,045) (2.4)
Homicide by discharge of firearms (2,010) (2.4)

Going by the statistics for this demographic group, if the primary motivation of the media was the welfare of Americans, then there would be over three times as many stories in the national news about traffic safety as there were about firearm homicide. There would also be three times as many stories about suicide as there were about firearm homicide. One would think there might be at least twice as many (let alone eight times as many) stories about cardiovascular disease as there were about firearm homicide.

It is pretty safe to say that is not the case.

It would seem that the media is less motivated by the health, safety, and well-being of the American people than it is motivated by a hatred of guns.

Here is one last point, to emphasize that I am not defending gun violence but attacking what the media chooses to emphasize. During the darkest days of the Iraq war, the media howled incessantly about our soldiers dying in Iraq, while a much worse slaughter was happening here at home. In 2005, 673 Americans were killed in action in Iraq, while 18,124 Americans (27 times that number) were firearms homicide victims here at home. Relying on the media, one would not have realized that.

The lesson here is, when it comes to health news (and all news in general), view the stories that the media chooses and thus emphasizes with a great deal of skepticism.

Sources
Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; vol 56 no 10. Hyattsville, MD: National Center for Health Statistics. 2008. http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf Accessed 4/25/09

United States Department of Defense. Global War on Terrorism - Operation Iraqi Freedom
By Month http://siadapp.dmdc.osd.mil/personnel/CASUALTY/oif-total-by-month.pdf Accessed 4/26/09

Homeland Security? For Swine Flu?

2009-04-26T15:10:00.005-04:00

I watched the press conference today in which the Homeland Security Secretary, Janet Napolitano, was coordinating the United States’ Swine Flu efforts.

From its inception, the Department of Homeland Security has been chargrd with taking the lead in a pandemic (which we do not yet have). I need convincing that this is the best policy.

Not only does a DHS Secretary lack the medical qualifications and expertise to lead the planning for this possible crisis, but this takes her attention away from the whole reason her position exists—protecting the United States from terrorism. The message is that we are not offering the most appropriate response in one area of concern while taking our eye off the ball in another area of concern.

She has been put in charge over the Cabinet Secretary (or actually Acting Secretary—that this position is still not officially filled three months into the administration points to another problem) whose assumed area of expertise is in the current area of concern—public health. The DHS Secretary was placed in charge over the Department of Health and Human Services (HHS) Acting Secretary Charles E. Johnson and the various agencies under his direction, including the Centers for Disease Control.

The Department of Homeland Security was created specifically to guard against terrorism on U.S. soil. Being the DHS Secretary requires one’s area of expertise to be protecting the U.S. against terrorism. If her area of expertise is in health rather than terrorism, then why is DHS Secretary in charge of health policy? One can argue that a possible pandemic IS a matter of domestic security, but that is wrong, especially at this juncture. The Department of Homeland Security should only become involved only if a pandemic had caused a breakdown of society with the resulting chaos placing the country’s infrastructure and citizens at greater risk of terrorism. We are not even near that situation, but even then, the DHS Secretary would not have the lead but be one of many considerations. Instead, a Department Secretary whose supposed area of expertise is not even in the area of current concern is in charge of Secretaries who are better qualified to handle the situation than she is.

Swine Flu and the Right Thing to Do?

2009-04-25T20:02:00.005-04:00

The outbreak of swine flu in Mexico (which has spread to the U.S.) raises some difficult questions.

As of this writing early Saturday evening (4/25/09), news outlets were reporting that 20 to 80 are dead in Mexico with over 1000 infected, and 0 dead in the U.S. with roughly 15 infected (California, Texas, Kansas and New York). The Mexican president has declared an emergency, giving himself broad powers to impose quarantines and cancel events. The Mexico City government has closed school indefinitely and canceled other activities involving gatherings. This strain of swine flu does not kill only the very young or very old. An unnamed Mexican government source claimed most of the dead there are between 25 and 45 years old.

I am not an expert in the spread of disease, so I do not know if it is too late for travel and trade restrictions, should conditions in Mexico deteriorate to the point where they may be needed. When should health-related travel restrictions be placed between countries, essentially placing a country under quarantine? A pre-mature travel ban could spark cries of racism or xenophobia. If a travel ban should be necessary, will authorities wait longer than they otherwise would out of racial or diplomatic sensitivity? Feelings and pride are irrelevant when lives are at stake.

There are other questions. What are the rights of private citizens to move around and conduct commerce vs. society’s right to be protected from the spread of disease? How far should worldwide swine flu conditions have to deteriorate before the World Health Organization (WHO) declares a pandemic? A pandemic declaration by the WHO asks for voluntary worldwide trade and travel restrictions. With the world economy already in shambles, there will doubtless be pressure to postpone a pandemic declaration as long as possible. Some countries would comply, while others would not. What actions should be taken against countries that are not complying and are thought to be endangering other populations?

If we are fortunate, we will not have to learn the answers to these questions.

Sources
http://in.reuters.com/article/oilRpt/idINN2443181920090424
http://www.bloomberg.com/apps/news?pid=20601087&sid=aEsNownABJ6Q&refer=worldwide
http://www.alertnet.org/thenews/newsdesk/N24449988.htm
http://www.breitbart.com/article.php?id=D97PNI383&show_article=1

A Non-Religious Case against Abortion

2009-04-25T15:12:00.014-04:00

I have concluded that abortion is wrong, but my reasons are not based on religion. Don’t get me wrong. Unlike the specious Bill Maher, I am not anti-religion. However, “the Bible says so” is not an acceptable basis from which to argue a point. While I am religious, my conclusions about abortion are based on humanistic and (yes) secular considerations.

First off, life begins at conception. Once the egg is fertilized, a chain of events is unleashed that, outside of malformation, medical problems, homicide or accidental death, invariably result in a fully formed adult human.

From conception through their mid-teens, human beings are in a constant state of physical development, gaining physiological capabilities and self-sufficiency. Not being fully physically developed is not an acceptable rationale for discounting one’s humanity. Does a pre-pubescent inability to reproduce make a child any less human? Does a baby’s inability to walk or speak make her any less human? Does not having teeth make an infant any less human? Does an infant’s inability to feed or defend himself make him any less human? Does having a soft skull make an infant any less human?

Of course, it does not.

By that rationale, not breathing air but getting nutrients from an umbilical cord does not make a baby any less human. Not having fully formed eyes does not make her any less human. Not having a fully developed brain does not make him any less human. Thus, development at any stage, including nascent development, does not make a person less human.

Human beings are physically dependent on their parents (especially, and increasingly so in modern times, their mothers) for nutrition and protection to varying degrees from conception through their mid-teens. A ten-year old depends on her parents for protection (no one is inclined to go to extremes to protect a child as is that child’s biological parents) and the means to acquire food. A five year old depends on his parents for protection and nutrition (lacking the means and knowledge to acquire proper food, both today and in prehistoric times). A six month old is dependent on her parents for protection and nutrition (mother’s milk or formula). In the same way, a person in utero is dependent on her mother for nutrition and protection from conception to birth.

It is intellectually inconsistent that society charges parents with the responsibility of providing nutrition and protection to their post-utero children but not in utero.

Many people mistakenly think that a child in the beginning is not human but a mere glob of cells. Let us look at in utero child development.

In a previous blog, I wrote about how genetic testing of fertilized eggs is now used to pick traits in children such as eye color, skin pigmentation, hair color, sex and more. If those traits are already determined in a fertilized egg, it is difficult to argue that the egg, zygote, fetus, or whatever one wants to call it, is non-human. While not yet manifested at this age, the child’s traits, including eye color, hair color, sex and even (to a large extent) personality are set. He or she is more than mere nondescript cells.

For some reason, pregnancy is officially calculated as starting on the first day of the woman’s last period, though conception generally takes place two weeks after that. Thus, most discussions of child development are misleading, since people are left with the impression that the child is two weeks older then he or she really is. In reality, the child initially develops and manifests widely known human characteristics much more quickly than people are led to believe. Therefore, I am going to describe child development in terms of “weeks after conception” instead of the common (and in my opinion, misleading) “gestational weeks.”

The first week begins with conception, and the child instantly starts to grow new cells as she travels down the fallopian tubes and lands in the lining of the uterus.

In the second week after conception, the child continues to grow new cells that divide into different groups, laying the initial groundwork for different areas of the body.

In the third week after conception, the child’s heart, spine and brain begin to form, though he is only 1/25 of an inch long. (This is about the time generally when a woman is missing her period and suspecting an unplanned pregnancy.)

In the fourth week after conception, while she is not more than of an inch long, the child’s heart starts to beat, pushing her own blood around her own circulatory system.

In the fifth week after conception, the mouth and digestive system are beginning to develop. Arms, legs and hands are starting to form. The baby is roughly 1/8 of an inch long.

In the sixth week after conception, the baby is about 1/3 inch long, and the eyes and nostrils are developing. Fingers, toes, and genitalia are beginning to develop. (Roughly, 62% of abortions are performed by this time (8 weeks gestation)).[1]

In the seventh week after conception, fingers and toes are taking shape, and the baby is at least ½ inch long.

In the eighth week after conception, the internal organs (including testes or ovaries) are all formed and the baby is about 1 inch long.

In the ninth week after conception, the baby is 2 inches long, and his skeleton is developing.

In the tenth week after conception, the genitalia are identifiable and sex is distinguishable.

In the eleventh week after conception, the baby is 3 inches long and has fingernails and toenails. (Roughly, 88% of abortions are performed by this time (13 weeks gestation)).[1]

There are many social and economic reasons why women feel compelled to abort their children. However, whatever motive one has for aborting a child, one cannot claim that abortion does not kill a human being. It does. An aborted baby is more than a discarded glob of random, unorganized cells. "It" is a dead human being.

References

[1] Abortion Surveillance — United States, 2005. Centers for Disease Control and Prevention. November 28, 2008 / Vol. 57 / No. SS-13. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5713a1.htm Accessed 4/24/09

Fetal development: What happens during the first trimester? Mayo Clinic. http://www.mayoclinic.com/health/prenatal-care/PR00112/METHOD=print Accessed 4/24/09

Pregnancy calendar. Nemours. http://www.nemours.org/e-service/kidshealth.html?p4if_ps=102 Accessed 4/24/09

¿Tu hablo inglés?

2009-04-23T16:03:00.001-04:00

What did you say? ¿Cómo? Many hospitals, emergency rooms, clinics, and healthcare personnel must deal with language barriers every day. With the numbers of immigrants in the United States increasing rapidly, the need for translators also increases dramatically. But, it seems that the lack of translators is not the problem, as is the doctors’ attitude towards using translators. In the article, “Lost in Translation,” physicians admit to not using translation services because it takes too much of their time, which can be used for more time with more patients. They admit to having a negative attitude toward employing translators when visiting patients in the hospital, even surgical patients. Dr. Pauline Chen, author of the article, when meeting with a Spanish-speaking patient after performing kidney transplant surgery, admits, “Pressed for time and acutely aware that a couple dozen more patients were always waiting, I never called an interpreter to Armando’s room during my daily rounds after his operation. Although interpreters were available at all times, it would take time, I thought, for one to arrive, and then the translation itself could slow things down.”

The article reports that there has been numerous research studies conducted on the use of translators and the effect of language barriers in healthcare. “…according to a new study published in The Journal of General Internal Medicine, doctors’ assumptions about communication — what they deem important in a conversation — may also have a role.” Dr. Chen says that although she would use translators to speak with patients about lab results, potential complications, or medication regime, she did not use them for “more routine checks.” She admits to “getting by” by feebly stumbling “through three, maybe four, words of Spanish.” In the recent study published by the Journal of General Internal Medicine, Dr. Alicia Fernandez and her research team at the University of California, San Francisco, studied language barriers at two hospitals with “excellent translator services.” Her study found that “While the doctors acknowledged that they were underutilizing professional interpreters, many made the decision not to call an interpreter consciously, weighing the perceived value of patient information against their own time constraints. Moreover, despite their personal misgivings, the doctors often felt that this kind of shortcut was acceptable and well within the norms of their professional environment.”

It seems clear from the results of the study that many physicians are bothered by the need for translators and see them as irrelevant and a waste of time. But what does this say about their attitude toward the patient? Does not their attitude toward using translators emote an attitude of resentment toward non-English-speaking patients? Do they not value their quality of life the same as those of English-speaking patients? Is it not the creed of physicians to “first do no harm,” regardless of race, creed, or in this case, language? Dr. Fernandez even admits about herself that she if “‘rounding late at night, (I) might just decide not to use an interpreter.” Through conducting this study, Dr. Fernandez realized that not employing the use of translators “‘…has become an acceptable shortcut in care. But the truth is that the patient deserves to speak to the doctor as well.’” She admits that this negative attitude towards using translators is not reflective of their feelings toward translators, their patients, or even their time pressures, but “yet “how we (as doctors) think about communication with our patients.”

According to the study, 43 percent of people in California do not speak English in their homes. So, the use of translators in a medical setting is critical to their ability to communicate with almost half of the California population. Too, not only does the doctors’ lack of translator use cause a problem, but the study also cites costs of translator services as a cause. Acknowledging this issue, Dr. Fernandez reports that “…many doctors simply do not have access to basic interpreter services…(however) California recently passed an unprecedented law mandating that health and dental plans supply interpreters and translated material to H.M.O. and P.P.O. patients.” Although this law may be a positive step towards increasing the number of translators in a medical setting, the article reports that “…still leaves a growing segment of the population – more than 20 million people in the United States – with inadequate care.”

If we are to improve quality of care for all United States residents, congress must acknowledge the growing need for quality healthcare for every one, even those non-English-speaking people. But where in the long line of problems with healthcare does the need for translators fall? With all the issues with healthcare today, including the millions of people without healthcare insurance, rapidly increasing nursing shortages, and the FDA coming under fire for controversial drug approvals, where does the effect of language barriers on quality of life fit in? What gets first priority? Not to knock language barrier problems or FDA drugs, but as one without healthcare insurance, I hope it is first in line. But that’s just my selfishness showing. Forgive me, I am working on it.

Poor Justice for the Innocent

2009-04-20T22:41:00.005-04:00

Living a Life Sentence

Kelly Cobiella

CBS Sunday Morning

April 19, 2009

Anything can happen to anyone at anytime and good things do not always happen to good people. One of the worst nightmares that can happen in a person’s life is to be falsely imprisoned and, even worse, executed. But this recurring nightmare has been experienced by thousands of people through the years. Some spend the remainder of their lives in prison, never returning to the life they once knew. Thanks to the breakthrough of DNA evidence, many have been fortunate to be exonerated of rape and murder charges after years and even decades behind bars. Others are freed as a result of determined sleuth work on the part of supporters or loved ones, people recanting original testimonies, suppressed evidence being revealed, or the surfacing of new evidence. Whatever the circumstances of their release, all of the newly freed face the same challenges of reintegrating into society.

After the initial elation of finally achieving the dream of freedom, reality is a real slap in the face for the newly exonerated. While decades passed, society moved on, technology advanced, and life slipped away. Homes were lost, careers destroyed, families broken up, insurance coverage stripped away, and children grew up. Release brings a new beginning for the wrongfully accused, with a prison record on their resumes. Many were imprisoned based on little or no evidence. In some cases, evidence was suppressed by police or prosecutors, physical evidence planted by police, other evidence manufactured by forensic scientists, and lying witnesses knowingly placed on the stand by prosecutors, all for the purpose of getting a conviction, whether to advance a career or for political or other reasons.

Beverly Monroe was 55, with a successful career as a chemist, when she was convicted of murdering her companion, Roger de la Burde, in 1992, even though police thought it was a likely suicide. There was no other evidence against Beverly but the prosecutor withheld this crucial information during her trial. Beverly’s daughter, Kate, was just starting her career as a lawyer and she quit her job to devote the next six years to freeing her mother, which she was able to do in 1999 based on the suppressed evidence. Beverly is now 62 and trying to piece her life together. Although potential employers have been sympathetic to her story, her prison record remains, and she has only been able to find a job as an administrative assistant with no benefits, a stark contrast to the success she had enjoyed before her conviction.

Following her mother’s release from prison, Kate Monroe moved to Utah to work as executive director of the Rocky Mountain Innocence Project, which has worked to pass a compensation law to aid the wrongfully convicted upon their release from prison. The law, which was passed in 2008, awards about $35,000 for each year of false imprisonment up to 15 years, and expunges the person’s criminal record. Only 25 states have such a program. Virginia, where Beverly Monroe lives, is not one of them. Another group called the Innocence Project has helped free 235 people with DNA evidence; 17 of them were on death row. The Innocence Project also works to reform the criminal justice system in order to prevent recurrences of such stories, many of which are far worse than Beverly Monroe's.

It’s true that mistakes can happen. But it’s hard to imagine the sheer powerlessness and devastating bitterness one must feel at the hands of someone who deliberately steals your life from you for personal gain. We never hear the names of the prosecutors or police officers who tamper with evidence or suppress information. There must be a law that is protecting them. We need laws that provide accountability for such misconduct. Or maybe we have them but the victims simply don’t have the fight left in them or the resources to engage in another battle. Or maybe they’re just grateful to be free. It seems that there is a conspiracy of silence regarding this issue. It is fair that victims of the justice system should be compensated and their records expunged in the case of wrongful incarceration. State governments should all adopt laws similar to the one passed in Utah and I further propose that resources should be allocated to psychological counseling and job counseling, as well as job placement and other services to ease the transition from prison to society. It wouldn’t give back the lost years but it would help to make the remaining ones better.

How Green Is the Color of Money?

2009-04-19T11:58:00.009-04:00

Stick Your Damn Hand In It: 20th Birthday of the Exxon Valdez Lie

Greg Palast

March 23, 2009

Twenty years after the Exxon Valdez dumped 11 million gallons of crude oil into Prince William Sound in Alaska, marine life still struggles to recover from the largest oil spill in US history. The oil spill was a result of negligence on the part of Exxon. The Valdez was sailing with faulty radar equipment and lacking other equipment that could have prevented the crash and contained the spill, as required by law. Exxon was not merely negligent: Executives made a deliberate decision to do without the oil spill equipment in order to save money, after they had promised to use it. Exxon blamed the spill on human error caused by a drunken captain, who was actually not even navigating the vessel at the time.

Prince William Sound is in a remote enclosed area that made it especially difficult to contain and clean up the spill. The effects were devastating on the environment, wildlife, and commerce in an area that was already fragile from the ravages of pollution. Some species, including one group of orcas, or killer whales, now face extinction, while another group of orcas is taking longer than expected to recover. Some species that do eventually recover (this may take another 10 years for the orcas) will never be the same due to altered family systems and stunted growth patterns caused by the spill. Air pollution carried across the Pacific Ocean from China and Southeast Asia has exacerbated the situation by causing toxic substances to lodge in the fatty tissue of the whales, resulting in a diminished ability to reproduce. The human toll included bankrupt businesses and individuals, suicide, starvation, and increased alcoholism within the Native Alaskan community of fishing villages. The $5 billion in punitive damages that Exxon was required to pay to the 30,000 Natives and fisherman of Prince William Sound was reduced to half a billion dollars, one-tenth of the original award. The litigation continued for 20 years, promises made to the villages and fisherman were never kept, and about one-third of the fisherman have died waiting for their award to start trickling in from Exxon. Meanwhile, Lee Raymond, who was president of Exxon at the time of the spill, retired in 2006 and received a $400 million retirement bonus.

Exxon Mobil recorded a $45.2 billion profit in 2008, up almost 19% from 2007, setting a new US record and toppling Fortune 500 giant Wal-Mart from its six-year number one spot in the process. This against the backdrop of soaring gas prices of well over $4 per gallon, which left many Americans unable to afford travel for the basic necessities of life, such as commuting to work or buying groceries. Exxon is currently running a PR campaign for green energy alternatives. These television advertisements are heavy with gender and racially diverse scientists and technicians idealistically singing the praises of Exxon’s explorations into eco-friendly fuel innovations. One such ad makes the claim that liquefied natural gas is a clean fuel. The UK Advertising Standards Authority (ASA) adjudicated that the ad was misleading and could not be aired, after some astute viewers notified the authority. Liquefied natural gas causes significant carbon emissions. Some of Exxon’s innovations have merit but fossil fuels remain the basis of Exxon’s business.

Most people have forgotten the Exxon Valdez, but the community and wildlife that have suffered the consequences of Exxon’s negligence and lack of accountability will never be the same. Twenty years later, proudly touting a newer, greener image, Exxon Mobil, with it’s policy of deception, contempt for the environment, and greed, remains essentially the same.

Have we become uncomfortably numb?

2009-04-16T19:45:00.003-04:00

Are We Numb to Mass Murder?
Jeff Glor
CBS News
April 5, 2009

In the wake of the mass shooting at the Binghamton, NY American Civic Association where 41-year-old Vietnamese immigrant Jiverly Wong gunned down 13 people who were studying for their citizenship exam before he finally shot himself, the writer of this article asks us, “Are we numb to mass murder?” The writer asserts that this is so, that the public’s reaction has become ritualized, and that people are more concerned with economics than gun control. Furthermore, it doesn't appear that our political leaders are inclined to do much about the problem, aside from offering condolences to the towns and the families that have been traumatized by these events, while hundreds hold vigil for the unfortunate victims.

Everyone still remembers the Columbine shootings 10 years ago, when 15 high school students and teachers were shot down by a fellow student, and Virginia Tech two years ago where the death toll was more than double that of Columbine. There were others before and after that. In the past month 47 people died as a result of six mass shootings. The trend has migrated to Europe as well: Finland had two mass shootings within one year in 2007-2008 and a teenager in Germany shot 15 people in Germany this past March.

These events are tragic, horrifying, and gruesome. And they have become common. But I don’t think people are numb to mass murder—I think they just feel powerless. Honestly, what can anyone do? We can all become paranoid and start mistrusting everyone we see and avoiding public places, but that would put a halt to our lives as we know them. Unless they are actually experiencing the event, people are of necessity going to detach from these events—you could go insane with grief, outrage, and incredulity over the commonality of these events and the fact that the virus has migrated to the rest of the world, as well. People have to go on with their lives. Look at Israel and the Middle East, where a suicide bomber could kill an entire café full of people enjoying an afternoon cappuccino in a matter of minutes: The citizens of these countries continue to live their lives, even though they could die at any moment. They just take precautions. Philosophers state that we should live each day as though it is our last—well, here it is in action. The human spirit can rise about tragedy.

Quite realistically, the economy is a far more immediate danger to survival for most people today than the possibility of being murdered in a mass shooting spree. People are justified in worrying about the economy. They are protecting their families. The chances of losing your investments or your home seem more likely than the chance of getting murdered.

I don’t think tougher gun laws are necessarily the answer. I think we need to focus on stricter enforcement and follow-up of existing laws, with new provisions for mental illness. I don’t want everyone touting a gun, either. But I also don’t want my Constitutional rights curtailed. The right to bear arms was an essential freedom that our Founding Fathers insisted on for the protection of our people against a (despotic) government that misused its power. I don’t want just the army and the police to be allowed to have guns and then private citizens are left without a means to protect themselves against potential abuses of power. I don’t have a gun and I don’t want one but I want to be able to know that I can have one when I need it. I hate guns.

Clearly, our society requires an overhaul of its system of dealing with troubled teenagers and people who exhibit the warning signs of potential violence. It may not be politically correct, but it can save lives. I think there is an element of copycatism involved in these crimes. One crazy person got the idea more than a decade ago and it caught on like wildfire. So, should we stop reporting on these crimes and giving these people their 15 minutes of fame? It might actually stop some of the violence but that’s not a solution, either. I believe it is time for our lawmakers and mental health experts to begin studying this problem in earnest and drafting a workable plan for stopping these crimes of rage.

Personally, I feel a little sadder, a little more frightened each time I hear about one of these slayings because, to me, with each new incident, I feel that the odds of my life being touched by such an event are increasing, that it is coming a little closer to home. I feel a little more worried each time I read about a mass murder. I feel a little less inclined to spend time in public places, a little more watchful of my surroundings. I feel that my freedoms are being replaced by fears. I don't like it but I don’t know what to do about it, other than pray for the victims, pray that the violence stops, and continue with my life.

Memory erasing/enhancing: the possibilities...

2009-04-14T18:44:00.001-04:00

A recent New York Times article asks: What would your life be like if you could erase certain memories by tinkering with a single substance in the brain? Imagine being made to forget a chronic fear, a traumatic loss, or even a bad habit. This notion seems like a cheesy Sci-Fi movie; however researchers are on the verge of making memory erasing a reality.

Dr. Todd C. Sacktor and his team of scientists from SUNY Downstate Medical Center have been able to show how a single dose of an experimental drug can, in animals, block the ability of the brain to hold onto specific types of memories.

The positive side to this research includes the fact that the drug blocks the activity of a substance that the brain apparently needs to retain much of its learned information. And if enhanced, the substance could help ward off dementias and other memory problems. With an estimated 100 million Alzheimer's and dementia sufferers worldwide by the year 2050, this appears to be a clearly beneficial target treatment.

This possibility of memory editing has enormous possibilities; yet it also raises huge ethical issues. For example, how will erasing specific memories affect humans? Any such drug could be misused to erase or block memories of bad behavior, even of crimes. It may seem beneficial to erase traumatic memories, but the erasure of other troubling memories, and the healthy dread of them, form the foundation of moral conscience.

I know that memories of punishments from parents and other authority figures have had a major impact on my decision making and resultant actions. If I had no recollection of the way I felt during punishments, then I would probably be apt to repeat the same mistakes. If somebody erased those types of memories, then it would be like somebody squashing my internal "Jiminy Cricket".

A substance that improves memory would raise larger social concerns in addition to ethical concerns. For example, when scientists find a drug to strengthen memory, will everyone feel compelled to use it? People already use smart drugs and performance enhancers of all kinds; so a substance that actually improved memory could lead to an arms race.

At this point in time, the ethical and social implications of memory erasing/enhancing are just another future dread. However, we can all find comfort in the fact that such drugs may never even make it to human trials. Also, we can always rely on our government to halt any possibilities of future research. I say this because there may actually be positive aspects to this type of drug, such as Alzheimer's treatment, and we know how the government has reacted to promising studies (pre-Obama days)…case in point: will stem cell treatments ever get off the ground?

BW706: Blog #12
Lisa Menard

Humanising Medicine

2009-04-09T18:35:00.001-04:00

Currently, I am a medical writer for clinical trials. The human aspect of my job is hard to ignore considering that I am writing about subjects' immunology and safety results. However, a recent New York Times article took me back to my earlier days of working as a medical technologist in a hospital microbiology laboratory; a time when the human aspect was not always present.

As a technologist, I spent many hours processing serum samples through machines, and, at times, feeling like a machine myself. In other respects, I had to force myself to de-humanize the certain samples due to their inherent nature. For example, I would pretend that stool samples were actually mud; however, it was difficult to keep the mental image of mud when that mud also contained corn.

The main point is the fact that the job duties became extremely mechanical in nature. The workload was high, and the manpower was low. Therefore, tasks must have been performed efficiently without extended thought, and it was very easy to forget about the human aspect of the job.

Dr. Yehonatan Turner, a radiologist from Jerusalem, appears to have the same problem in his field, but he thinks that he has come up with a solution.

When Dr. Turner began his residency in radiology, he was frustrated that the CT scans he analyzed revealed nothing about the patients behind them. So to make things personal, he imagined each patient was his father. But then he had another idea; to attach a photograph of the actual patient to each file.

Dr. Turner’s hunch turned into an unusual medical study. Its preliminary findings suggested that when a digital photograph was attached to a patient’s file, radiologists provided longer, more meticulous reports. And they said they felt more connected to the patients, whom they seldom meet face to face.

In the digital age, adding a photo to a file is a simple procedure, and the study’s authors say they hope it becomes a standard procedure; not just for radiologists, but also for pathologists and other doctors who rarely have contact with patients.

However, attaching photos to patient files could prove difficult in the United States. Privacy rules might require patient consent each time a photo was used.

Putting aside any ethical implications concerning privacy, the logistical considerations alone should be enough to thwart any thoughts of this photo system. Who supplies the photo? Would photo costs be covered under health insurance? What is done with the photos after a X-ray is processed? Would healthcare institutions need a separate filing area for all of these photos?

While Dr. Turner's heart seems to be in the right place, I think that his passion for photography and art should remain separate from his radiology career. I mean, where would the photograph madness end? If I were still a medical technologist, would I want to see the face of the patient's stool that I am plating?

I think the answer is that each individual in the medical field should take it upon themselves to find their own human inspiration behind mundane and mechanical tasks. For me, it was my once week expeditions out of the microbiology lab. I volunteered to be the individual to maintain the bloodgas machines in the Intensive Care Unit. If seeing people dying doesn't make you see the human aspect, then you're definitely in the wrong business.

BW706 Blog #11
Lisa Menard

You Mean I Don’t Need a Pap Every Year!

2009-04-08T23:49:00.000-04:00

I am flabbergasted and stunned. After reading the article in the New York Times, “DNA Test Outperforms Pap Smear,” I am speechless. And, I’m not just referring to the new development that a new DNA test for the virus that causes cervical cancer will eventually replace the Pap smear. I’m referring to the fact that the article reveals a fact of which I was not aware. “Since 1987, she (Debbie Saslow, director of gynecologic cancer for the American Cancer Society) said, the cancer society and the American College of Obstetricians and Gynecologists have recommended Pap smears only every three years after initial negative ones. In 2002, they recommended the HPV test too, and evidence is mounting that the Pap smear can be dropped.” Dr. Saslow went on to say that, “‘But we haven’t been able to get doctors to go along… The average gynecologist, especially the older ones, says, ‘Women come in for their Pap smear, and that’s how we get them in here to get other care.’ We’re totally overscreening, but when you’ve been telling everyone for 40 years to get an annual Pap smear, it’s hard to change.’”

The article then reveals that this new development, DNA testing for cervical cancer, may only have to be done every 3 years. “Not only could the new test for human papillomavirus, or HPV, save lives; scientists say that women over 30 could drop annual Pap smears and instead have the DNA test just once every 3, 5 or even 10 years, depending on which expert is asked.” However, the significance of this test will depend on the gynecologists’ willingness to administer this test instead of the Pap smear. In the 1950s, when cervical cancer was a leading cause of death for women, the Pap smear was extremely effective. However, today, cervical cancer only accounts for less than 4,000 deaths each year. So, the importance or significance of the Pap smear has lost its validity. The article notes that most countries may have been reluctant to administer the DNA test because of its overwhelming cost. But, “In poor and middle-income countries, where the cancer kills more than 250,000 women a year, cost is a factor, but the test’s maker, Qiagen, with financing from the Gates Foundation, has developed a $5 version and the price could go lower with enough orders, the company said.” In this country, Pap smear results may take several days. But the DNA screen will be read by machines, providing results much quicker. In third-world countries, Pap smears fail because women often can not return and there are fewer available trained gynecologists. A study conducted in India revealed, “…none of the women who were negative on their DNA test died of cervical cancer.” With this test, women over 30 may not need testing but every 5 to 10 years, improving quality of life and reducing deaths due to cervical cancer.

So, if this is true, why would the doctors in the United States not provide this type of information to their patients? I’ve been having unnecessary panic over getting a Pap smear annually, when I could have been getting them every 3 years. Why would the doctors not inform us of this fact? Is it to make more money, and not necessarily to improve our quality of life? I have several sisters, and after speaking with them, they revealed that they were never told this by their gynecologists. Why? Other research revealed that:
* If you are younger than 30 years old, you should get a Pap test every year. If you are age 30 or older and have had 3 normal Pap tests for 3 years in a row, talk to your doctor about spacing out Pap tests to every 2 or 3 years. If you are ages 65 to 70 and have had at least 3 normal Pap tests and no abnormal Pap tests in the last 10 years, ask your doctor if you can stop having Pap tests. (http://www.womenshealth.gov/faq/pap-test.cfm#pap04).
* You should have your first Pap smear when you start having sex or by age 18. Continue having a Pap smear once a year until you've had at least 3 normal ones. After this, you should have a Pap smear at least every 3 years, unless your doctor thinks you need them more often. Keep having Pap smears throughout your life, even after you've gone through menopause. (http://familydoctor.org/online/famdocen/home/women/reproductive/gynecologic/138.html).
* If you are over age 30 or your Pap smears have been negative for 3 years in a row, your doctor may tell you that you only need a Pap smear every 2-3 years. (http://www.nlm.nih.gov/medlineplus/ency/article/002125.htm).

So, I have to continue to wonder about the motivation behind gynecologists’ insistance on annual Pap smears, especially for women over 30 years old. Is it monetary based or quality of life concern? According to the article, the hesitation is not because of high costs of the DNA test. “Dr. Jan Agosti, the Gates Foundation officer overseeing its third world screening, said Qiagen’s new $5 test — which proved itself in a two-year study in China — runs on batteries without water or refrigeration, and takes less than three hours. In countries where women are ‘shyer about pelvic exams,’ she added, it even works ‘acceptably well’ on vaginal swabs they can take themselves.”

You can be sure that I’ll be bringing up this matter with my gynecologist, especially since the dreadful time has come this month. Now, I can’t wait to go to the doctor.

Three Steps Back for Women

2009-04-06T20:30:00.001-04:00

Worse Than the Taliban
Jon Boone
The Guardian
March 31, 2009

Afghanistan’s President Karzai reportedly signed a law last month that contradicts the country’s own constitutional provisions for equal rights for women. The new law, which was rapidly passed with little debate, and has not been published, allows for the Shia sect to have its own jurisprudence regarding family law, much to the dismay of some female parliamentarians. This law is also in conflict with international treaties. The new law comes out in time for the upcoming presidential elections in Afghanistan, which are expected to be a close battle this year, as Mr. Karzai has become increasingly unpopular. It is believed that the new legislation curries the votes of Shia Muslims, which comprise about 10% of the Afghani population, as well as the Hazara, who are also Shia, and a powerful minority in Afghanistan. The Hazara represent about 20% of Afghanistan’s population.

The articles of the new law are believed to include provisions that women are required to have their husbands’ permission in order to leave the house, seek work or education, or visit the doctor. Additionally, women are not allowed to refuse sex when demanded by their husbands. The law also gives custody of children to fathers and grandfathers. Some female parliamentarians argue that, although the law is not perfect, it is an improvement over earlier drafts of the law, which included a proposed marriage age of nine for girls (it was raised to 16) and provisions for temporary marriages. According to the ministry of justice, the law still has “technical problems” that must be resolved before it will be published.

The United Nations Development Fund for Women (UNIFEM) have decried the new law but the international community appears to be avoiding the issue, Presdident Obama included, hiding behind the shield of cultural sensitivity. I have to admit I was truly disappointed as I watched Mr. Obama’s response to a reporter’s question regarding the new law at a news conference following the NATO summit in Strasbourg, France this weekend. The president appeared to lose his customary poise and articulate fluidity, as he hesitated, stammered, and fidgeted with his notes. He referred to the law as “abhorrent” but he was clearly discomfited by the question as he requested that the reporter remember the reason for our being in Afghanistan and the culturally sensitive nature of the issue.

Cultural sensitivity is a very important issue, and I understand the delicacy of the situation, but it can also be a cowardly excuse not to address the basic human rights of women…again. Shouldn’t women, who comprise roughly half of humankind, have equal say in the direction that their culture is taking? Yet the abuse, rape, and false imprisonment of women and girls and the disregard for women’s basic rights continues to be systematically sanctioned by societies and governments, to greater or lesser degree. Sexism is the most insidious of injustices because it begins in the family and permeates every aspect of life. Men behave the way they do because they can—it is the world boys’ club sanctioned by religion and tradition.

The rights of women (followed by children and animals) are the last to be acknowledged, codified, and enforced in every society. Women suffer twice in an oppressive society: first at the hands of the law, then at the hands of their husbands and fathers. Human rights in general take a back seat to economics (especially oil). Remember Uganda, Rwanda, Darfour? What about China? The United States (reluctantly) had sanctions against South Africa during Apartheid, where half the population were oppressed—how is this different? (Kudos to us for taking action in Kosovo in the 1990s: they didn’t even have oil!) I’m not declaring war: I am asking for awareness and action on the part of the international community. No society will ever be whole, ours included, until every voice is heard, and has weight, and the rights of the most vulnerable are protected.

Social Darwinism’s Impact on Personalized Medicine

2009-04-05T16:40:00.001-04:00

The educational and health complexities in American society cannot be explained by a single theory. However, no one theory continues to have as much of an impact on our social construct than Charles Darwin’s theories of evolution and natural selection. It is doubtful that Charles Darwin himself predicted the impact his assertions would have on our interactions within present-day society as well as the effects propagated throughout the world. Yet, his theories of genetic variations, incorrectly applied, filter into our socio-political and health paradigms and permeate our educational and health infrastructure while politicians and corporations quibble over moral and ethical obligations that drive a wedge between cultures defined more by economics than biological differences.

A central theme of population genetics is that “race is an inherent biological characteristic that accurately reflects human ancestry and the flow of common threads of genetic material in biologically distinct populations over time and geography” (Fine et al., 2005). As such, genetics research has the potential to identify populations at risk of developing particular diseases, thereby providing the opportunity for tailored preventive medicine therapies as well as personalized medicine by use of identified biological markers (Burchard et al., 2003). Although mapping race and genes is not a new phenomenon, modern technology has the propensity to propel these theories into research and, if proven true, actual practice.

Opponents of using the biological notion of race argue that the species Homo sapiens consists of a single population not biologically distinct while citing the Human Genome project that shows humans share 99.9% of their genetic makeup (Fine et al., 2005; Lee 2005). According to this theory, race is not a biologic construct but a social construct with detrimental consequences that sustain arguments for racial profiling. However, racial profiling based on phenotypic and socio-demographic characteristics already exists and is the foundation for disparities in education, health, and health care. It is not in society’s best interest to ignore the impact of biologic variations particularly when the differences adversely impact health and health economics for large portions of the population that suffer from rare biologic anomalies that are unique to specific racial groups: for example, sickle cell anemia and Tay-Sachs disease just to name two.

Arguments for and against biologic notions of race and race-based research are circular with no clear beginning (origin) or end (definitive conclusion). However, the adverse applications of Social-Darwinism and the subsequent racism that stems from its theories continue to plague logical, data-based decision making with respect to health and health care. Genomics and pharmacogenomics technologies have the capacity to propel society beyond petty aggravations of antiquated notions of race and, subsequently thwart health disparities while paving a clear path toward personalized medicine.

However, it is important to assure society that genomics technologies do not go unchecked. One way of ensuring that genomics technology does not exacerbate health disparities is the application of a public health code of ethics (Thomas, et al 2005) routed in the principles of medical ethics while ensuring questions related to the allocation of resources for the overall good of the community are adequately addressed; less society continues to sweep notions of race and health disparities under the proverbial rug of genetic and social equipoise. Such notions are steeped in obsolete ideas of genetically dominant-survivalist-theories that propagate health disparities while leading us further away from superior medical technologies and optimal health.

Note: This blog is based on articles from the 2005 issue of the American Journal of Public Health – Race and Genetics

References

Burchard EG, Ziv E, Coyle N, et al. The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med. 2003; 348:1170-1175.

Fine MJ, Ibrahim, SA, Thomas, SB. The role of race and genetics in health disparities research. Am J Pub Health. 2005; 95(12): Editorial 2125-2128.

Lee SS. Racializing drug design: Implications for pharmacogenomics for health disparities. Am J Pub Health. 2005; 95(12) 2133-2138.

Thomas JC, Irwin DE, Zuiker ES, and Millian RC. Genomics and the public health code of ethics. Am J Pub Health 2005; 95(12) 2139-2143.

Reaching Out to God at the 11th Hour

2009-04-04T21:51:00.002-04:00

One Man’s Ambivalent Retreat from His Racist Past
Helen O’Neill
Associated Press
April 4, 2009

Call it human nature. But why do people wait until it’s almost too late to change?

Elwin Hope Wilson is a 72-year-old man near the end of his life, suffering from the complications of diabetes and a very guilty conscience. Mr. Wilson was a Klu Klux Klansman for much of his life and performed many despicable acts against Black people in South Carolina. He is now seeking forgiveness by reaching out to Black men his age and apologizing in Black churches. He owed a special apology to Congressman John Lewis of Atlanta, who was a civil rights leader during the Freedom Rides 48 years ago, and brutally beaten by Mr. Wilson at a bus station in 1961.

A group of nine Friendship Junior College students, who became known as the Friendship Nine, took the brave stand of ordering food from a "Whites only" lunch counter in Rock Hill, SC on January 31, 1961. They were arrested and took the “jail, no bail” stand that landed them in prison for a month doing hard labor in a chain gang. This policy was subsequently taken up by other Freedom Riders throughout the south. Mr. Wilson never knew the name of the man he had beaten until he read a story about Congressman Lewis’ return to Rock Hill, SC in 2008 for a public apology from the York County Council and presentation of a plaque to the Friendship Nine. That lunch counter now has the names of the nine protesters engraved on its stools, a proud yet sad reminder of their bravery on that fateful day.

Apparently Mr. Wilson was a drinker and just plain old mean to everybody, but he especially hated Blacks (at least he wasn't a hypocrite). He was an embarrassment to his family. His conscience began to tug at him several years ago, most poignantly when he saw the ghost of a Black man in his rocking chair that caused Mr. Wilson to beat his fists in the air. Mr. Wilson is unable to explain his hatred of Blacks or how it originated, and why it ended. His change of heart appeared to be sudden and surprised his family, but it appeared to increase as his health declined. He began to apologize to family members whom he had embarrassed and people he had threatened or harassed. He felt a great burden lifting from his heart.

Some of the Friendship Nine accepted Mr. Wilson’s apologies, while others questioned his motives and declined a meeting. He also receives threats from the KKK for betraying them. But many, Blacks and Whites included, consider Mr. Wilson a hero and have been healed by his actions. Now he is a celebrity, with many demands on his time and his health to appear at churches to speak and tell his story. By his own admission, he is still a curmudgeon but he now understands the impact of his behavior.

I don’t much care about Mr. Wilson’s current state of health. And I don't much care if he goes to heaven or hell. I truly wonder what his attitude would have been if his health hadn’t failed and he was guaranteed another 20 years of quality life. But I do hope that his remorse is heartfelt and that his apologies have helped to heal some hearts that have been victimized by him. I hope that there is closure for some whom he has scarred. People change when they are ready. I suppose that growth and insight can come at any age, and I believe that it does, but I just wish people would get their religion a little earlier in life when it has more meaning. But I am also changing and forgiving him as I write this blog. Better late than never.

What is happiness, really?

2009-04-04T20:27:00.002-04:00

I recently purchased a book titled, The Geography of Bliss, in which the author, who spent 10 years as a foreign correspondent for National Public Radio visiting some of the unhappiest places on earth, decided to visit some of the happiest. There is actually a map of the happiest and unhappiest places on earth. Denmark has topped the charts for the past 30 years as the happiest country on earth. The United States is currently ranked number 17 out of 95, up from 23 in 2006 (Zimbabwe and Moldova ranked at the bottom), and number 97 out of 140 in peacefulness.

We as Americans believe that we have such a high standard of living. We have convinced ourselves, rightly so, that we are the greatest nation on earth, but we have so much to learn from other countries that appear to have so much less, yet are ranked higher in happiness. People in other countries have enough. We have excess everywhere we turn: extremes of wealth and poverty, consumerism, obesity, you name it.

I think that our American need to be the best and have the most has created a very unhealthy lifestyle, especially in areas like the Northeast. We spend too many hours working and driving and too little time relating, exercising, and enjoying ourselves. Parents compensate for being absent by spending guilt money on their children. More and more stuff and less and less quality time is the name of the game. We have also lost the fine art of conversation. People don’t have anything to talk about except who worked more hours than whom (which often turns into a p*ssing contest), what they bought, and everyplace they had to drive the kids to. People don’t talk about books they’ve read, or a meal at a special restaurant that they enjoyed, or the beauty of a sunset at their vacation island.

I had a conversation yesterday with a lovely man from Columbia. He described life in his town, where people dress up in the evening to go for a stroll through the square, the streets are closed off for walking on the weekend, and people don’t have a whole lot of money, but seem to really enjoy themselves and their relationships. And they are much healthier. I find that this is sadly lacking in our American lifestyle. People really do have a lot but no one seems to be enjoying any of it very much. Stress levels are very high and satisfaction is low.

But I think the authors might be confusing satisfaction and contentment with happiness. Morley Safer of 60 Minutes did a segment on Danish happiness in 2008 to find out why the Danes are so happy. A Danish research team concluded that, although the Danes do a lot of complaining, they have modest expectations; therefore, they are rarely disappointed. I lived in Denmark for 13 months from 1978-1979 and I can tell you that my stay there was one of the happiest times in my life. As a people the Danes have a very high self-esteem that borders on arrogance. They are very outspoken and not at all politically correct. But they sure are a lot of fun to hang out with. I recently asked a Danish friend what he thought of the researchers’ finding and he told me that, because of their social welfare system, “I know that whatever happens, I cannot fail.”

My friend’s statement pinpointed the contrast between life in the US, which can be one long adrenaline rush, and life in some of the happier, safer places on earth. People come to the United States for challenge, excitement, and the chance for a new life. It’s a crap shoot. We fight for our survival everyday here because failure can put us out in the street, as we have seen with our recent economic crisis. But that is also what makes us so creative, innovative, and competitive. We have to be—it really is a matter of survival.

But our failure right now can be a good thing. I think we have traded our health and happiness for having more stuff. This economic crisis is forcing young people in their 20s to move back home. It’s not the ideal, but families are getting closer. For the first time in decades, people are saving more, buying less. Everyone is getting more conscious of the environment now, too. We are resetting our values. I think this will all lead to healthier lifestyles in general. People are switching to new careers and learning new skills that they never would have considered before. I think we as Americans can adopt a healthier lifestyle, maybe tone it down a bit, but I don’t think we can ever be the happiest nation on earth—that would mean that we have stopped searching, exploring, daring, taking chances. Innovators and dreamers are never satisfied or content, and that is what we are. But we can be healthier while we are pursuing our bliss and that is something that we can achieve.

You Get What You Pay For

2009-04-02T16:35:00.001-04:00

The health care insurance crisis is now affecting even those who have health insurance. In the article, “Cancer Debt: The Hidden Costs Behind Insurance,” patients reveal how their insurance coverage did not cover the entire costs for their breast cancer doctor visits and procedures. Even though Susan Braig was insured with a “catastrophic” policy that covered hospitalization, she still has accrued $40,000 in debt after being diagnosed with breast cancer in 2004. Another patient, Nelda Lopez, mentions that although her plastic surgeon was listed under her insurance as being covered, her insurance did not cover the reconstructive work for her double mastectomy.

As noted during a previous blog on the problem with health care insurance, a classmate stated that insurance coverage was not as expensive as people believed, and inexpensive coverage was available for those who could not afford the overwhelming costs of health care insurance. However, based on the information from this article, as with any other expense, you get what you pay for. You pay for cheap insurance, and you get less-than-quality coverage. The article reports that, “…officials at the American Cancer Society say that with the bad economy and people buying cheaper insurance policies, the number is growing.” So, when you buy cheap insurance policies, make sure to read the fine print. Even a “catastrophic” policy that covers hospitalization has limitations, such as high deductibles.

What is the health care insurance industry doing to prevent this from continuing to happen, and to provide citizens with better insurance options? Isn’t the United States government obligated to provide quality health care and insurance coverage to all of its citizens, regardless of race, creed, or socioeconomic status? According to the CDC's National Center for Health Statistics, the number of uninsured persons under the age of 65 in 2007 was 43 million (16%), and the number of uninsured children under the age of 18 in 2007 was 8.9%. It would seem that after reviewing the overwhelming statistics of people who are uninsured, the health care insurance providers would try to develop a better solution, other than cheap insurance with high deductibles. It is obvious from this article that cheaper insurance does not necessarily mean you receive quality health care coverage. The article reveals that, “The cancer society has set up a hotline for people having trouble paying for cancer treatment. Without much advertising, call volume was up 12 percent in January compared to the previous year, and up 37 percent in February.”
According to the CDC, health expenditures in 2006 reached an overwhelming $2.1 trillion, with health expenditures using public funds accounting for 46% of that number. During this economic crisis when unemployment numbers continue to rise, numbers of people are losing their homes, and the market is unreliable, the number of uninsured individuals has dramatically increased. The CDC reports these statistics:
· From January-September 2008, 59.6% of unemployed adults aged 18-64 years and 22.3% of employed adults in this age group had been uninsured for at least part of the past year. Also, 32.2% of unemployed adults aged 18-64 years and 13.5% of employed adults in this age group had been uninsured for more than a year.
· From January-September 2008, 18.9% of persons under 65 years of age with private health insurance were enrolled in a high deductible health plan (HDHP), 5.0% were enrolled in a consumer-directed health plan (CDHP), and 18.0% were in a family with a flexible spending account (FSA) for medical expenses.
· From January-September 2008, 43.3 million persons of all ages (14.5%) were uninsured at the time of the interview, 55.2 million (18.5%) had been uninsured for at least part of the year prior to the interview, and 31.1 million (10.4%) had been uninsured for more than a year at the time of the interview.

With these overwhelming statistics, you have to wonder what numbers will incite worry in the hearts of the CEOs of health care insurance providers? When will it be enough? As I’ve mentioned before, I am one of the uninsured individuals and have pondered actually purchasing a cheap insurance policy, or a “catastrophic” policy as mentioned in the article. However, with the extremely-high deductibles associated with those cheap insurance policies, I have been reluctant to make the purchase. Now, with the information from this article, I am further doubting the quality of these policies. What do you think? Is the high-deductible plan worth it? Or, should I continue to grace the offices of the public-health department, until I’m able to afford a better health care plan? Is it ethical for me to have to make these types of choices about health care, because my salary is in the low- to mid-income bracket? Should my health care choices be judged based on my socioeconomic status?

To pay for her cancer debt, Susan Braig, “…has started making something she calls ‘prescription jewelry.’ She uses pills, capsules and medical supplies that have been sealed or glued so they're no longer usable. Her goal in making jewelry out of medical gear is ‘to show that health care, like cancer, is a luxury.’” And, Nelda Lopez, “…is still paying off (the$2,100 plastic-surgery bill) one-and-a-half years after the procedure. Meanwhile, she has postponed steps two to four of the reconstructive surgery, which would make her reconstructed breasts look more natural.” When will we all be able to make better health-care choices? Hopefully, one day. I'm still waiting...

Positively Promising Studies versus Promised Positive Study Results: More than Just a Matter of Semantics

2009-04-01T19:30:00.000-04:00

Dr. Joseph Biederman, the world’s most prominent advocate of diagnosing bipolar disorder in even the youngest children and of using antipsychotic medicines to treat the disease, is in the middle of two controversies: one relates to conflicts of interest in medicine and the other involves the use of antipsychotic drugs in children.

As reported in a New York Times article, Dr. Biederman earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007, but he failed to report all but about $200,000 of this income to university officials. Just a minor omission on his part, right? I hope you can sense the sarcasm, because I have more for you.

I'm also sure that this hefty paycheck must have been warranted. I mean his studies must have yielded results that benefited the company for which he wrote (Johnson and Johnson) right? You bet your britches I'm right. So what's the problem?

In drug presentations to company executives, one of Biederman's slides referred to a proposed trial in preschool children of risperidone. The trial, the slide stated, “will support the safety and effectiveness of risperidone in this age group.”

Another set of slides in the documents listed a planned trial to compare Risperdal (risperidone) with competitors in managing pediatric bipolar disorder. He stated that the trial “will clarify the competitive advantages of risperidone vs. other neuroleptics.”

Finally, there was also a slide that mentioned a planned study in adolescents of Concerta. In this slide, he stated that the study will “extend to adolescents positive findings with Concerta."

"Will support…"

"Will clarify the competitive advantages…"

"Extend to adolescents positive findings…"

From these examples, you can see that the problem is that Biederman had promised successful studies before the studies even began. I'm not sure who taught Biederman the scientific method, but that person should be fired.

His statements could have been re-worded and included in a hypothesis (e.g., product A is non-inferior to product B), but his statements definitely should not have been included as objectives of the study. An acceptable objective would have sounded more like, "…to evaluate the safety/efficacy of product A compared to product B".

These documents raise questions about how well-designed Dr. Biederman’s trials were in that he promised a result to his funders. Especially when there was so much hidden money involved.

So not only was there a conflict of interest (i.e., payment for promise of positive outcomes), the validity of his studies could have or may actually have put the many patients' lives at risk when taking the products in question.

BW706: Blog #10
Lisa Menard

Why Cats Need Nine Lives

2009-03-29T18:19:00.002-04:00

Two Teenagers Charged With Setting Cat on Fire
Sewell Chan
The New York Times
March 19, 2009

Two teenage boys were arrested two weeks ago for pouring lighter fluid on a cat and burning it alive inside an occupied building. The cat was so badly burned that it had to be euthanized. The teenagers face up to 25 years in jail if convicted. One of the teenagers had a previous conviction for beating a man in his bed before demanding money from the victim. This is a very short article about the abuse of a species that has had a very long and colorful history. My blog is not meant to minimize the abuse of any other species.

People who are cruel to animals usually have a callous disrespect for any life: It is known that serial killers characteristically begin their careers by torturing and killing small animals. Twenty-five years is a just punishment for these boys’ crimes, especially in light of the progression to bigger, human targets that their actions are likely to take.

Cruelty against animals is despicable. Crimes against cats are particularly odious because of the hate-related nature of these acts. Cat torture and immolation is a centuries-old “pastime”: The New York Times has articles in its archives dating back to the 1800s describing such acts of violence. Often, such acts were simply dismissed as "boys being boys." Cat burning was a also a form of mass entertainment in 16th century Paris;
and the Danish fastelavn carnival that occurred seven weeks before Easter traditionally included beating a barrel with a black cat inside it to ward off evil. I also found lots of links on UTube pertaining to live cat burnings (links not provided). I didn't open them so I can't tell you if they were real.

There is much superstition surrounding cats and they have long been associated with witches and “crazy cat ladies” (myself being one – or both). Millions of women and cats were burned to death and tortured during the witch trials, here and in Europe. Much has been written about the social, economic, and religious politics of these acts. But karma has its way of working things out: The slaughter of cats (and dogs, to a lesser degree) during the medieval period (1230 to 1700) contributed to the bubonic plague that devastated Europe in the 1600s. The rat population, allowed to multiply unchecked, attacked the grain stores, devouring the grain and dropping infectious fleas that spread the disease. More than 25 million people died during the plague.

There are many misconceptions about cat behavior and the physical and emotional needs of cats, which can lead to such acts of torture and violence and just plain old neglect. People generally believe that cats can fend for themselves and be left alone for long periods. This is not true. Cats are more individualistic than dogs but their basic needs are the same, no matter how differently they may be expressed. They have a strong need for company, affection, food, and shelter. The difference between a cat and a dog is that the cat will demand it on its own terms. Companion animals, both cats and dogs, are not able to fend for themselves once they have become dependent on humans.

I have heard otherwise intelligent human beings and self-proclaimed animal lovers make some of the most outrageous statements, and behave accordingly, regarding cats. Last year, a former neighbor sought my advice regarding a friend who had a situation with her 17 year-old-cat. The woman recently moved in with her boyfriend, who had a two-year-old cat. The two cats did not get along and no measures had been taken to ease the transition for the new housemates—they had simply been thrown together into their new environment and expected to get along. After about two months, hardly enough time to adjust, it was decided that the older cat had to go. My neighbor, who is the most devoted of dog owners, suggested taking the cat to another location and abandoning it, since cats can just fend for themselves. I did mention that the cat was 17-years-old. This neighbor also found it amusing that her Chow dog (a fighting breed), who was often poorly secured, often got into our yard and terrorized our cats. This activity was actually encouraged. The dog did eventually take a nip at a human.

Negligence is a very common form of cruelty. The French writer and pilot, Antoine de Saint-Exupery, wrote in his book, The Little Prince, “You are responsible forever for what you have tamed.” I wholeheartedly agree with his philosophy and I would take it a step further to say that we, as humans, are responsible for taking action against all acts of cruelty, especially those involving the most vulnerable members of our society. A kind neighbor took the initiative to seek medical help for the poor cat. We, as a society, can demand strict punishments for those who abuse and torture animals. By stopping an animal abuser, you may also be saving a human life.

Being Friends With Your Doctor Improves Your Health?

2009-03-29T15:44:00.002-04:00

The article, “How Connected Are You to Your Doctor?” reveals that in a study, “…investigators studied over 155,000 patients…about 60 percent of patients studied had the kind of relationship with their specific doctors that could be considered ‘connected.’ But a sizable minority did not. About one in three patients were merely ‘connected’ to an entire practice of physicians but not a single doctor; and just over 5 percent of patients were not ‘connected’ at all.” The study revealed that “patients with the strongest relationships to specific primary care physicians were also more likely to receive recommended tests and preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.”

In my experience, I have always found that being friends or more connected with my doctor made me more comfortable talking about personal issues in my life and more open to trying other types of treatments. I have hypertension and being friends with my doctors allowed me to be open to discussing stresses in my life that could have an influence on my blood pressure, like experiencing the grief over my father’s death. Talking about my father’s death and being open about my feelings helped my doctor know the appropriate medicine to prescribe or if medicine was even needed, especially since stress is a major cause of hypertension. When I had insurance, I had a primary care physician.

According to the article, different practice models, from walk-in clinics (docs-in-the-box) to solo practice models, were originally designed to meet the need of the patient, but has instead met the need of the physicians. In the article, Dr. Steven J. Atlas, the lead author and co-director of primary care quality improvement at Massachusetts General Hospital in Boston, “That business model (walk-in clinics) says we are fulfilling a need, but is it really what patients want, or is it the only thing they can get? You could argue that the way we provide care now is to meet our needs as physicians. We are telling patients what we want to do. What we have to do is flip that around.” Now that I don’t have insurance, I have to go to the health department to see the doctor, and because those doctors see a number of patients daily, it is less likely that they will have good relationships with their patients or be connected with them. I’m sure my doctor wouldn’t remember my name or my recurring diagnoses without my chart in front of her. Also, I’m not open with this doctor like I was with my previous primary care physician who I saw regularly, and I don’t discuss any personal issues because I don’t feel connected with her, which reduces my trust level and comfort level with the doctor. This doctor doesn’t encourage me to share my feelings and my life with her, like my previous primary care physician. I wonder if it’s because of reduced costs, too many patients, and not enough time? So, is it better to schedule as many patients as you can in one day to meet revenue goal, or to leave more time for patient care to improve quality of life?

According to the Spiral Notebook, “In a video-taped study of 171 office visits, doctors who encouraged patients to talk about psychosocial issues such as family and job had more satisfied patients and the visits were only an average of two minutes longer. Incidentally, doctors also benefit from the patient-centered approach, researchers note, because they feel more job satisfaction and are less likely to burn out.” A New York Times article on "Doctor and Patient, Now at Odds," reports that “The relationship is the cornerstone of the medical system – nobody can be helped if doctors and patients aren’t getting along. But increasingly, research and anecdotal reports suggest that many patients don’t trust doctors.” The NY Times blames higher costs and declining reimbursements for the reasons doctors don’t spend more time with patients. The NY Times reveals that “News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.”

A good relationship with your doctor can improve patient care and quality of life. A Psychcentral article, "Improving the Doctor/Patient Relationship in Medicine," reports that “Physicians who communicate well with their patients and listen more carefully to their complaints score higher in doctor satisfaction scores, have fewer complaints filed against them, and may even help their patients’ health outcomes. Good doctor interpersonal and communication skills, the authors argue, are integral to helping patients get better.” In the article, Dr. Atlas notes that “‘By focusing on new treatments, new technology and instant access, we (doctors) have undermined the patient’s ability to have a longstanding relationship with a doctor, to have a doctor who knows him or her as a human being. If all your primary care doctor does is order tests and make referrals to specialists, he or she will miss the fact that you are stressed out because you lost your job or your health insurance.’”

To have better quality of life and improved patient care, we must be connected with our doctors, so that we can be more open and more comfortable.

P-R-A-C-T-I-C-E…But not on me!

2009-03-25T18:42:00.002-04:00

There are times in our lives when, no matter how strong we think we are, we are placed in a vulnerable situation. Such instances may include a simple visit to a doctor's office or more a severe event such as surgery. At these times, we, as patients, are placed in an extremely vulnerable position. We are ill or injured, and we are putting our health in the hands of another.

Well, what happens when you visit a doctor who appears to be "wet behind the ears", or you find out that your surgeon is actually a resident and the attending will not even be in the room? Does this make you feel comfortable in your vulnerable state, or are you wondering if you are actually getting the best care possible?

A recent New York Times article poses this same type of ethical consideration. According to the article, "to become a medical expert it takes practice, practice, practice, and, unfortunately, some error along the way." This conflict is at the heart of medical training; what might be best for making a skilled, independent-thinking doctor may not always be best for the patient.

In the pursuit of patient safety, educators have deliberately prevented residents from acting independently on their own judgment in situations where a patient poses a theoretical risk. The fact is that all physicians in training pose an inherent risk to patients.

Educators should do everything they can to minimize this risk but recognize that it may impair physicians’ self-confidence. However, it is hard to feel confident and independent unless you are given ample opportunity to stand on your own and risk making a mistake.

And how does a physician obtain that confidence? As stated earlier, practice, practice, practice.

This may seem acceptable to the patient during a simple doctor's visit; however, physicians are in a bit of an ethical conundrum in the more serious situations such as surgery. Is the patient really getting the best care possible in this situation?

Atul Gawande, author of Complications: A Surgeon's Notes on an Imperfect Science1, addresses this same conundrum. Gawande introduced surgeons as human with common human traits and faults. He stressed that, as humans, surgeons must practice their skill.
Gawande then went into further detail to discuss the ethics involved with training. As humans, we must follow a code of ethics; and, as humans, surgeons are no exception.

When given the choice, patients would choose an attending physician over a resident. This decision is based on the fact that patients want the best care possible. However, in order to get that care, surgeons must be trained. Therefore, learning is usually "hidden behind drapes".

While Gawande is a surgeon and he understands the importance of this hidden training, he admitted that he has been guilty of acting like a normal human-being. When his daughter was ill, he chose the best care possible instead of the training opportunity for another physician. With this example, he depicted the human side of a surgeon as being a caring father who only wants the best for his daughter. Therefore, with this example, it appears that there is no simple answer to this training issue.

As a patient, I not only perceive physicians to be infallible but I also expect them to be. However, although surgery has become as high-tech as medicine gets, I guess we must retain a recognition for the limitations of both science and human skill….not very easy to do when your life is on the line.

1.) Gawande, A. Complications: A Surgeon's Notes on an Imperfect Science. New York, NY: Picador; 2002.

BW706 Blog #9
By: Lisa Menard

Yes, Doctor, Come On In…

2009-03-25T18:02:00.001-04:00

The article, “Having Almost Become Extinct, House Calls Stage A Welcome Recovery,” reports that although doctors making house calls stopped in the 1980s because of lack of insurance coverage, a small group of doctors, nurses, physician assistants, and practitioners are “reviving this once-common practice for keeping Americans healthy and in touch with their doctors.” I say, about time. I miss those days when you could call the doctor late at night and he’d come to your house to check on you, instead of you having to drive to the ER and wait for hours to hear, “Oh, it’s just a cold. Take two aspirin and call me in the morning.” According to the article, “For generations, the home visit was an institution, something a doctor, black bag in hand, just did. In 1930, house calls made up about 40 percent of physician encounters with patients in the United States, according to a recent article in the journal Clinics in Geriatric Medicine. By 1950, that number had dropped to 10 percent. And by 1980, home visits accounted for a mere 1 percent.”

I guess the question here is what are the ethical implications to house visits? How will this affect new regulations, like HIPAA? House calls faded away because of technological advancements, increased non-coverage by private insurance companies, and financial incentives. “As new diagnostic tools and advanced treatments became available in hospitals and clinics, that's where people wanted to go…More doctors chose specialized fields that relied on the technology of hospitals, while those who chose primary care could see easily twice as many patients in offices and clinics as they could traveling from home to home…And then there's the fact that private insurance has rarely fully covered such visits.”

Too, I would suspect that many doctors’ malpractice insurance premiums would drastically increase. With home visits, how will the doctor insure himself against being sued for wrongful deaths and other medical malpractice? Without the supervision of other staff members as well as the necessary tools if something goes wrong while at the home visit, doctors increase their risks for malpractice suits. However, I would think this practice would increase quality of life for the elderly, who have problems making it to doctor’s visits, but need them regularly. According to the article, home visits are increasing quality of life for the “forgotten population,” who don't see a doctor routinely because getting out is so difficult, are “getting much lower-quality care than they should have.” Too, this would also help reduce costs for the elderly by decreasing the amount of co-pays for each clinic visit.

Although the practice of house calls has long been uncommon in the U.S., it is still common practice in other countries, including France, Denmark, Netherlands, and Canada, according to the article. “According to the Clinics article, in Britain, which has a strong tradition of primary care medicine and a national system of subsidized health care, doctors make 10 times as many house calls per 1,000 patients each year as do U.S. doctors.” Though we don’t hear much about doctors making house calls in these times, Medicare modified its billing procedures in 1998 to enable practitioners to easily receive payments for house calls. “Since then, Medicare statistics show a large bump in physician house calls, from 1.5 million in 2000 to almost 2.2 million in 2007.”

Although technological advancements were one reason for the decline in house calls, “Ironically… technology has now made the house call a reasonable alternative to office or hospital visits for certain patients. Doctors still rely on the black bag basics (stethoscope, otoscope, blood pressure cuff, blood-drawing equipment), but now they also come equipped with laptops with electronic medical records and wireless capabilities, portable EKG machines, even bedside X-ray and ultrasound devices that were once found only at a hospital, according to Ernest Brown of Unity Health Care, which mainly serves poor people in the District.” In addition, “Point-of-care testing (where blood, urine and other tests are done at the bedside, with results available in minutes) has become so easy that home-care practitioners can operate very efficiently.”

So, why are more people not taking advantage of this practice? Why are more doctors not making house calls and encouraging this practice among their colleagues? “According to the Clinics article, studies have suggested that house calls may keep people in their homes longer and reduce mortality, particularly in the frail elderly population. That is probably due in part to physicians' being able to identify new or worsening medical problems that, left untreated, could contribute to further disability and even death.” Increased quality of life should be reason enough for physicians’ to begin offering house calls as part of their clinic visits, especially for the elderly who have to see a doctor regularly, but are not able to get out. Not only will this improve quality of care, but it will reduce costs associated with caring for the elderly. The article states that, “Although homebound patients represent only 5 percent of the Medicare population, they consume more than 43 percent of the budget, according to a congressional analysis. An ER visit can be more than 10 times the cost of a typical house call, which Row pegs at $100 to $150.” However, on the other hand, “…the cost-saving benefit of house calls might actually hurt the medical centers that provide them.”

So, the question would be, is it better to increase quality of life by providing house calls or not provide them to maintain quality care at medical centers? Is it better to enhance the life of elderly patients, increasing the length of their lives, or risk decreasing their quality of life for monetary purposes? I know that I’d love it if my mother’s physician provided house calls to her patients, and especially when my father was getting sicker with Alzheimer’s and getting him to office visits became a chore. Many times we had to take him to the ER for non-emergencies that could have been taken care of at home. It would have definitely made life easier. That would have been one less argument and one less frustration.

Do you wear a helmet?

2009-03-19T16:38:00.001-04:00

My husband became very interested in snowboarding last year. So he convinced me to go the local ski shop were we purchased him all the gear that he needed. One thing that we did not purchase however was a helmet. I figured my husband was going to be taking it pretty easy and sticking to the bunny slope since this was his first season of snowboarding.

Unfortunately, Natasha Richardson passed away on March 18, 2009 from a traumatic brain injury. Richardson was taking a beginner lesson for skiing when she fell and hit her head on the BUNNY SLOPE with no helmet for protection. At first Richardson felt fine, but later complained of a headache and was rushed to the emergency room where they found bleeding in her brain.

The death of Richardson has once again sparked the idea of whether or not to make it a requirement to wear helmets on the slopes. Some agree that it is important for people to wear helmets and that is should be made a requirement. Studies do show that helmets do help protect the head from significant blunt trauma when in an accident.

However, there are those for example that work at ski resorts that say if helmets were made a requirement, it would significantly make their job more difficult. It would require employees to police the slopes to make sure that people were abiding by the rule.

Jeff Hanle, a spokesperson from Aspen Skiing Company, stated that at their resorts “only children under the age of 12 at the Aspen ski schools are required to wear helmets”.

So the great debate begins… should people be required to wear helmets or not? I believe that everyone should be required to wear helmets and professional athletes should promote the importance of wearing helmets. If seatbelts are required by law, helmets should be as well.

Transplanted Kidneys: Love em', then leave em'

2009-03-19T16:06:00.001-04:00

A recent New York Times article tells of a heart-wrenching story of a woman, named Margaret Oliver, who received a lifesaving kidney transplant. The government covered the costs under a special Medicare program for the hundreds of thousands of Americans with kidney failure; the only condition for which Medicare extends coverage to everyone.

Three years later, Medicare stopped paying for the expensive immunosuppressive drugs that Ms. Oliver needed to minimize the risk that her body would reject the organ. This was because the program covers 80 percent of the cost of immunosuppressive drugs, but only for 36 months after the transplant.

This week two senators introduced legislation that would require Medicare to cover the drugs for the life of the transplanted kidney. This legislation is not only beneficial for a transplant recipient's health status; it also provides a significant pharmacoeconomic benefit.

Transplantation generally provides better long-term outcomes and a higher quality-of-life than dialysis; however, patients then need to take immunosuppressive drugs for as long as they have the transplanted kidney. While many organ recipients are able to obtain health insurance through employers or spouses, others, like Ms. Oliver, find themselves with few options in the private insurance marketplace. If they lose the kidney, they have to return to dialysis and return to the organ waiting list. This may be the case with Ms. Oliver because the many months of interrupted treatment significantly weakened her new kidney and increased the chances that she will lose it in the near future.

Now that just doesn't sit right with me. If the immunosuppressive drugs are only covered for three years, then we might as well give in and offer transplants to known alcoholics; there is the same post-transplant liver failure possibility in both instances….so why the heck not?

Okay, well let's say that the government just isn't quite getting the health benefit. So let's put it in terms the government will understand; money.

While a transplant costs more than $100,000, the annual expenses for drugs versus dialysis speak for themselves. Medicare spends, on average, $17,000 a year for the immunosuppressive drugs for a kidney transplant recipient, compared to about $70,000 for a year of dialysis. As far as pharmacoeconomics go, the monetary benefit of extending
immunosuppressive drug coverage should be sufficient rationale for the government to pass the senators' legislation. I mean, isn't money all the government is worried about anyway?

BW706: Blog #8
Lisa Menard

Teen Pregnancy on the Rise...Again

2009-03-19T09:39:00.001-04:00

In the article, "Teenage Birth Rate Increase for Second Consecutive Year," it is reported that the, "Nationally, the birth rate among 15-to-19-year-olds rose 1.4 percent from 2006 to 2007, continuing a climb that began a year earlier. The rate jumped 3.4 percent from 2005 to 2006, reversing what had been a 14-year decline." Although the reason for the increase is unknown, they speculate that, ".. it could be a result of growing complacency about AIDS and teen pregnancy, among other factors. The rise may also reflect a broader trend that affects all age groups, because birth rates have also increased among women in their 20s, 30s and 40s and older unmarried women." The article also suggests that the economic downturn may contribute to the rise in teen pregnancies because, "When families are stressed by economic forces, parental communication and supervision may decline, which in turn may have an effect..." So, can we assume then that parental communication and supervision the previous years were better, or is it safe to say that parental communication and supervision has been lacking for years.

Today, unlike in the past, most households are two-income with both parents working long hours and away from home for long periods. A recent poll estimated that 34% of teens and parents blame parental work on the reason they don't spend more time together (http://clinton4.nara.gov/WH/EOP/First_Lady/html/teens/survey.html). And if parents aren't spending time with their teens, then they're not talking to them about sex or other issues. The article, however, doesn't list a decline in parental communication or supervision as an underlying problem to teen pregnancy. Instead, the article notes failed policies and governmental programs. "But opponents said the findings provide new evidence that the approach (abstinence education) is ineffective and that the money should be shifted to programs that include educating young people about contraceptives -- efforts that have been shown to be highly effective." The article also reports that, "...other experts said the two-year data probably represent a trend and fit with other research showing a stall in the long drop in sexual activity among teenagers, as well as a decrease in condom use."

Is it the job of the government to primarily plan programs to reduce teen pregnancy, or does some of the responsible lie with the parents, too? Is it ethically sound to make the government primarily responsible for educating our children and talking to them about issues like sex, drugs, and alcohol? According to the National Campaign to Prevent Teen and Unplanned Pregnancy (NCPTUP), “There are many different solutions to the widespread problems of teen and unplanned pregnancy, at the individual and societal level, and public policy certainly plays a key role.” However, it does not play the primary key role. The NCPTUP reports that, “Teens consistently say that parents most influence their decisions about sex. However, the vast majority of parents (82%) agree that when it comes to talking about sex, they often don’t know what to say, how to say it, or when to start the conversation. Investments should be made to help parents—through a variety of innovative and user-friendly resources—communicate their values on sex, love, and relationships to the next generation.”

Yes, I agree that policies and programs implemented by the government are necessary, but is it not the job of the community and the parents to educate teens on this issue to improve quality of life, not only for the teen, but the child they would have? According to NCPTUP, “A child’s chance of growing up in poverty is nine times greater if the mother gave birth as a teen, if the parents were unmarried when the child was born, and if the mother did not receive a high school diploma than if none of these circumstances are present.” In addition, “Teen childbearing cost taxpayers $9.1 billion nationally in 2004 and the one-third decline in teen childbearing between 1991 and 2004 saved taxpayers $6.7 billion in 2004 alone.” If the numbers reported by NCPTUP that, “three in ten teen girls gets pregnant at least once before the age of 20, resulting in well over 400,000 teen births each year, and the United States still has the highest teen pregnancy and birth rates in the industrialized world,” then that is a number of children living in poverty.

To combat this problem, not only do we need to implement more policies and programs to educate teens, but we also need to educate parents on talking to their kids. It is the job of the government, the community, and the parents to provide assistance to the nationwide problem. If not to reduce the amount of money spent, but to reduce poverty and improve quality of life for teens and babies born into these situations.

From Tragedy to Triumph

2009-03-18T20:11:00.002-04:00

Scientist at Work: Alice W. Flaherty
From Bipolar Darkness, the Empathy to Be a Doctor
By Elissa Ely, MD
The New York Times
March 17, 2009

I’m glad to be writing about someone who used a personal tragedy to help others. Dr. Alice W. Flaherty had achieved more as a medical doctor, neuroscientist, and published researcher by the age of 35 than most people accomplish in a lifetime. However, a postpartum crisis of grief following the delivery of stillborn twins triggered the onset of mania that was characterized by hypergraphia, the compulsion to write anything and everything, anywhere and everywhere, including the use of her own body as a manuscript page. Dr. Flaherty was ultimately hospitalized for bipolar disorder. Her experience with mental illness led to a bestselling book, “The Midnight Disease: The Drive to Write, Writer’s Block and the Creative Brain,” and a new, empathetic approach to treating patients that stemmed from her own need for empathy during her illness.

Ten years after the initial onset of mania, Dr. Flaherty is director of the movement disorders fellowship at Massachusetts General Hospital, specializing in deep brain stimulation, and an assistant professor of neurology at Harvard Medical School. She applies her preoccupation with the neuroanatomy of empathy to the treatment of her own patients, always aware of the fact that she is also a patient. She has been able to channel this seeming disability into something greater: the ability to relate to patients from a place of experience, especially depression, that allows them to identify with her. Dr. Flaherty manages her illness with medication, but she still has periods of mania and she still writes on her arms. But she wouldn’t have it any other way. She uses her manic episodes as the driving force for new ideas about treatments and theories of the mind; the subsequent depressions are used to consolidate her thoughts and edit the flood of writing from the manic wave.

Such creativity and brilliance are characteristic of many patients with bipolar disorder: Jim Carrey, Robin Williams, Robert Downey Jr., Tracey Ullman, Sting, Jane Pauley, Winston Churchill, and Virginia Woolf are some names that may be familiar. Robert Downey Jr., one of the “brat pack” of the 1990s, attained notoriety for his well-publicized struggle with drugs and the law, as much as for his brilliant acting. Drug and alcohol abuse, hypersexuality, excessive spending, psychosis, and violence are all characteristics of the manic phase of bipolar disorder. The suicide rate is high. Many don’t achieve the level of insight that Dr. Flaherty has been able to attain in order to transform the mood swings into something constructive. Many patients don’t adhere to their treatment regimens and wind up losing careers, relationships, and even their lives.

Bipolar disorder is so difficult to treat because it often takes years to diagnose accurately. The standard therapies are valproic acid (an anti-seizure medication) or lithium (a mood stabilizer) and adjunctive anti-depressant and atypical anti-psychotic medications. These drugs cause numerous side effects, including weight gain, hyperglycemia, sexual dysfunction, and feelings of dullness. Many patients who have enjoyed the euphoria and high energy of hypomania and mania can’t tolerate the “earthbound” heavy feeling caused by their medications. An acute episode of mania or depression or refractory chronicity that result in hospitalization can take months and even years to rebound from. Not to mention the stigma of having a mental illness. Another physician and well-known spokesperson for mental disorders, Kay Redfield Jamison poignantly described her journey into madness in the autobiography, “An Unquiet Mind.” Dr. Jamison survived numerous suicide attempts before she was finally able to gain control of her disease and reclaim her life. Such is the course of bipolar disorder.

According to Dr. Flaherty, “Neurology and psychiatry should be treating the same organ.” Indeed, some psychiatrists do treat bipolar disorder as a neurological condition. But a mental illness is more than a condition; it is a person’s life. What distinguishes Dr. Flaherty from most caregivers of psychiatric patients is her own patient status. The injection of empathy and identification into the patient-physician relationship can have a more profound effect on the prognosis for that patient than simple adherence to a medication regimen. This type of relationship provides hope to patients. They are able to see a successful, healthy individual who had to transcend many of the barriers that they now face and translate that picture into a possibility for their own lives. Dr. Flaherty is able to empower her patients because she sees things as they would and can adjust her treatments accordingly. Caregivers in any situation have the opportunity to transform lives with a simply shift in perspective in their communication with patients. And it wouldn’t cost anything in terms of time or money.

Donna Proszynski
Blog 5

Homeless Veterans...?

2009-03-12T19:38:00.001-04:00

Many argue that war is a necessary evil. It is justified by both aggressors and defenders and even aggressors disguised as defenders. On either side of the argument are soldiers deemed heroes – despite the politics behind a war its citizens are asked to support the troops who stand in harms way to defend their way of life. In the US, the “support our troops” campaign is a fairly recent political stance in America’s policies on war. After the Vietnam War, returning soldiers received a horrifying reception as traumatizing (in some cases more) as combat. The Veteran’s Administration recognized the harmful impact to psychology and invested more money in mental health & hygiene research. Old traumas received face-lifts and expanded medically-accepted definitions in the Diagnostic and Statistical Manual (DSM) of Mental Disorders as well as the International Statistical Classification of Diseases and Related Health Problems (ICD).

The research results for post-traumatic stress disorder (PTSD) for war veterans as well as other war-related psycho-social traumas successfully averted the media’s attention toward the psychological consequences of war. Thus, soldiers from Desert Storm received ceremonial welcome-home celebrations while the VA braced itself for the onslaught of physical disabilities as well as needed mental-health services. Unfortunately, there exists a gap in services such that the VA estimates that approximately one-third of the adult homeless population are veterans – mostly from Vietnam with small portions of the population from Desert Storm. The VA (http://www1.va.gov/homeless/page.cfm?pg=1) acknowledges the relationship between homelessness and military service but cautions against the interpretation that the relationship is causal – that is, military service does not cause homelessness. Instead the VA asserts that family background, access to support from family and friends, and various personal characteristics are stronger indicators of risk for homelessness. “Personal characteristics” is a vague descriptor that could mean anything from physiologic and socio-demographic characteristics to personal preferences. Most likely, though, the term relates to the standard descriptors of gender, race, education, and drug use. As such, the vast majority of homeless veterans are male, single, live far below the poverty level, suffer from mental illness with overlapping substance abuse problems. According to VA statistics, about 56% of veterans are African American or Latino.

Indicators for homelessness are complicated but decipherable. And the risks for homeless veterans can be averted by ensuring that funding is allocated for Veteran’s Affairs medical facilities. That’s obvious. However, what may not be so obvious is the relationship the indicators have to our current health care, educational, and economic quagmire. That is, we have to be persistent about changing our current systems and implementing policies that ensure both security and health so that no one falls in the gaps. Particularly for veterans who are charged with ensuring our security. Thus, support of our troops should not be relegated to a mere slogan for t-shirts and bumper stickers but truly be part of the demand in our current state of reform. NYC should not have to “bolster its efforts to shelter homeless veterans” (www.nytimes.com/2008/12/16/nyregion/16vets.html?_r=1 ) if policies are in place to usurp risk factors for homelessness among veterans and non-veterans to begin with.

Holly Tomlin

BW 706, Blog 5

Becoming Thin…At What Cost?

2009-03-12T19:18:00.001-04:00

We have all heard about crazy diets such as the grapefruit, pickle, Atkins and so on. Well there is a new diet on the market…brain surgery. Now we can all eat what we want until we get nice and plump. Then we will just get brain surgery to help us stop our cravings.

As technology advances so do our outrageous ideas. It used to be when someone was overweight, they would go on a healthy balanced diet and hit the gym a couple of days during the week. Now people are having their skulls drilled into.

Carol Poe of West Virginia was recently the second woman ever to undergo deep brain stimulation for weight loss. Before the surgery, Poe age 60 that stands 5’2 weighed 230 pounds. At Poe’s highest, she weighed a staggering 490 lbs.

Dr. Julian Bailes, chairman of West Virginia University’s department of neurosurgery, stated that Poe was a great candidate for this clinical trail approved by the FDA. During the three- hour surgery, Poe was awake. They drilled into her brain and inserted wires that carried electrical impulses into her brain. The wires were linked to a pacemaker device that was implanted in her chest. Over the months to come, doctors will increase the voltage going into Poe’s brain. One week after the surgery, Poe had lost 3 lbs.

It is very important that we continue to expand our knowledge about the human body and the way it works. However, spending money on such clinical trails I find to be a waste. None of us were born overweight. I understand that it can be extremely difficult for those that are, but whatever happened to the tried and true way of just eating healthy? It’s not a mystery of how to lose weight… but were not sure yet how to cure cancer. What is more important?

Doctor Fabricates Studies on Pain Medication

2009-03-12T18:10:00.001-04:00

One would assume that doctors are ethical. However, in an article on MSNBC.com, an anesthesiologist from Boston Massachusetts is being accused of fabricating studies completed on the pain medications Vioxx and Celebrex. According to the article, Dr. Scott Reuben made up some or all of the data that was published in anesthesiologist journals from 1996 to 2008. There were a total of 21 papers published.

Dr. Scott Reuben from the Springfield Baystate Medical Center is now on leave. In his research he stated “favorable results” from the pain killers that he tested. They included Bextra, Celebrex, Lyrica, and Vioxx. Dr. Reuben also stated that the antidepressant Effexor worked effectively as a painkiller.

In reviewing the research completed by Dr. Reuben you would assume that he had personal ties with some of the companies. Well, Dr. Reuben received five research grants from Pfizer the maker of Bextra, Celebrex and Lyrica between 2002- 2007. In addition, Dr. Reuben was a member of the Pfizer’s speaker bureau in which he gave talks to other colleagues about Pfizer’s drugs.

Dr. Reuben’s research may have had an everlasting effect on some patients that were treated by doctors that believed his research. According to the article, Dr. Benzon the chief of pain medicine at Chicago’s Northwestern Memorial Hospital stated that “studies show that Celebrex and its relatives have been shown in some studies to interfere with bone healing — but not in Reuben’s research. Because of that, Benzon said he, and probably other doctors, too, began using those drugs more often in patients having bone-related operations including spinal surgery”. In addition, Dr. Benzon explained that the most alarming issue is that some of this research has been out there for over 12 years. No one knows to what extent Dr. Reuben’s research has affected patients.

When articles come out explaining the unethical behavior of those very people we trust our families lives with, you wonder “who can I really trust”. It is not known if Dr. Reuben fabricated his research for monetary gain. However, the next time you go to the doctors and they are pushing you to take a medication that does not seem right to you….get a second opinion. Anyone of us could have been a patient of Dr. Reuben’s.

Female Condoms to Prevent HIV?

2009-03-11T21:49:00.000-04:00

From my understanding, male condoms and other contraceptives warn that these products may not prevent sexually transmitted diseases, pregnancy, or HIV/AIDS. But the article, “FDA approves inexpensive female condom,” touts that the new female condom, made with less expensive materials, will be targeted to “women in Africa and other areas where AIDS is a major concern.” According to the article, “Female Health’s initial Female Condom was approved in 1993 to prevent pregnancy, as well as sexually transmitted diseases, but has not been widely used in the United States, which made up just 10 percent of its 34.7 million unit sales in 2008.” The company hopes that the reduced costs “will help more groups offer more condoms in the hope of preventing HIV/AIDS and other STDs.”

But is it probable to believe that women in Africa will be able to not only have access to this product, but will be able to use it? How logical is it to believe that a female condom will reduce the occurrence of HIV/AIDS in Africa? If this was possible, would it be safe to assume that men in Africa had access to male condoms, and yet did not use them? According to AVERT, “Relative to the enormity of the HIV/AIDS epidemic in Africa, providing condoms is cheap and cost effective. Even when condoms are available, though, there are still a number of social, cultural and practical factors that may prevent people from using them. In the context of stable partnerships where pregnancy is desired, or where it may be difficult for one partner to suddenly suggest condom use, this option may not be practical.”
AVERT also mentions that, “the distribution of condoms to countries in sub-Saharan Africa has also increased: in 2004 the number of condoms provided to this region by donors was equivalent to 10 for every man, compared to 4.6 for every man in 2001. In most countries, though, many more condoms are still needed. For instance, in Uganda between 120 and 150 million condoms are required annually, but less than 40 million were provided in 2005.”
So, based on these statistics, would making female condoms accessible to females in Africa make a difference in the HIV/AIDS epidemic? Would these condoms have an impact on the US population affected by HIV/AIDS? Although condoms may reduce the risk of STDs, HIV/AIDS, and pregnancy, if not used properly, their effectiveness decrease. According to AVERT, “The main reason that condoms sometimes fail to prevent HIV/STD infection or pregnancy is incorrect or inconsistent use, not the failure of the condom itself. Using oil-based lubricants can weaken the latex, causing the condom to break. Condoms can also be weakened by exposure to heat or sunlight or by age, or they can be torn by teeth or fingernails. Also, remember to check the expiry date of your condom!”
The article reports that the FDA allows the United States Agency to distribute the female condom to global programs dedicated to preventing the spread of the virus that causes AIDS. My question is that if male condoms have always been available in the US and other countries, why is the numbers for AIDS, teen pregnancy, and STDs still continually rising? Shouldn’t we try to educate on these issues, rather than just developing and selling products that may or may not reduce the risks of attracting these diseases or unexpected pregnancies? Don’t we have an ethical responsibility to prevent these risks through knowledge than through profit?

Hepatitis Secrets Revealed

2009-03-11T20:17:00.000-04:00

According to results of an investigation published by the CDC, at least nine kidney patients were infected with hepatitis C while being treated at Life Care Dialysis Center. This fact may sound like just another story concerning hospital acquired infections; however, there is much more to the story. The Center's closing by state health officials was warranted in more ways than one.

On the surface, the clinic was described as a filthy place where employees did not wash their hands properly, disinfect equipment, or always wear gloves when treating patients. Dried blood was even found on treatment chairs. As it turns out, this was not just pure laziness; many staff members were unaware of the center’s written policies about cleaning and disinfection. Whether or not the staff was telling the truth remains to be seen, but it appears that the center has severe training issues; untrained staff should not have been dealing with patients in the first place.

Medical guidelines require strict testing and monitoring of dialysis patients for hepatitis C infection; however, the clinic tested patients on an erratic basis. Out of the patients that they did test, the aforementioned nine tested positive for hepatitis C.

Hold on, this is the worst part of the story. The clinic knew that these nine became infected after they started coming to the clinic, but it never informed them; it notified state health officials in only three cases. This deviance combined with erratic testing means that many other patients may also have been infected at the clinic.

Dr. Walter Wasser, the physician who was the operator and medical director of the dialysis center, was fined $300,000 and surrendered the clinic’s operating certificate, but the state Office of Professional Medical Conduct has not taken formal action against him. Where is the justice in that? Does a fine and a bit of public embarrassment make up for the patients' losses?

The future of these nine newly-positive hepatitis C patients may include cirrhosis, liver failure, and cancer. If you add the diminishing quality of life over an extended period of time, does this punishment seem fair? What about the family members of these patients? Who is reimbursing them for their inherent struggles and emotional setbacks due to the clinic's carelessness and deceit? Even if large sums of money were given to these patients and the careless were sent to prison, would it still be enough?

This is the type of story that makes me hope and believe in Karma….

Reference:
The New York Times Website. Rabin RC. Hepatitis C found in clinic patients page. March 2009. Available at: http://www.nytimes.com/2009/03/06/health/06clinic.html?_r=1&ref=health. Accessed 04 March 2009.

He Went Down in a Blaze of Bullets - No! That’s Just PowerPoint.

2009-03-11T19:57:00.000-04:00

At training, the presenter stood in front of PowerPoint slides with data embedded in text masquerading as sentences that were really fragments. On the first slide, the first bullet stated that with treatment A only a “small percentage” of patients achieved goal on all four target indicators. A second bullet indicated that after administration of drug X about 80% of patients reached goal on one of the four target indicators; thus, making the assertion that prognosis improves drastically with drug X. Shouldn’t the other 3 indicators be included in order to make this assertion? The third bullet on the slide skipped to another topic and the fourth bullet introduced another topic all together. The fifth bullet attempted to tie the first four bullets together with a summary statement that only pointed to a failed attempt at a conclusion in the sixth bullet. Next to the table of bullets stood a bar graph – lonely and pathetic in it’s attempt to illustrate a health trend. The graph did not relate to the six statements crammed in the table at all. Confusing? Confusing, annoying, and misleading.

Yet, this is our modern day tool for information exchange: PowerPoint or ppt if you, too, suffer from abbreviation turrets. The example above may be more illustrative of the presenter’s inability to put together a coherent presentation. However, the information contained on one slide, in fact, the first slide is indicative of poor presentation skills that significantly impacts effective communication. PowerPoint is a useful tool for presentations when used properly – sentences uncomplicated by jargon and straightforward data that stands alone for the reader to make logical deductions from one bullet to the next. And don’t forget the references when introducing unique data. Instead, the fragmented ideas and thoughts of presenters are literally replacing technical reports and passing off as original data sources.

What happens when technical reports are replaced with incomplete data? Anarchy! Ok, maybe that’s a bit extreme; but there are serious implications for misinformation that has consequences for every industry. Health and science industries are no exceptions and, perhaps not surprisingly, encourage this type of information exchange (for example, see http://www.edwardtufte.com/bboard/q-and-a-fetch-msg?msg_id=0001yB). As such, vital statistics are misrepresented and incorrectly interpreted by both the presenter and audience alike. PowerPoint presentations should be restricted to presentations – a brief synopsis of a full report that decision makers, in particular, should have access to while providing the rest of the audience references to verify the validity of the presentation content.

Trainings, lectures, and reports are essential to an organization’s vitality. Unfortunately, it appears that many organizations are taking the lazy way out of communication by offering representations of incomplete data that bias the audience. This ultimately jeopardizes the organizations’ reputation. PowerPoint in and of itself is not to blame; however, lazy reporting and sloppy presentation cannot be a substitute for communication, especially when important decisions are at stake.

Holly Tomlin
BW 706, Blog 6

In Healthcare Reform, Caveat Emptor

2009-03-09T18:17:00.008-04:00

Some might take issue with this article’s title. Applying ‘”caveat emptor” (“buyer beware”) to healthcare reform presupposes that healthcare is a commodity to be bought and sold. Like other services, healthcare IS a commodity that (to an extent) NEEDS to be bought and sold.

I admittedly do not know the details of the President’s health care proposal (I can not find any), but I know what I do not want to happen. I do not want the system to lose performance (including efficiency) incentives for doctors, patients, insurers, pharmaceutical companies, and device manufacturers. While some people are altruistic, the vast majority of people (and companies) are not.

Communism failed because there was no incentive for anyone to do anything.

The same principles apply to healthcare. If all doctors are paid the same, doctors will have no incentive to be better doctors. Even further, if the exceptional doctors are not rewarded, then exceptional people will not become doctors.

People like to rail against “the obscene profits of the drug companies.” Those obscene profits are the reason that drug companies bother to invent new drugs. It is not a coincidence that most pharmaceutical research is based in the United States. Our policies reward innovation and investment. Price controls on drugs would have many undesirable “side effects.”

If health care is "free," people are more likely to run to the doctor for trivial health complaints, further clogging a system that is guaranteed to become backlogged.

Getting any non-emergency procedure would likely require getting on a long waiting list, as they have to do for non-emergency procedures in Canada and Britain. There is a reason many Canadians come to the US for non-emergency procedures, and whatever the reason (waiting list or available quality of care), it is undeniable evidence that their system is not superior to ours.

One reason our health care system is comparatively expensive is the higher availability quality of care. Competition between hospitals and health care companies spurs them to have the latest technology to diagnose and treat patients. On the other hand, if people are forced to go to your hospital, you can do without that new MRI machine. You have no incentive to retain the best doctors, who WANT to have the latest technology to treat their patients. If it is a government monopoly, where else are the patients going to go? Where else are the doctors going to go? Perhaps, they will both go to another country.

While demonized (admittedly, some criticism is valid), health insurance companies do create pressure for efficiency. Without such scrutiny, inefficiencies would never be addressed. Money and resources that could have been used to actually treat people would be wasted.

Besides, I am not sure that private health insurance is currently as cost prohibitive as many people contend. On my own, I purchased health insurance from a major insurer that is almost as good as the programs I had through employers, and it is only $114 per month, including prescription benefits and the ability to choose my own doctor. Granted, I am a single man, but I am over 40 years of age. People use Cobra all the time as an example of out of control health premiums, but Cobra is a rip-off. After leaving my last two radio companies, I had Cobra offers of $500 and $600 per month. No thanks.

As the administration embarks on their effort to sell health care reform, people need to pay attention to the details. Scanning the administration’s health care reform website (http://www.healthreform.gov/), I found it contained a lot of platitudes and nebulous goals, but concrete recommendations were conspicuously absent.

If one pays attention to the details of the administration's sell job, it gets harder to buy into the feel good hype and harder to be frightened by the scare tactics. For instance, the number of Americans who have been bankrupted by medical expenses is grossly exaggerated by the administration. (http://blogs.abcnews.com/politicalpunch/2009/03/false-talking-1.html). While a comparatively smaller number of medical bankruptcies STILL is something that needs addressing, a comparatively smaller number of bankruptcies makes the changes needed to address them much less drastic.

Socialized medicine would not be free, as proponents think it would be. It would cost.

Boy, would it cost.

Finally, I'll Be Able To Get That Surgery I Need

2009-03-05T20:28:00.002-05:00

Every since I braved the obstacles and overcame my fears to reach my dream of becoming a writer, I have been without health insurance. After quitting my 8 to 5 job at the Children's Hospital in pursuit of a career as a writer, I became self-employed and like so many others, uninsured. I will never forget the day I received that letter in the mail from Blue Cross Blue Shield informing me that although my coverage under the hospital had become unactive, I could remain covered for only $600 each month. Well, I quickly and swiftly began to ponder my current situation of no income, rent, bills, and car note before the earth-shattering realization that I could not afford to remain covered. Normally, this would not have bothered me, except I have had recurring medical problems beginning with hypertension and high cholesterol. I could not bear the thought of having to seek health care at the public health department. I could not fathom having to go to the Coop (Cooper Green Hospital, the hospital for the uninsured that was known for losing patients to death and losing them literally in the hospital), but here I was, self-employed and uninsured. So, when the time came for my annual pap smear (which I hate and can not stand to think about, and it is due in a couple of months), I had to muster the courage, gird my loins, so to speak, and make the dreaded appointment for the public health department.

So, you can imagine my elation and utter excitement to learn that President Obama was making plans to change health care and decrease health care costs, making it affordable for everyone, including me. In a recent article in the Washington Post, "At Summit, President Obama Urges Solutions for Rising Cost of Health Care," President Obama made further progress on his promise to make health care affordable when he addressed the White House Summit. In the article, President Obama promises to expand insurance coverage, improve health care quality, and decrease skyrocketing health care costs. "'The same soaring costs that are straining families' budgets are sinking our businesses and eating up our government's budget, too,' Obama said in an East Room appearance."

Although it feels as if I am alone in my struggle to receive high quality health care without insurance, I know there are millions of people in the US struggling to make insurance costs. And many of those people have to also worry about insuring their families. Thankfully, I am only worried about insuring myself, so the costs for health care are slightly less for an individual. However, it is still difficult because of my preexisting conditions. In the article, President Obama, "...stressed that reform efforts cannot succeed without reducing costs, but he also said it was important to distinguish between short-term and long-term costs."

For 3 years, since the beginning of my self employment, I have seen and experienced the desperate for need for not just health care, but quality health care. Because the health department physicians work in this public health environment, they are not as vigilant and caring in their health care practices. Thankfully, I know more than others and am able to ask the right questions and conduct the necessary research into my condition and the medications I am prescribed. But what about the others in the office who are not fortunate enough to have those resources available to them? Would they receive the care they deserve, or will they fall through the cracks of the health care system? Is it too late for health care reform? Has the damage already been done?

In my case and those of millions of others, it is not too late to take advantage of the much needed health care reform proposed by President Obama. Of course, there are the naysayers and the skeptics who believe that President Obama's plan is too risky and right now is not the time to take on more problems. To this President Obama replies, "'When times were good, we didn't get it done. . . . There's always a reason not to do it. And it strikes me that now is exactly the time for us to deal with this problem...What better time than now, and what better cause for us to take up.'"

To those people, I say, when will be the right time. It is almost as if they are saying to me that it is not a good time for me to get health care coverage; not a good time for me to receive quality health care. When will it be a good time? When my hypertension becomes severe and I become more susceptible to heart attack and stroke? According to the article, "Medical spending, now about $2.3 trillion, consumes about 16 percent of the gross domestic product. And although the United States spends more per capita on health care than any industrialized nation, Americans do not live longer or healthier lives, according to a range of international measures."

President Obama's inital plan includes "...(setting) aside $634 billion in his proposed budget to be dedicated to health reform. The 10-year reserve fund could be used to provide health insurance to some of the 46 million Americans who do not have it today. To raise that money, Obama would cut itemized tax deductions for the wealthiest Americans and trim federal payments to hospitals, home health aides, drug manufacturers and some physicians." Unfortunately, the budget must be approved by Congress before it can take effect.

So, once again, I wait and hope. I wait for the day when health care will be affordable and hope that it comes one day soon. President Obama's goal of The Summit: "'...to start determining how to lower costs, improve quality and expand coverage to all Americans. And our goal will be to enact comprehensive health care reform by the end of this year.'" Maybe by the end of this year, I will be able to go to the hospital when I am sick, go to the doctor knowing I have an appointment (not hoping one will be available if I can not get through on the line within the two hours alloted for appointment time in the morning like at the health department), and go to the emergency room of a high-quality hospital without worrying that I will receive the quality health care I deserve.

To Take or Not to Take (the keys)…That is the Question

2009-03-05T19:10:00.002-05:00

Normally, when formulating my blogs, I ponder the ethics involved and make judgments based on my present knowledge; and while I may feel strongly about a certain point of view, my emotions rarely get involved. However, a recent New York Times article, Safety: When to Ground Alzheimer's Drivers, found me on a personal level.

This article interested me because my grandmother was diagnosed with Alzheimer's many years ago. In general, the disease has gradually taken away her "personhood". However, recently, she has gone downhill rather quickly. She doesn't recognize herself in pictures, and the depression/anger has begun to set in.

My family got lucky with my grandmother; she voluntarily took herself off the road many years ago. However, what if that was not the case? Figuring out when to take the keys away poses a problem for doctors and families. With so much already taken away from her, mentally and physically, how could we take away her freedom and mobility without much thought?

A new study reports that a series of cognitive tests may help doctors determine which early Alzheimer’s patients are likely to pose a danger behind the wheel. The researchers said the findings could prove valuable as an aging population results in more drivers with dementia on the road.

I was eager to read on to find out what is being done to protect Alzheimer's drivers and other drivers on the road; however, I soon found that the study did not meet my expectations.

For the study, researchers asked 40 drivers with probable Alzheimer’s disease and 115 elderly drivers who were healthy neurologically to undergo a battery of cognitive, visual and motor tests. They were also asked to take a 35-mile driving test with a research assistant in the car and cameras recording their performance.

First of all, I have a problem with the lack of numbers in this study. With only 40 test subjects and 115 control subjects, how can these data be generalized to the actual population with any power of confidence?
Not only are the populations too small, but why are they unbalanced? Why would researchers compare 40 to 115? It seems like the study design is a bit biased and any results would embellish differences between the two groups.

Now, for the actual study results, the Alzheimer’s drivers made about 25 percent more mistakes than the other drivers. This may be an expected result; however, the actual number of mistakes was not given. How can a statistically significant difference be stated on percentages alone?

It is obvious that, from my personal experience, concrete predictions cannot be made as to when an Alzheimer's driver should be grounded. The progression of the disease varies to such a degree, even in the individual, that judgments must be made on a continual basis. I feel that to make a generalization from a small-scale, biased study would be unethical on multiple levels.

It is one thing to administer driving tests for teenagers; it is a prize and a right of passage. However, testing Alzheimer's drivers has a completely opposite connotation; it means you are no longer fit to take care of yourself or to make your own decisions. Autonomy is definitely at stake, and it should be a conjoined effort among all involved, not a set point based on one study.

Is that Smell Tobacco Smoke or the Smell of Sausage Being Made?

2009-03-04T00:45:00.003-05:00

If someone has read my blog postings and my comments on others’ blogs, it is not hard to figure out that I am conservative. True conservatives are often misunderstood, and the term “conservative” is most often erroneously viewed as interchangeable with the word “Republican.”

As a conservative, I believe that, as a general rule, less government interference is better. Also, I believe, as a general rule, that government agencies should exist only if they provide a service that directly benefits the entire population and that the private sector by its nature is incapable of providing. Examples of such agencies are the FAA (Federal Aviation Administration), the military, and the FDA (Food and Drug Administration).

The FDA is critical for the prosperity of this nation. For instance, I can be a lot more productive if I can concentrate on my business or job because I do not have to take a substantial part of my day every day to test my food to make sure it is not poison.

I read an article in today’s Washington Post (http://www.washingtonpost.com/wp-dyn/content/article/2009/03/03/AR2009030303661.html?hpid=moreheadlines) reporting that there is a bill making its way through Congress designed to allow the FDA to take over tobacco regulation. Such legislation is long overdue. However, there is one fatal problem with the bill. Existing products are grandfathered in, making the new rules essentially irrelevant. The new rules would apply only to new products.

Understandably, the tobacco company with the largest market share, Philip Morris, supports the legislation, while the companies that hope to take Philip Morris’ market share, namely everyone else, is against the legislation. New products that could conceivably take away Philip Morris’ market share would face the more daunting regulatory hurdles, while the existing products would not. Thus, the status-quo would be solidified.

Congressional politics are keeping the FDA from properly regulating tobacco, just as Congressional politics kept the FDA from properly regulating “dietary supplements” that (in most cases) do little more than produce very expensive urine.

In politics, they say that one needs to take what one can get. “Two steps forward, one step back.”

War and Human Rights

2009-03-03T00:49:00.005-05:00

Last week President Obama announced his much anticipated plan to extricate the United States military from Iraq only to add that more troops will be deployed to Afghanistan, particularly at the border with Pakistan. According to military strategist this will prevent terrorist cells from expanding and growing. Really?

I’m not a strategist. I’m not a political analyst.

I am a human being.

I know this because there are more human rights documents now than any other time in our history (Geiger 2000) – each filled with definitions, explanations and examples of what constitutes humanness and the rights associated therewith. However, after sifting through the rhetoric and digging through their debris, you will find the contents of those documents buried right next to the very bodies they were developed to protect: mostly women… and children. Ostracized, beaten, and victimized in peace-time there lives should not be further subjugated by war and it’s crimes.

War is not the Hollywood-esc-romanticized barbarism of Gladiator where two opposing sides meet face to face until “the death” – defeat and surrender. It is, as it has always been, a mix of technologically advanced calamity (Diamond 1999) and merciless abuse and torture (Watts 1997) to which the most vulnerable are subjected. Soldiers in conflict do not think of the Geneva Convention’s stance on medical neutrality when bombing hospitals and clinics in Sarajevo, Kuwait, Haiti, Somalia, Sudan, the West Bank and Gaza Strip (Geiger 2000). Instead these vulnerable, military rendezvous points are continuously rationalized as long as the end result is justified in terms of victory.

War is the invention of the desperate. There are no victors in war and the victims have all-too-familiar faces. No matter their color or race, age, religious belief, social or political stature – there is no difference between them and us. Thus, it is imperative that we remain vigilant about war and its manifestation through global illiteracy that would have too many people thinking that military strength is the way to peace (Miles 2000, Macedo 2006).

Peace is not a reward. It is not a right defined by mere documents that too many cannot read nor fully embrace even if they tried (this does not preclude a personal desire to have peace); however, peace cannot be limited to buzzwords, catch-phrases, or social-political welfare for free-press and celebrity. The road to peace does not have to be so long or as destructive as long as we work earnestly toward social justice (Hammad 2005) and continue to put pressure on the political administration to seek alternatives to war; unless we prefer to live in a vicious cycle of retaliation and destruction.

Holly Tomlin

BW 706, Blog 4

References

Diamond J. Guns, Germs, and Steel: The Fates of Human Societies. New York, NY: W. W. Norton & Company Inc; 1999.

Geiger HJ. The Impact of War on Human Rights. In: Levy BS and Sidel VW, eds. War and Public Health. Updated Edition. Washington, DC: American Public Health Association; 2000: 39 - 50.

Hammad S. First Writing Since. In: Zaatar Diva. New York, NY: Ram Devineni; 2005: 98 - 102.

Macedo D. Literacies of Power: What Americans Are Not Allowed to Know. Boulder, CO: Westview Press; 2006.

Miles L. Education for Peace. In: Levy BS and Sidel VW, eds. War and Public Health. Updated Edition. Washington, DC: American Public Health Association; 2000: 323 - 335.

Watts S. Epidemics and History: Disease, Power and Imperialism. Great Britain: Redwood Books, Wiltshire; 1997.

The Ethics of Outsourcing

2009-02-26T19:14:00.002-05:00

There has been a growing trend for drug companies to outsource clinical trials; the human studies that determine the safety and efficacy of medicines.

Now, as reported in the New York Times, an article about the globalization of clinical trials is raising questions about the ethics and the science of increasingly conducting studies outside the US, when the studies are meant to gather evidence for new drugs to gain approval in this country.

The article, “Ethical and Scientific Implications of the Globalization of Clinical Research,” by several Duke University researchers, suggests an ethical quagmire when drugs intended for wealthy nations are tested on people in developing countries. The authors suggest that human volunteers in foreign countries may be unduly influenced by the promise of financial compensation or free medical care to participate in clinical trials.

The report also asks whether drug research conducted in developing countries is relevant to the treatment of American patients. The authors write that drug research in developing countries, where certain populations may metabolize medications differently because of environmental factors or genetic mutations, might not be relevant for American patients.

Some critics say the authors used overly simplistic data mining to raise an alarm, without presenting hard evidence of widespread ethical or scientific problems. I also have a few observations of my own; some in agreement and some in disagreement with the Duke authors' statements.

The Duke authors are warranted in their worries about volunteers from developing nations being unduly influenced by financial compensation and free medical care. Many of these nations are poor, and the volunteers may be viewed as particularly vulnerable. However, the Declaration of Helsinki, recognizes the need for special protection in vulnerable populations; this protection comes in the source of the clinical trial protocol.

The protocol must include, among other things, information regarding potential conflicts of interest, incentives for volunteers, and provisions for treating and/or compensating volunteers who are harmed as a consequence of participation in the research study. This protocol must be reviewed and approved by an independent research ethics committee before the study can even begin. If the volunteers' health and rights would be subjected to malbeneficience or injustice in any way, then the protocol would be rejected.

Protocol reviewers must take into account the risks involved with the study and weigh those risks against the benefits. If the only benefits for the volunteer are monetary, then researchers are conducting an unethical trial. Participation in risky trials warrants a greater monetary compensation, and volunteers outside the US may be vulnerable because they will accept less money than an American would expect; however, how can one put a monetary value on someone's life?

Medical research involving a disadvantaged or vulnerable population is only justified if the research is responsive to the health needs and priorities of this population and if there is a reasonable likelihood that this population stands to benefit from the results of the research.

I also agree that volunteers may be unduly influenced by free medical treatment. It may be enticing to participate if the volunteer is offered free medical treatment; especially for patients who would never have received treatment at all. However, do the risks of the trial outweigh the benefits of a check up or treatment?

Duke authors also brought up the topic of relevance. Relevance may be a factor when studying safety and efficacy in different age groups, but I feel that, in many instances, relevance is a non-factor because we are all humans. However, populations that are underrepresented in medical research should be provided appropriate access to participation in research.

For example, in many clinical studies based in the US, the majority of participants are Caucasian. However, aren't there many other races/ethnicities represented in the US population? What if the Duke authors are correct, and a drug may have a different effect on African Americans because of mutations such as Sickle Cell Anemia? Wouldn't it prove to be beneficial to go outside the US and enroll subjects of that race/ethnicity?

The authors also questioned the relevance of testing outside the US because they feel that certain populations may metabolize medications differently because of environmental factors. If we are to believe this statement, then should we perform separate clinical trials within the US for Americans in Hawaii (tropical rainforest climate) as well as for Americans in Alaska (subarctic/tundra climate)? Where does it end?

The authors also seem to treat all foreign countries alike. Research conducted in some places outside the United States, like Canada and Sweden, might be perfectly relevant to American patients. For example, a clinical trial of the Merck drug Gardasil, a vaccine against the human papilloma virus, was conducted in Costa Rica, where there is a high incidence of the disease.

Whatever the interpretations, the use of offshore clinical trials is growing, and physicians must be conscious of the ethical, legal and regulatory norms and standards for research involving human subjects in their own countries as well as applicable international norms and standards; and no national or international ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research subjects.

Stay tuned for another episode of “The Microwave Generation – We Don’t Work for Anything”

2009-02-25T23:11:00.001-05:00

I know I’ve said this before, but this subject is definitely one close to my heart. The article, “A Boy’s Obesity Led His Mother to Send Him For Stomach Surgery,” tells the tale of a mother who researched the Internet to find a surgeon to perform stomach surgery on her 15-year-old son after she could not find a gastric bypass surgeon to perform the procedure due to his age. The boy, Andrew, who was 5-foot-4 and weighed 260 pounds told his mother, “There were times when I felt I just couldn't go on.” According to the article, after being rejected by the gastric bypass surgeon and, “already a veteran of numerous failed diets, exercise programs and summer “fat” camp, Andrew became convinced that weight-loss surgery, which had transformed the physique of a family friend, was his only hope.” Andrew reported that his teacher walked past him in the lunchroom and said loudly, “‘Are you sure you should have gotten doubles?’”

Told that he would have to wait 3 years until he turned 18-years old to have the surgery, “he pleaded with his mother for help.” So, his mother, instead of taking every step she could to help him lose weight, like cooking and eating healthier, taking him on walks or to the gym, and encouraging him to make a lifestyle change, because she was “worried about his (her son’s) increasing girth, high blood pressure and severe sleep apnea, Cheryl Burrill said she didn’t think her son could wait three years. Scouring the Internet, she found Reston surgeon Eric Pinnar, who specializes in “lap-band” surgery.”

So, the “microwave generation” filled with kids and teenagers who want everything in life to come easy for them without ever having to work hard for it have found a way to eat whatever they want, get as fat as they want, and then beg their parents for stomach surgery to lose weight. I not only find fault here with the parents and the teenagers requesting this surgery, I also have an issue with the doctors who are performing these surgeries. According to the article, “Although a handful of doctors have operated on children and teenagers, some weighing more than 700 pounds, bariatric surgery has been regarded by many doctors as too risky and drastic for patients under 18. A 2007 study estimated that 2,744 teens underwent weight-loss surgery between 1996 and 2003, a number that more than tripled between 2000 and 2003. Many pediatricians and pediatric surgeons have been leery of the procedures, which have not been studied in children, require lifetime adherence to a strict dietary regimen, and can cause hazardous nutritional deficiencies and, in rare cases, death.”

Now that this phenomenon is gaining popularity, gastric bypass surgery studies are being conducted by the NIH and the FDA, reporting that this surgery may decrease the numbers of obese adults by early intervention through encouraging gastric bypass in teenagers. The article goes on to say that “‘We know that the vast majority of morbidly obese adolescents become morbidly obese adults, and that medical and behavioral therapy doesn't work for them,’ said Evan Nadler, director of New York University's minimally invasive pediatric surgery program who is involved in the FDA lap-band study. ‘These kids are sick. This is truly a disease, a problem we can treat with the best means we know how. [Surgery] is the only known mechanism for sustained and significant weight loss.’”
The article then reports that “Two other factors are fueling the reevaluation of weight-loss surgery: the relentless increase in childhood obesity and the dismal results of behavioral treatment, consisting of some combination of diet, talk therapy and exercise. Behavioral treatment has a long-term failure rate estimated at roughly 95 percent.”

If we start at home teaching our kids how to live health lifestyles from birth, we would not have these problems. Instead, we allow our children to eat whatever and whenever they want because we want to avoid confrontations. What happened to the days when you actually did what your parents told you to do? What happened to the times when your mother and father ran the household and not the child? I know that when I was growing up, there was no such thing as weight loss surgery. You got outside and you ran around and played all day. You did not sit around the house, watching TV, playing video games, texting your friends, and listening to your iPod while munching on all the sweets you wanted to eat. You ate home-cooked meals every day, and there was NO WAY my parents would even entertain the thought of spending thousands of dollars on surgery because somebody at school teased me about my weight, whether it was the teacher or a student.

Have we become so jaded and superficial that appearances are more important than teaching our kids life principles, like putting down the Snicker’s bar and instead eating a piece of fruit, or getting up off the couch and run some laps around the neighborhood? I am sorry, but I know about healthy eating because I have had to make the sacrifice to lose weight for my own health problems. Yes, it is hard, but it can be done with dedication and commitment, and lots and lots of patience. You did not get fat overnight, so you will not lose weight over night or even over one year. It may take 2 or 3 years. Are our precious children to privileged to wait a reasonable amount of time before they start seeing results?

In the end of the article, one of the teenagers who received weight loss surgery brags on how great she is sticking to a diet and playing sports. Why could she have not done that before the surgery to lose the weight? Would it not be less expensive to just change the grocery list and buy a treadmill? And what about the doctors? Are they so desperate to increase their wallets that they will risk the lives of teenagers to decrease theirs? Now that this is gaining more popularity, when will it stop? We better get ready, because soon we will be signing-up our 4 and 5 year olds because they are a little too chunky. And that will be sad. Because I love babies with fat cheeks. Hey, I was one.

"Which Kid is the Favorite?” is Now a Life and Death Question

2009-02-24T01:16:00.006-05:00

It is now reality. We can choose the traits of our children--boy, girl, blond, brunette, blue eyes, green eyes, brown eyes…. Before you get to excited, let us look at it a little closer. Like most things, paradoxically, the closer you get, the less clear things become.

How is it done? A number of eggs are fertilized. By taking a sample from each egg, the doctors identify genetic markers in each egg that will likely result in certain traits. The parents then pick the egg with the combination of traits they like best. The rest of the eggs are likely discarded. Do we want to live in a country where (for instance) the blond haired, blue-eyed boy gets to live while the brown eyed, brown haired girl does not? Let me put it this way: If this technology had been around in the late 1930's and early 1940's, the Nazis would have applied it with gusto.

Besides the moral question of determining who lives based on eye or hair color, there are practical considerations. Our species has been honed over the millennia by evolution (which is not a theory but a fact, period—no debate). Over time, a tapestry of genes and traits was woven that made our species more robust. Genetic mutations and different combinations of genes resulted in a more diverse gene pool (and thus more diverse traits) that made annihilation of the species by one disease or circumstance less likely. Some traits are linked with other traits, so when eye color, hair color or sex are manipulated, other seemingly unrelated traits are manipulated as well, affecting more than just appearance. For contemporary society, research has shown that, as politically correct as it sounds, some traits are more popular than others. What happens when we start to manipulate which genes get passed down and which genes do not? Are we unknowingly manipulating other traits (disease resistance, cancer susceptibility)? I am not a geneticist, but it seems possible.

While there are possible health-related consequences, there are also social consequences. What if boys are more desirable than girls? In many parts of the world (and subcultures within our own country), they are. Will we end up like China, where their 28 year-old policy of one child per family has resulted in female babies being aborted and a CURRENT ratio of 120 men for every 100 women? By one account, 70% of aborted babies in China are female. (http://www.msnbc.msn.com/id/5953508) While females are less “desirable” as a child, they are still desirable as a mate (that is putting it gingerly). Female abductions and trafficking are skyrocketing in China. As a man, I can state unequivocally that the consequences of that giant block of men without mates will cause problems for that society MUCH bigger than just part of its population merely being unfulfilled. As a result, women, and the entire society, will be adversely affected.

I am not saying we should stop or hinder science. It is great that we have this knowledge and ability. However, just because we have the knowledge does not mean we should use it trivially. Our knowledge in these fields is nascent, and we should proceed with extreme caution.

(This blog posting was inspired by this article: http://online.wsj.com/article/SB123439771603075099.html.)

Stem Cells Cause Harm Not Help?

2009-02-19T23:17:00.000-05:00

For years, we have been debating the issue of stem cell research and using stem cells to develop cures for diseases. This issue has been a major concern among voters and even influenced who we voted for. My thoughts have always been in favor of stem cell research, and even after reading this article, my opinions remain the same. However, for those who are against stem cell research, I can see how this article may provide more ammunition to sway others to their opinion.

The article (http://www.google.com/hostednews/ap/article/ALeqM5gXPm4dnGNyn2DTR2t_FmA0GW_4JgD96DLTT00) reports that an Israeli child diagnosed with a rare, fatal brain disease, ataxia telangiectasia (A-T), received three injections of neural stem cell from fetuses. After his third injection at age 10, the boy’s brain disease had become severe enough for him to use a wheelchair. But can this be blamed on the neural stem cell injections or is it just a natural progression of his disease?

“But was the boy prone to tumors anyway or were the fetal stem cells to blame? A Tel Aviv University team extensively tested the tumor tissue and concluded it was the fetal cells. Among other evidence, some of the cells were female and had two normal copies of the gene that causes A-T — although that boy’s underlying poor immune function could have allowed the growths to take hold.”

Doctors speculate that the boy’s disease “wasn’t conducive to stem cell therapy in the first place.” So, can we blame the stem cells or the doctors for attempting this procedure without knowing the risks?

“’Patients, please beware,’ said Dr. John Gearhart, a stem cell scientist at the University of Pennsylvania who wasn't involved in the Israeli boy's care but who sees similarly desperate U.S. patients head abroad to clinics that offer unproven stem cell injections. ‘Cells are not drugs. They can misbehave in so many different ways, it just is going to take a good deal of time’ to prove how best to pursue the potential therapy, Gearhart said.”

Another doctor urges that better research is needed to “‘maximize the potential benefits of regenerative medicine while minimizing the risks.’”

I am constantly telling my siblings that medicine is experimental, and to develop cures and medications for conditions, sometimes you have to go through the rule-out process before the right one is found. That is the same with stem cell research. We have to understand that there will be risks and there may be failures. But if one failure leads to one success, then in my opinion, it is worth it. If we believe that there are casualties of war and one person dying is better than 200,000, then why don’t we have that same mentality with healthcare and medicine? Can we put death caused by diseases in the same category as war? Aren’t we fighting a war against disease? If we are, then there are bound to be casualties of war, any war, whether it is a war against disease or terrorism, or to protect our freedoms.

Bayer: The Modern Hypothecary?

2009-02-18T18:47:00.001-05:00

Today, some of the most popular branded drugs are nearing patent expirations, thus opening the doors to generic competition. In order to compete with generic companies, many big-name drug makers, such as Bayer Healthcare Pharmaceuticals, now rely heavily on direct-to-consumer advertising. An example is commercial advertisements for their product, Yaz.

In 2006, the FDA approved Yaz as a birth control pill that has a side benefit of treating mood-related psychological problems called premenstrual dysphoric disorder.

In 2007, the agency approved another side benefit of Yaz; that of improving moderate acne. However, Yaz contains drospirenone, a progestin that can cause excess potassium production in some patients, and its side effects include an increased risk of serious heart and other health problems.

Aimed primarily at women in their 20s, Yaz has been known for its slogan — “Beyond Birth Control” — which promotes it not only as pregnancy prevention, but as a lifestyle drug. This is where Bayer's problems started.

The FDA first moved against the Yaz campaign last October, with a warning letter to Bayer saying that two television ads overstated the drug’s benefits while understating its risks. By giving consumers the impression that Yaz was generally a drug for acne and general mood problems, the company’s ads ran afoul of federal laws against promoting the unapproved uses of a drug.

As part of an unusual crackdown on deceptive consumer drug advertising, the FDA and the attorneys general of 27 states have required Bayer to run new ads to correct previous Yaz marketing.

In addition, Bayer has agreed, for the next six years, to submit all Yaz ads for federal screening before they appear. Wait a minute…hold up; something sounds "bass ackwards" here.

The Food, Drugs and Cosmetics Act of 1938 gave the FDA greater authority to regulate the food and drug industry. Under this act, the FDA was granted the power to regulate the therapeutic claims drug manufacturers printed on their product labels.

Perhaps the most striking feature of the 1938 law was that the act introduced mandatory pre-market approval for new drugs; (I feel the problem beginning to emerge…wait for it….wait for it…) but authority over drug advertising, however, rested with the Federal Trade Commission (FTC). (And here is our problem!)

The FDA regulates the initiation of clinical trials, they accept safety and efficacy results of the trial, they approve a drug for marketing, and they even regulate safety of drugs post-marketing; but the FTC is the authority over drug advertisements?

If pre-market approval of new drugs by the FDA is required, then why aren't commercials also pre-approved by the FDA before airing? Isn't a commercial the same as a drug's package insert? And what does the FTC know about clinical trials, i.e., safety and efficacy anyway?

So, is Bayer unethical because they have been involved in deceptive advertising? Yes and no.

Yes, because while these commercials empower women to make their own decisions, it is also Bayer's responsibility to provide all of the information to consumers just as they would to the FDA. In the case of direct to consumer drug commercials, there is a fine line between creative marketing and responsible marketing. While Bayer may try to use different techniques to market their product, each commercial must be treated like a verbal package insert.

However, I also say "No" because Yaz is available by prescription only. While a commercial may suggest to a woman to speak with her physician concerning Yaz, it is also the physician's responsibility to know the benefits and risks and to prescribe drugs accordingly; not because a consumer viewed a commercial.

Either way, it appears that the Yaz controversy may raise new questions about whether the FDA oversight is sufficient. If deemed insufficient, then direct to consumer advertisement may become a thing of the past. With a staff of 52 people, the FDA division that oversees drug promotion cannot keep up with the tens of thousands of marketing and advertising items produced annually by drug manufacturers.

New UK Breeding Standards for Show Dogs

2009-02-14T22:16:00.002-05:00

Artificial insemination is a common practice among dog breeders. In 2003, a female champion black standard poodle named Yes was conceived using 25-year-old frozen semen from another champion named Snapper, who died in 1990. It is highly unusual to use frozen semen that old and Yes’ extraordinary success as a product of artificial insemination using old semen is also highly unusual, according to Katie Thomas in Keeping Championship Bloodlines Alive (The New York Times, February 11, 2009). Another breeder recently used 20-year-old semen to produce a litter of Irish Wolfhounds. She and her partner were surprised at how different the litter bred from the “heirloom” semen looked in comparison to the Irish Wolfhounds of today.

The selective breeding of dogs to produce certain traits has been a common practice for several hundred years. Initially, this was done for practical purposes, such as hunting, herding, and retrieving. However, with the increasing popularity of dog shows, physical features and personality traits have been bred into and out of each dog species that may have nothing to do with a particular breed’s function and are simply a matter of fashion. Some of these traits may have been anomalies, abnormalities, or aberrations that would actually give the animal an evolutionary disadvantage in the wild. And some have caused health problems, especially in the case of inbreeding.

The benefits of artificial insemination, besides allowing the breeding of dogs from a long distance, include adding variety to the gene pool, which can become quite stagnant through inbreeding, and the ability to preserve and reintroduce old traits that may have been bred out of a particular breed, especially if the semen was produced before a particular health problem was introduced into the breed. This type of ”heirloom” semen may become quite valuable in light of a recent movement in the UK to address the ethics of breeding for fashion that may produce unhealthy traits in a dog breed.

New breeding standards have been introduced by The Kennel Club (UK) for 209 dog species, including the classic British bulldog, which, under the new requirements, will have a shrunken face, a sunken nose, longer legs, and a leaner body, much to the outrage of professional breeders and pedigree dog societies (Healthier New Bulldog Will Lose Its Churchillian Jowl; The New York Times, January 14, 2009). This change came after public outcry about breeding practices, following a BBC One documentary, Pedigree Dogs Exposed, which was aired last summer. Judges have been instructed to use new breed standards and inbreeding has been banned. However, many judges are also breeders and there is much opposition to the controversial changes.

Many bulldogs must undergo artificial insemination in order to conceive because mating is anatomically difficult. Most give birth by Caesarean section because the puppies’ large heads get stuck in the birth canal of the small-hipped female bulldog, making natural birthing difficult and dangerous. The bulldog has long been a symbol of strength but the traits that have been bred into it, such as the massive chest and pronounced underbite, actually make it physically weaker. Other breeds that will be affected by the new mandate include the Shar Pei, with its trademark skin folds that cause eye and skin problems, and the Pekingese, which has a flat face that causes breathing problems. These changes will, of course, take years as healthy traits are bred back in and unhealthy traits removed. (An example in the cat world would be the pushed in faces of Persian cats and the resultant blocked tear ducts that cause eye drainage problems.)

If the American Kennel Club (AKC) hasn’t been inspired by the decisive actions of its counterpart across the pond, I hope it is soon. I have always wondered why the Humane Society hasn’t done more about this issue. The thought of a female bulldog somehow being separated from her family and getting pregnant as a stray, only to die a painful death birthing her puppies because humans have designed her to be unfit for the most natural of physical functions is abhorrent to me, not to mention horrifying in its inherent cruelty. This should have been illegal right from the start. The attitude that an animal is a “product” to be engineered for human use, study, and convenience is one that I feel should have been obsolete by now. There are arguments pro and con regarding the use of animals for food, clothing, and research, and I don’t intend to discuss those any further. However, there is no excuse or rationalization that can justify or provide any validity to the manipulation of animal DNA for sheer vanity and human entertainment, as is evident in the breeding of show dogs.

I applaud the UK Kennel Club for its immediate and decisive action on behalf of show dogs. It is easy to assume that these are pampered animals leading luxurious lives. We hear so much about the plight of mutts and stray dogs, but pedigree animals suffer from a unique brand of cruelty that affects their health and the integrity of their bloodlines. Dog breeding is big business and it is minimally regulated. There are many reputable dog breeders but puppy mills abound. I hope the United States follows in the footsteps of the United Kingdom and recognizes the need to protect the health of show dogs and all dogs that are bred for sale.

Blog 4

Prison Reform for Health Care's Sake?

2009-02-13T02:43:00.002-05:00

Prison Reform for Health Care’s Sake?

Jails and prisons lie at the intersection of criminal justice policies that target already marginalized populations, health disparities, public health, and proven biomedical strategies. The explosive rates of incarceration since 1980 are direct consequences of criminal justice policies that adversely impact urban communities disproportionately affected by detrimental correlates of poverty – particularly poor health as a result of an influx of illicit drugs. Illicit drugs are a double-edged sword: on one end are the dealers and the other are users. In the eyes of the law both are criminals and, in some cases, subject to similar sentences. Therefore, a good portion of the national prison population consists of individuals incarcerated for non-violent offenses or, put another way, “crimes against themselves” (Russell Simmons, 200X).

Is it a wonder that jails and prisons are overcrowded?

In California, the problem is compounded by the fact that other states often transfer inmates to already overcrowded facilities. Should we / the tax-paying-population be concerned that a three-panel judge ordered the release of several thousand inmates (over the next few years) for health care reasons? Or should we be more concerned that the prison system has an expendable population of several thousand to begin with? If that is the case, is ‘health’ a disguise for a seething undercurrent of a much larger problem?

Physical and mental well-being (or health) start with a healthy environment which includes access to the very resources that secure health: employment and comprehensive education. Neither is abundant or is sparingly available in urban communities. But drugs are! And so are mixed messages that, on the one hand, proselytize the advantages of acquiring an education, for example, while simultaneously depleting financial resources that make educational success possible; or, shameless promotions of financial success through illicit drug sales while limiting the alternatives to starving or barely surviving through a less-than-minimum-wage salary.

If one is not mentally unstable from his environment before incarceration, most certainly the conditions within will destabilize him. With rehabilitation programs limited to constructing home-made weapons as cheap but as deadly as Walmart-sold guns, it should not be a surprise that these men and women return to their broken-environment in a worse mental and physical state than they were before incarceration – hence, the high recidivism rate. So it should not be a surprise that correctional facilities are overcrowded. And it is an insult to be shocked, let alone, outraged at the poor health of inmates since their health was poor to begin with.

The question, therefore, is not that corrections facilities are overcrowded but how did they get that way? More importantly, what is the plan to mitigate this problem from occurring again? Or, are we more comfortable with locking people away as a measure to correct problems we’re unwilling to confront and rectify?

Holly Tomlin
BW 706 – Blog 3

2009-02-12T14:52:00.003-05:00

The Octuplets’ conception: was it unethical?

In an article on msnbc.com, the American Society for Reproductive Medicine questioned the actions of Dr. Michael Kamrava. The organization is investigating the procedure that Dr. Kamrava completed on Suleman. The organization has guidelines for the number of embryos that should be placed in a woman. However, if a doctor is found to have violated the guidelines, the organization cannot stop the doctor from practicing.

Suleman’s first pregnancy was from that of in vitro fertilization where she gave birth to 6 children. I feel as though you can’t say that it was wrong for her to get in vitro a second time because she was a single mother with 6 other kids. However, I do believe that the guidelines that were created by the American Society for Reproductive Medicine should be followed. If doctors do not follow the guidelines of two to three embryos, then they should lose their license. If we left it up to doctor to decide what the correct number of embryos to implant were we would have doctors doing whatever they wanted.

In Suleman’s case, I believe that not only is the doctor to blame but Suleman herself. Instead of Suleman having a million children to make up for her “terrible childhood”, she should have gone to see a psychologist. Just as an ethical plastic surgeon would send a patient who has body dysmorphia to a psychologist, Dr. Kamrava should have sent Suleman to a psychologist. Now all of us are stuck supporting her kids because she had a “terrible childhood”. We all have bad things that happen to us during our life time. It’s LIFE; no one said it was easy.

Euthanasia - To Murder or Not to Murder, That is the Question

2009-02-11T22:55:00.002-05:00

Okay, so get ready to not like me anymore, especially after you read this post. I have tried to avoid posting on subjects that rev my engine, except for last week that is, until now. When I read the article, “Italy Seeks Clarity on Euthanasia,” I just knew I had to respond.

So, basically, the article (http://news.bbc.co.uk/2/hi/europe/7881441.stm) reports that Italy’s politicians were in the process of creating a new right-to-die law, after the case of Eluana Englaro. Englaro was a 38-year-old patient who had been in a coma since 1992. Just as the Senate was preparing to pass a law to keep Englaro alive, the doctors pulled her feeding tubes and she died. Of course, this issue raised some serious concerns among the politicians and anti-euthanasia and rights-to-die activists.

“Prime Minister Silvio Berlusconi expressed similar sentiments. ‘Eluana did not die a natural death, she was killed,’ he said, blaming President Giorgio Napolitano for blocking his emergency decree that would have forced doctors to resume feeding her.”

However, the President reported that the prime minister had acted, “unconstitutionally by attempting to overrule the courts, which had judged that Ms. Englaro should be allowed to die, in accordance with her father’s wishes.”

My first issue with this entire case is when did it become the government’s place or right, let alone anyone else for that matter, to intervene in determining when someone else lives or dies? We have become so involved in the lives of others, whether it be celebrities or regular every day citizens, that we cross the lines between legalism and ethics. Is it right for us to force our beliefs on someone else’s life, when it interferes with their beliefs? When is it okay for the media and the rest of the world to play God with our lives?

I am, by the full meaning of the words, a Christ believer and Christ follower. So, my beliefs may often, as they always do, conflict with the morals or beliefs of most of the world. So, I do not fully understand how it becomes our right to become involved in determining who lives or dies. I’ve always been under the impression that this was inevitably God’s decision. No matter who wants to fight it, drag it into court, print it in the newspapers, pass a law against it, or whatever. My life’s beginning was not decided in the courts or the newspapers, and neither will my life’s ending.

This is the same issue as the Terri Schiavo case when the state of Florida had to become involved in deciding if Schiavo’s feeding tube would be removed because Schiavo’s parents disagreed with her husband’s right to have his wife disconnected from life support, even though the husband had a do not resuscitate order. Many people would argue that as long as the brain is still working, then you’re still alive, regardless of whether you have function of the rest of your body and organs. Then the question of quality of life comes into play. Is it really living, if there’s no quality of life? Should we be denied the right to quality of life?

This issue sparks a lot of controversy within the church and the government. It then becomes a religion versus ethics issue. Just like in Italy where the Roman Catholic Church became involved in Englaro’s case.

“The Roman Catholic Church, which was angered by the moves to withdraw Ms Englaro's life support, and prayed for God's "forgiveness" for those who "led her" to her death, agreed. ‘A just law is necessary for the good of our society and our civilisation,’ said Cardinal Angelo Bagnasco, head of the powerful Italian bishops' conference.”

On the religious aspect, some may even question if it’s biblical to even be hooked up to machines. Would not some fanatics say that God would not want us hooked up to life support at all, if He is our life support? Of course, I have my opinions on that matter, but I will not voice them here for fear that this post would be several pages long and spark numerous posts of controversy.

Is it really euthanasia if we are preserving quality of life? Is euthanasia just simply another word for murder?

The questions and the arguments are numerous, and have been argued for centuries. So, who’s right? In the end, we all have our strong opinions and views on this issue and no one will sway the other from their point of view. So, on this issue, I guess we just all have to agree to disagree, loudly.

Moral Distress

2009-02-11T21:43:00.002-05:00

When Doctors and Nurses Can’t Do the Right Thing
Pauline W. Chen, M.D.
The New York Times
Doctor and Patient
February 6, 2009

The writer, a physician, describes her experiences of witnessing what an ethics consultant she knew called “moral distress.” The ethics consultant, also a medical doctor, stated that this was a growing concern at her hospital. Moral distress is the feeling of being trapped by competing demands from bureaucracy, family, and professional peers that forces doctors and nurses to compromise their commitment to what is best for patients.

Dr. Chen described a scenario that involved a very talented nurse who possessed tremendous perspicacity regarding clinical situations. She noticed over the years, however, that this nurse’s communication style devolved from sharp insight to vague non-commitment when communicating with doctors and supervisors. One situation in particular provoked the writer of the article to question the nurse about her change in attitude.

An intensive care unit (ICU) patient who appeared beyond help was taken into the operating room repeatedly over a period of a month. The patient’s abdomen was riddled with an unrelenting bacterial infection that was refractory to treatment. The nurse’s concern for the welfare of her patient as well as her questions regarding the futility of the surgeries were repeatedly ignored by the surgical team. She began to resort to sarcasm and, ultimately, resigned herself to silence whenever she was asked to take the patient in for yet another unsuccessful surgery.

The nurse shared her frustration over not being able to advocate for her patients. She was faced with the moral dilemma of choosing to do what was right for the patient or protecting herself from being criticized by doctors or warned by her superiors. This frustration is shared by many nurses. A recent study found that 15 percent of nurses leave their jobs because of moral distress. Doctors grapple with their own version of moral distress but not to the same extent as nurses.

According to Ann B. Hamric PhD, RN, the lead author of a University of Virginia study of ICU nurses and physicians, moral distress may stem from a variety of situations, but it is, in large part, a product of the work environment. Doctors and nurses both suffer from feelings of a lack of autonomy and threatened integrity, fearfulness, and lack of respect. Doctors feel that lawyers and risk managers are dictating patient care over and above the physicians’ professional judgement. The United States has had a nursing shortage for years and a primary care shortage is pending. Dr. Hamric believes that the first step to dealing with moral distress is to recognize it as an issue and then to make a point of discussing it in the health care setting. If health care providers are unable to maintain their professional integrity and do what is right for their patients, the shortage will inevitably become a crisis.

I feel that respect, fairness, and autonomy are at the core of this issue. At the heart of nursing is the imperative to advocate for the patient. The nurse is the liaison between the physician, the social worker, the family, and the patient. No one is more intimately involved in the patient’s care than the nurse. This caregiving role distinguishes nursing from medicine and gives nurses a unique and valuable perspective. Patient hospital ratings are often directly proportional to the quality of nursing care received. Yet nursing professionals continue to feel undervalued and disrespected.

When healthcare providers work as a team of dedicated professionals rather than in the constraints of an outmoded hierarchy, everyone benefits. I was lucky enough to work with an amazing group of doctors and nurses (there were some bad apples, of course). I felt respected by the doctors, my colleagues supported me, my insights and recommendations were valued, and many of my patients appreciated the care I provided them. However, the manpower shortage confronted us on a daily basis. Mandated overtime was the norm. Burnout was common, resentment over not being able to give patients the full attention they deserved was an underlying theme, and safety was an overriding concern. Turnover was high as, week after week, my supervisor tried to balance the schedule, deal with upper management who had no clue about the realities of working on a hospital floor, and, somehow, appease the increasingly disgruntled troops. She too eventually left.

We were paid well and raises came often. But there was no life outside of work. We were required to work every other weekend. That meant working for two weeks at a time before getting two days off in a row. That, in addition to overtime. Days off had to be requested at least a month in advance and weren’t always granted. Sick days were offered but nurses who called out more than two days in a year were denied a raise. Some nurses did feel disrespected. On-call doctors were rude and imperious. The buck always stopped with the RN: Whatever the nurses aides didn’t get to or didn't feel like doing was dumped on the nurse; if social work wasn’t able to do something the nurse picked up the slack; doctors talked down to the nurses and some had the frightening reflex of blaming the nurse for their own mistakes. There were more patients than nurses to care for them.

Numerous studies, analyses, task forces and questionnaires later, nothing much has changed to improve the nursing shortage. The answers seem obvious to nurses but there seems to be a conspiracy of ignorance among the powers that be. The problem is systemic and one that is confronting professionals everywhere. Money is more important than people, timelines are more important than quality, the status quo is more important than teamwork, and upper management everywhere have their own agenda. There is no single solution to this problem but it doesn’t appear that any real efforts have been made to resolve it. If we were living in a different time, place, and culture, there would have been a revolution by now. But there seem to be too many competing interests for anyone to unify for a common goal and purpose. I don’t know the answer. I left nursing too for another job that has its own challenges with moral distress. That’s life in America I guess.

Salmonella...come and get your salmonella

2009-02-11T19:53:00.001-05:00

Imagine, you go are going about your normal routine. You feed the dog. Then you feed the kids; they've been extra good today, so it's ice cream and brownies for desert. Sounds like a normal day, right?

Now imagine a food manufacturing plant with live roaches, mold and slimy residue on floors and equipment, and improper sanitation procedures. Disgusting, right?

Now you may be asking what your normal routine has to do with this food plant. In short, Peanut Corporation of America knowingly shipped products that had tested positive for salmonella. This product ended up in your dog's food and in your kids' ice cream and brownies. Now, they are among more than 500 illnesses and eight deaths caused by this contamination. You know that it's not your fault; you had no way to know. However, there must be someone to blame.

Federal officials have begun a criminal inquiry of Peanut Corporation of America after learning that it knowingly shipped products that had tested positive for salmonella. This bit of knowledge would leave you to believe that the plant is entirely to blame; however, it is not as straightforward as that.

The plant was subjected to regular visits and inspections by federal, state, and private inspectors; and most of these inspectors found the plant to be in tip-top shape. Now, food manufacturers and public health officials are trying to determine how so many inspectors missed what some have said were obvious problems at the plant.

Kellogg, one of the companies that recalled peanut products, received reports of third-party independent audits of Peanut Corporation of America. These audits were supposed to review the supplier’s food safety program, microbial test results, and internal audit results. Kellogg is now looking into whether the third-party auditor actually reviewed state inspection reports or the plant’s test results.

The salmonella outbreak at Peanut Corporation of America shows the illusion of independent audits. Auditors rely on tangible facts, but when it comes down to it, they are also relying on trust.

For example, the president of the third party auditor, Jim Munyon, said the company would not have received a superior rating if his auditors had seen the filth the federal government described. “It would mean that we didn’t see it on the day we were there,” he said of the rating. “What goes on the rest of the time, we don’t know.”

As consumers, we trust Kellogg when we buy and eat their products; Kellogg trusts their auditors; the auditors trust Peanut Corporation of America; and Peanut Corporation of America trusts its workers.

So who's to blame; the workers, Peanut Corporation of America, the auditors, or Kellogg? You can be sure that your kids aren't thinking about that as they are standing over a toilet vomiting. However, maybe each entity (the worker, the corporation, the auditor, and Kellogg) should take each step in their daily routines, from manufacture to marketing, with the visual of your kids in mind. Better yet, maybe they should take each step as if the product is specifically for themselves. Then, just maybe, we could feel comfortable relying on trust…oh yeah, and audits.

Photojournalism and the public’s health: art or information?

2009-02-10T02:51:00.002-05:00

My addiction to taking pictures started when my grandfather traded my cheap little camera for his better quality 35mm Kodak. Long before I considered myself a photographer, I just liked taking pictures. I’d annoy family and friends, intrude on mating animals, disrupt a dance, or make babies cry with curious clicking or a blinding flash. In the end, that shot of my 20-month old niece dumping milk over her baby brother’s head was worth my brother’s laughter and irritation.

I bring a camera everywhere I go. A few years ago I upgraded and bought a new one specifically for my move to Kinshasa, Democratic Republic of Congo. I wanted to document everything with photos. I shot my house and the flora and fauna surrounding it. My neighbors and colleagues obliged my interest in their culture by stopping and striking poses for their American friend.

The first time I encountered resistance was on the street - cruising down the main boulevard a group of police officers with rifles sat on either side of a bench hoisted on the back of a standard Toyota pick-up truck. It wasn’t just that the passengers of the truck intrigued me but how young the policeman looked. Unfortunately for my portfolio, there were laws about taking photos on the street. I couldn’t risk exposing my camera to the officers so I tried to conceal it. One of the officers spotted it and reprimanded me with a shake of the head and wagging his forefinger. I wasn’t bold enough to disobey the law in a foreign country – especially when the law blatantly displayed their rifles with a shoulder strap of bullets. The second time I whipped out my camera on an unsuspecting passerby I was met with fierce eyes and a hand gesture that only included his middle finger. After that, I learned a hard lesson about treating people as inanimate objects for foreign curiosity.

A fellow American colleague helped me put my intrigue into perspective. Just ask, he said; if not directly (since I didn’t initially speak the language), at least indirectly with gestures of the eyes not only visible through the camera’s looking glass. Permission – wow, what a novel concept? Unfortunately that wisdom fell on deaf ears when we attempted to empathize with the privacy of a young girl suffering from the debilitating physical symptoms of a deadly disease. At least, we tried to compromise, cover her eyes with a black bar for some measure of anonymity. The investigators and presenters did not see (no pun intended) that logic and, after that scientific health exchange, that young girl unknowingly became the poster-child of a disease that may have taken her life.

As a scientist and artist I am torn between the constant quest for knowledge and the desire to display that knowledge photographically. However, exploitation is rampant around the world. Especially when politically, economically, and socially-disenfranchised people are involved. Out of respect for them, I have to put my intellectual power and artistic ability aside and respect their right to privacy and to consent. The fear, understandably, is loss of the creative moment or lost opportunities for information sharing. Yet, there is a much appreciated richness when the spirit of collaboration is invoked and no one moment or person is taken for granted.

Holly Tomlin

BW 706 – Blog 2

Health Literacy - A Cry for Universal Health Care

2009-02-09T22:22:00.001-05:00

Health care is now a business that rivals the industrial complex. Its major consumers are victims of lopsided capitalist principles that exploit weaknesses within our educational systems – mainly literacy. If literacy is at an all-time low in this country, health literacy must be virtually non-existent. But what does this mean? And more importantly, why should anyone care? These questions are made complicated by arguments that weave a moral blanket of hypocrisy which does not provide comfort – let alone security - to those most impacted by a poor health infrastructure. That is, too often we blame the sick for having sickness and the uneducated for not knowing when the real cause of either or both is mis-education combined with quests for power and, ultimately, control.

Literacy is not merely the act of reading and comprehending fragments of generic knowledge. It is a tool for understanding the constellation of knowledge that shapes our views of the world and defines our positions in it. Understanding who we are in terms of how our bodies work optimally is essential to securing a competitive advantage – particularly in a free-market economy. However, large swatches of the US population are disproportionately denied basic health needs such as potable water, adequate shelter, and access to basic health care - they do not have insurance or they have inadequate insurance which is poorly defined and, therefore, subject to intricate loopholes. The health literature is replete with epidemiologic data illustrating the link between access to basic health needs and illness while the health economic literature highlights the impact of sickness to the work force and societal growth. So wouldn’t it make sense to promote and support a healthy society if for no other reason than the well-being of our economy and securing a prosperous future? It does to me.

However, in order for this to happen we need to eliminate the barriers to access which includes class-based health insurance and, more importantly, advance a comprehensive education about the relationship of personal health to societal development. Yet, too often, we exert power by enacting laws on the basis of a sense of moral superiority; and we use oppressive means to control basic needs. This is best exemplified by the gross amounts of narcotics and pharmaceuticals that act to subdue harmless physiologic impulses and abolish the most basic human right – the right to health (as defined by the World Health Organization). Or, perhaps it is the intention of the powers-that-be to keep certain people ignorant and weak from poor health. What better way to control people than to continuously exploit their vulnerabilities while making them dependant on small acts of welfare disguised as generosity?

Holly Tomlin
BW 706 –Blog 1

The "Crazy Kid Lady" of California

2009-02-05T18:57:00.006-05:00

We have all heard of “crazy cat ladies,” who collect unmanageable numbers of cats in one house only to have the cats themselves suffer. We now have the “Crazy Kid Lady” of California. There are parallels between the two, with the main and obvious difference being that there are children involved rather than animals. As is usually the case, these questions are much more complex than most people appreciate.

I used to think that parental rights were absolute, with the exceptions being sexual abuse, physical abuse, and refusal to allow low-risk yet life-saving medical treatment. I still largely believe that. The question of who is to determine the best way to raise a child is central to my reluctance to have the state have too much power in this regard. However, recent events in California and the movie “Gone Baby Gone” have made me moderate my tone somewhat. (While I do not base my beliefs on the plots of fictional movies, a good movie can show a different perspective on an issue. Anyway, it is a worthwhile movie, but it is not for the easily offended.)

It is safe to say that this woman has issues. She went out of her way to have these babies (due to her health she could not have conceived without in-vitro fertilization) despite her financial and familial situation. She already has six children under 8 years old. She is a single mother (Do not try to tell me that is not a factor. It is.) She is unemployed. It is valid to criticize her.

People are also criticizing the doctor for going forward with this procedure. Much of this criticism is valid, including criticism of the number of embryos implanted. This doctor ignored well-established guidelines. Standard procedure for a woman her age is implanting two embryos. Multiple births carry increased risks for the children and parent involved. Another valid criticism is that the doctor should not have performed the fertilization at all given the woman’s situation. While doctors are only expected to know what the patient tells them (outside of medical records), this is the same doctor who preformed the fertilizations for all six of her previous children.

Most people agree that both the woman and doctor are wrong. Even then, there are many angles and questions related to this story that are not easy to pin down. For instance, in our rush to criticize the woman and the doctor, let us remember that we are not talking about a litter of puppies here. These eight children (and the preceding six) are human beings who are entitled to the same dignity and individuality that we afford anyone else. No one wants to grow up hearing that the only reason they exist was that their mom was nuts and her doctor was a bad man. While these circumstances are not optimum for these children, given the choice between being here and not being here, they would take the former. Also, let us not become too self-righteous over this woman giving life to 14 children for whom she can not properly care, as we often do not do what is right for the small children in our own lives. Further, roughly 1 million “fertilized eggs” yearly never even have the chance to become one of 14 children in a squalid house, which they undoubtedly would have preferred to their own fate. There is something upside-down about Americans' uproar over this creation of 14 lives, while there is relative ambivalence about the destruction of millions of lives. (Regardless of whether you think abortion regulations should be tightened or loosened, abortion is still a sad, unfortunate thing that ends a developing life. My views fall somewhere between the nuts on one side who think it is justifiable to shoot abortion doctors and the nuts on the other side who think that abortion is a right of passage along a woman's path toward self-actualization. However, this is another conversation entirely.)

Thus, while keeping an eye on the “crazy kid lady” and everyone else culpable in this debacle, let us also take more than the occasional glance in the mirror.

$18 Billion in bonuses, I wish I worked on Wall Street

2009-02-05T18:55:00.001-05:00

In an article from CNN.com Obama denounced the $18 billion in bonuses that employees on Wall Street received last year. He described the bonuses to be from “a culture of narrow self-interest and short-term gain at the expense of everything else”.

It is about time that someone stands up to the socially irresponsible executives and put them in their place. In order to help control the use of unethical bonuses, Obama has created a plan that would place limitations on how executives can be paid if they are making over $500,000 a year. If an executive is to make over $500,000 they must be paid the remainder in stock. In addition, the executive cannot sell off the stock until the company has paid back the government. Most importantly, the new rules are going to be implemented by the Treasury Department and therefore do not need be approved by congress.

Obama has also created rules that will allow shareholders of banks to have a larger say in the salaries that are given to the executives. Also, the new rules will make it easier to track money spent on things such as holiday parties and office renovations.

When many of us heard about the huge bailout that was going to save many crooked companies, we were upset that nothing was going to be done to the executives that were spending millions to renovate their offices and millions on their new private jet. It is wonderful to see that Obama is FORCING executives to take responsibility for their unethical actions and is creating rules that force these companies to conduct business, as they should in a responsible manner.

One can only hope that we learn from our mistakes. However, as we all know…history usually repeats it’s self.

Doctors benefiting financially from pharmaceutical companies…Go Figure!

2009-02-04T20:28:00.000-05:00

An article entitled “ Doctors: Under the drug industry’s influence?” explored the idea that doctors are being influenced by drug companies to promote specific drugs to their patients.

Not only do doctors receive free pens, meals and those hard to get concert tickets, some doctors have been known to accept monetary gifts. While attending college, I worked as a pharmaceutical technician. I can vouch for the “great” gifts that the pharmaceutical companies would leave for us. When pharmaceutical companies would visit our company, they almost always came bearing a wonderful lunch for us.

More recently the integrity of doctors and pharmaceutical companies were questioned when the Iowa Republican Sen. Charles Grassley and Dr. Joseph Biederman, a prominent Harvard University psychiatrist failed to disclose payments from drug companies.

Dr. Marcia Angell of Harvard Medical School in Boston expressed the importance of doctors keeping their distance from industry. She continued to state the doctor should pay for their own educational meetings and not attend lavish events that are thrown by industry.

The article continues to explain how doctors give patients free samples, thinking as though they are helping their patients. However, they are simply assisting in a very effective marking technique.

After reading that free samples are a marketing technique, I feel guilty for accepting free samples from my doctor. As I think about it now, typically when doctors give you free samples, they almost always give you a prescription to get the drug when you run out of samples. They are good.. really good.

Now with the economy in a downward spiral, hopefully pharmaceutical companies will learn that it is important to have corporate responsibility.

Informed Consent…We Dun' Need No Stinkin' Informed Consent

2009-02-04T19:03:00.002-05:00

Hundreds of African American men were murdered, children were fed poisoned Quaker Oats, and honorable soldiers were exposed to toxins. Were these the acts of multiple serial killers? I guess it all depends on how you look at it.

Studies involving human subjects/patients have been a topic of controversy for many years. Government reactions, such as The Declaration of Helsinki, are meant to put controversies to rest; however, recent accusations within an article published in the New York Times are yet another example of weaknesses in controlling human studies.

Apparently, in the late 1980s, the Boston's child-welfare agency developed a policy to allow foster children to enroll in drug trials at a time when there were no approved treatments for children infected with H.I.V. and AIDS. Sounds harmless right? They had acted in good faith and in the interests of the children. However, you must remember; it all depends on how you look at it.

Liam Scheff, a freelance journalist in Boston, charged that the children were put in trials without their parents’ knowledge and were given medications known to cause death. He said that the drugs in question had Food and Drug Administration warnings on them and that they had “caused permanent injury and painful death in adults who have taken the exact same drugs at normal prescribed doses".

As a result, in 2005 the city commissioned the Vera Institute of Justice, an independent nonprofit group, to investigate the claims.

The Vera Institute of Justice found no evidence that any children died as a result of the trials or that the foster children were selected because of their race. Sounds like Liam can put his money where his mouth is, right? We're not done yet.

On the flipside, it was also found that the child-welfare agency had not always followed its own protocols and kept poor records. Sixty-four children participated in 30 medication trials that were not reviewed by a special medical advisory panel.

Moreover, the informed consent forms from biological parents or guardians were missing from the child-welfare files in 21 percent of cases. In some cases handwritten consents were found instead of the official consent forms. No big deal, right?

Wrong! The problem with this case is the issue of enforcement. It's all well and good that we have guidelines and policies set in place, but if researchers do not follow these guidelines, then what use are they? Without informed consent, there is no way to know if the parents/legal guardians knew the details of the study or if they even agreed to the child's inclusion.

The unethical events within this story may not have the same magnitude and lasting effects as the Tuskegee Syphilis Study; however, isn't this story an ethical consideration that must be viewed with same the amount of gravity?

I guess it's all depends on how you look at it…

Prepared Statement to the Senate Foreign Relations Committee from Al Gore

2009-02-04T17:58:00.003-05:00

Former Vice President and Nobel Peace Prize winner Al Gore went before the Senate Foreign Relations Committee on January 28 to advocate President Obama’s spending plan for addressing the issue of global warming and to reiterate the importance of reducing carbon dioxide emissions and other pollutants implicated in the climate change crisis. His prepared statement was posted in The New York Times by John M. Broder in Gore Restates Climate Case in Senate.

Mr. Gore stated that the plan’s focus on four key areas—energy efficiency, renewables, a unified national energy smart grid, and movement toward cleaner cars¬—will result in a four-fold benefit of creating new jobs and hastening economic recovery while strengthening national security and addressing the effects of climate change.

The speech describes a triple crisis of climate change, a worsening economic situation, and the endangered state of our national security that is linked by a dangerous over-dependence on carbon-based fuels that shackles our society into a cycle of borrowing money from China to pay for oil from the Persian gulf so that we may burn it to pollute the planet, all at the whim of OPEC and its fluctuating oil prices. While we continue participating in this destructive cycle we are moving toward irreversible tipping points that will undermine the habitability of our planet and civilization as we know it.

Just as our ecological, economic, and security threats are entwined in a seeming Gordian knot, the solution to the crisis appears clear-cut to Mr. Gore: the acceptance of President Obama’s Recovery package in its entirety, as a bold first step. Mr. Gore challenged the belief that Americans must choose between the environment and our way of life and between moral duty and economic well-being. He believes that the Obama Plan is an effective strategy to address all three crises and the path to restoring our place as an economic and moral world leader, independent of ties that compromise our way of life. According to Mr. Gore, it is essential that the United States quickly expands its capacity to generate clean electricity so that we can move forward effectively in the plan.

The second step to solving these crises would be the institution of a cap-and-trade system for CO2 emissions that would also serve to restore our country’s credibility. As the Copenhagen treaty talks draw near, this action would place us on a more balanced footing with other countries and many states that have already instituted such a system, and allow us to take a leadership role in creating a fair, effective, and balanced structure for restoring the global environment. Mr. Gore outlined what he felt would be key elements to a successful agreement in Copenhagen, which included targets, timetables, solutions, and the need for accountability.

While the United States has remained inactive on the global climate scene, developing countries have assumed increasing leadership roles in calling for action in the world arena and taken bold initiatives in their own regions. Heads of state and even some corporate leaders have become involved in this movement. The American public is also becoming more aware and engaged in the scientific evidence for global warming. Mr. Gore stressed that this is a bipartisan issue that requires immediate and unprecedented action based on new scientific evidence and pointed to successes within the Reagan and Bush administrations that have helped pave the way to Copenhagen.

Making the change from a mentality of conquest to a philosophy of conservation has been a difficult challenge for Americans as a group. We have a love affair with our automobiles—they are an intrinsic part of our culture and our mythology. But it is time for us to move into the 21st century. While other countries have forged ahead with innovative green technologies, we have clung to old standards buttressed by the greed of large corporations like “The Big Three” who have systematically and deliberately extinguished the fires of green technologies such as the electric car and solar power. We have become obsolete, out of touch, as countries like Germany surpass even their own goals for attaining solar and wind energy, and some of us continue the shrill chant of “drill, drill, drill.”

I remember a television commercial from my childhood: a traditional Native American man standing by the roadside as cars drove by dumping litter at his feet, a single tear rolling down his sad face. How that commercial broke my heart each time! The Native American philosophy was to always consider how the actions of one generation would affect the lives of future generations. Modern Americans have became so short-sighted that we couldn’t even conceive of the possibility that our enemies would have the patience, foresight, and dedication to wait a decade or even a generation to strike at us. Out innocence and our arrogance took a big hit on 9/11.

Winston Churchill said, “Americans can always be counted on to do the right thing…after they have exhausted all other possibilities.” I believe that we have arrived at that point. Americans are resilient and innovative. We need to dig deep into our collective consciousness and dredge up some of that trademark American optimism that always gets us to the other side. This is a terrible time in our history. But it is also an opportunity for American ingenuity to shine once more and bring us back to a leadership role in the world.

OMG! The Baby Lady Again

2009-02-04T12:45:00.002-05:00

Okay, I know this story has been run into the mud. There have been thousands of blogs, articles, and news stories about this lady and her eight babies, plus the six she already has at home. But coming from a big family myself (there were 12 of us), I felt compelled to reply to this crazy, unbelievable story. So, here it goes.

The ethical issues surrounding this story is overwhelming. First, you have the fertility clinic and doctor who knowingly implanted eight embryos into a woman who has filed bankruptcy, has no income, and has been living with her parents, whom have accumulated much debt and become bankrupt themselves trying to take care of the mother and her other six children, while she attends college. Then you have the mother, who has tremendous amount of problems (financially and mentally, as noted by her mother), decide to pursue multiple births. Not to mention, the physical damage the mother has inflicted upon her body. Now, this same woman is asking for $2 million to tell her story on national television.

While the media has caused a stir of panic over this supposedly overwhelming story of "medical triumph," as articulated in a MSNBC article, every day more facts about the birth mother come to the forefront that now makes us question our initial reaction of elation and support.

As Dr. Summer Johnson notes in her article, "Update: And Baby H Makes 8...No, 14":

"As the story over the California octuplets born this week has unraveled, the ethical issues surrounding their birth have expanded beyond those of just the health and welfare of the mother and 8 tiny little fetuses but to questions of social justice and the choice of the mother to have 8 more children, period."

Hailing from a big family myself, I know the difficulties of raising and caring for a numerous amount of children. I often wonder how my father and mother kept their insanity, let alone the clothes on their backs. I'm extremely proud to say that because of my father's pride, dedication, and committment to being the sole provider for his family, we never needed governmental assistance and we never went hungry, cold, or deprived of anything and everything we wanted. So, for the birth mother to assume these tremendous responsbilities without the financial and emotional support she needs (which she'll need plenty of), how will she take care of these 14 children? According to AOL News,

"Fox News crunched the numbers and announced that it will cost Suleman - and us! -- $35 million to raise these kids. And even fellow MOM (mom of multiples) Kate Gosselin of the TLC reality show "Jon & Kate Plus 8" has jumped in to criticize: "Personally, I would never have set out to even have a seventh child - especially if I was a single parent."" (http://news.aol.com/article/whats-the-octuplets-anger-really-about/328057#Comments)

Should the State of California's Department of Child Services step in to access this mother's living situation, as well as her mental state, before allowing her to go home with these babies? I mean, isn't it the duty of the State to ensure these children will be well cared for mentally, socially, and financially? What measures will the State take to investigate the fertility clinic who implanted the eight embryos, knowing the mother's situation?

And, now, knowing that the grandmother suggested mental healthcare for the mother who she believed unstable and obssessed with having children, should we even allow this mother to take these babies home from the hospital?:

"She always blamed me for having only her," Angela Suleman told the Web site. "...She was always upset that I didn't have more." Angela Suleman also told Us that Nadya first talked about having a large family when she was a teenager. "I have been supportive, but you know, now that I am thinking back, she wanted children so much that it was almost not normal as far as I am concerned," Suleman said, adding that she once consulted a mental health professional about the issue." (http://news.aol.com/article/octuplets-grandmother/328911)

Please forgive me if I am rambling, but after reading that the mother now wants to be paid to tell her story and give advice on being a mother, I could not contain myself any longer. According to Fox News,

"The mother of octuplets born in California last week is seeking $2 million from media interviews and commercial endorsements to help pay the costs of raising the children, the Times of London reported. Nadya Suleman, 33, plans a career as a television childcare expert...Although still confined to a Los Angeles hospital bed, Suleman reportedly intends to talk to two influential television hosts this week — media mogul Oprah Winfrey and Diane Sawyer.
Her family has told agents she needs cash from media deals." (http://www.foxnews.com/story/0,2933,486645,00.html)

So, now the mother is seeking fame from her medical miracle. I think I speak for everyone who pays taxes and will have to pay even more come April 15, please make sure this lady can have no more babies!

Family Surrogate-Based Research for Alzheimer’s Patients

2009-01-29T08:09:00.000-05:00

I just read that a new study is finally allowing surrogate consent for Alzheimer’s patients. Having been in the situation as care-giver for a parent with Alzheimer’s, I say about time. I find it appalling that this “surrogate” consent was not allowed earlier. As if research for Alzheimer’s needed any more stalling. How can we advance in research for Alzheimer’s and dementia, if studies are not done on patients suffering from these diseases in their varying stages? For instance, when my father was diagnosed with Alzheimer’s, he was immediately prescribed Aricept. However, because of his rapid advancing stages, the Aricept was not beneficial for him, and no other drugs were available to help or slow down his dementia. According to the article:

“By the time they (patients) have been diagnosed with Alzheimer’s disease, many patients’ decision-making ability is so impaired that they cannot give informed consent to participate in research studies. Close family members are left with the decision, but there is no clear policy for this so-called “surrogate” consent. Because of that, research about the increasingly common disease is often stalled. But a new study led by the University of Michigan Health System suggests that older Americans are very supportive of family surrogate-based research, and would support having their family members enroll them in research in case of future incapacity. The study appears in the new issue of the journal Neurology.”

Although the article notes that, “ethnic and racial minority groups were slightly less willing to participate in surrogate-based research,” there has been support from these groups. I know that I am a strong supporter of Alzheimer’s research and the concept of surrogate consent. I only hope that this decision was made 4 years earlier, when my father would have been able to benefit. The article mentions that, “The rates of Alzheimer’s disease are rising rapidly; in 2000, there were 4.5 million Americans with the incurable disease, and by 2050, this number is projected to be 12.5 million if no effective treatments are found.” Although my Dad will not be one of the lucky ones to benefit from this new decision, I’m happy that millions of others will. Who knows, this research may even help me one day, or one of my siblings.

I hope some of you dislike me relatively soon.

2009-01-29T01:57:00.006-05:00

This is my first blog entry ever, anywhere. I had no idea how I was going to approach it. As I read the various blogs of my peers with their different perspectives and approaches, I kept asking myself, “What should a biomedical ethics (bioethics) blog be?”

During the past Presidential election cycle, bloggers from various degrees of the political spectrum immolating (I think the term “flaming” is no longer adequate for the current level of political discourse) those of even slightly differing viewpoints defined (fairly ot unfairly) what it means to “blog.” However, my training in medical writing leaves no doubt that opinion has absolutely no place in biomedical writing. I think we can all agree that any individual blog, the collective blogosphere, and even the internet in general are poor places to gain credible knowledge of evidence-based medicine. (However, there are online repositories and databases of evidence-based medical information, such as http://www.ncbi.nlm.nih.gov/pubmed, http://www.medlineplus.gov/, and http://www.cochrane.org/.) By their nature, blogs have a point of view. They are for commentary and (more often) advocacy, not journalism.

In a bioethics blog, we are not primarily concerned about whether scientific medicine is effective or safe. That is for the scientists, the doctors, and (ultimately) the FDA to decide. In a bioethics blog, we are primarily concerned with the ethics associated with the application of scientific medicine. We have to ponder the difficult, even ugly, questions. A lot of these questions are in the news today:

No one questions the contention that stem-cell research may lead to medical advances. However, the ethical question is what happens when fetuses become valuable and thus become a commodity? Will there be incentives to harvest fetuses? What kind of behavior will that spur?

A related question (which is considered by some to be old and cliché but is more difficult and relevant than ever) is, “When does life begin?”

A wildly disproportionate percentage of health care expenditures in a person’s life is incurred at the very end of his or her life. It is a difficult question, but are those expenditures justifiable?

What is more important, providing “equitable” health care for all patients or preserving providers’ incentives to be innovative and efficient? (If you think that is an easy choice of the former over the latter, then think again.)

Who is to blame for the explosion of medicine-related lawsuits in America, “greedy, predatory lawyers” or “incompetent, indifferent doctors?”

Should the government place extra taxes on the manufacturers, sellers, and consumers of certain products (soda, fast food, tobacco, alcohol, etc.) or even ban them altogether? Where do self-responsibility and individual choice come in? Who decides what is bad for another? Where does it end? Could limits on TV watching eventually be mandated by law?

It will be fun exploring these issues. I tend to alienate everyone on every side of every issue, because I do not subscribe to any one orthodoxy. If at least one of you does not end up personally disliking me, then my blog will not have been very good.

Extra Extra: War on Salt?

2009-01-28T22:39:00.003-05:00

This time, Dr. Frieden, commissioner of New York City’s Department of Health and Mental Hygiene has sodium reduction in mind. He is known for his previous conquests on trans fat, smoking, and posting calorie counts on menus. However, salt is going to be harder to fight since all of its effects on health aren’t proven. The only plan we have of a low sodium diet is for health reasons and that is the DASH (Dietary Approaches to Stop Hypertension) diet, where you consume foods low in sodium, calorie and fat.

Dr. Frieden’s plan is to reduce the sodium in prepared and packaged foods. He’s expecting that if we reduce sodium little by little, then we can adhere to a low sodium diet for the average person. Sodium is an acquired taste just as spicy foods are to a person, if we can reduce the consumption of it and wean you of it, you most likely can survive on bland tasting foods. This is not an ideal situation we can achieve anytime soon or probably, never.

Mostly because salt is in everything, even if you prevent it from being in processed foods it is still in your daily diet. According to the RDA (Recommended Dietary Allowance), the average person is to consume less than 2,400 mg of sodium a day (1 teaspoon of table salt/day). I think we achieved this teaspoon of sodium consumption by the end of breakfast. The only way the average person can go on a low sodium diet is discipline, health, or they have to completely wipe out all foods rich in sodium, which is mostly everything. Reducing salt in packaged foods can help but we still have a long way to go to achieve the low sodium diet goal. Basically, it is people’s choice to eat what they want, and if they want to be in good health, eat sparingly. A little bit of everything is better for you than a large consumption of everything. It’s as the saying goes “don’t take more on your plate than you can handle”. The same goes with life.

Source: http://www.nytimes.com/2009/01/28/dining/28salt.html?_r=1&ref=health

The Epidemic That Wasn’t

2009-01-28T15:53:00.004-05:00

The Epidemic That Wasn’t (The New York Times: January 26, 2009) reports on the outcomes of children born in the 1980s and ‘90s who had experienced prenatal exposure to crack cocaine, which was a prevalent issue at that time. Researchers have been following these children through adolescence and beyond to monitor the long-term effects of fetal exposure to crack on their brain development and behavior. The surprising results of this research indicate that, although the harmful effects are present, consistent, and measurable, they are subtle and have less of an impact than had been predicted.

Cocaine does slow fetal growth. Infants are smaller at birth and their head size is smaller, but this is a temporary effect that normalizes as these children grow. The largest of several studies of the IQ scores of cocaine-exposed children showed that the exposed children averaged 4 points lower on IQ scores at age 7 than unexposed children. However, a pooled analysis of studies of more than 4,000 children did not reveal any significant effect on IQ or language development in cocaine-exposed children aged 4 to 13. Cocaine-exposed children can have difficulty focusing on and performing tasks, particularly if visual attention is required. Behavioral effects of fetal exposure to cocaine include increased frequency of defiant behavior and misconduct, more so in boys than girls. However, experts point out that these children are not distinguishable from “normal” children in a group and that some of these effects are more likely related to socioeconomic factors, such as stress in the home, substandard education, inadequate access to healthcare, exposure to violence, and poverty.

There is no doubt that in utero drug exposure is harmful to developing fetuses. But, as pointed out in the article, the problem may have been handled as a moral versus a health problem. During the 1990s many women were prosecuted and jailed for illegal drug use during pregnancy and it is common for women who use illegal drugs during pregnancy to lose custody of their children. According to 2006 and 2007 Department of Health and Human Services data, 5.2% of pregnant women reported illicit drug use; however, the same data showed that two-to-three times as many pregnant women used alcohol and tobacco (11.6% and 16.4%, respectively), both of which are legal and have well-documented evidence of their effect on fetal development and lifetime health effects. In contrast, the long-term effects of cocaine on children’s cognitive development and behavior appear relatively small when compared to the effects of alcohol. The effects of cocaine and tobacco are comparable. So far, no link has been established between prenatal cocaine exposure and predisposition to drug use, although such a link has been reported in the case of prenatal tobacco exposure.

Children who have been exposed to cocaine and their mothers are often stigmatized and vulnerable to negative expectations from society. Numerous evidence-based interventions and resources are available to help mothers regain custody of their children and start a new life, including drug and alcohol recovery programs, halfway houses, parenting classes, counseling, vocational training, financial and life coaching, and Head Start programs for the children. As unfair as the treatment of crack-addicted mothers appears in comparison to that of alcohol- and tobacco-addicted mothers, these salutary interventions might not otherwise have been available to them

I remember when crack babies were a topic of conversation. Heartbreaking stories abounded of little babies born to crack-addicted mothers—inconsolable infants who required constant holding by volunteers in the nurseries of hospitals. These highly irritable newborns were expected to mature into a generation of problem children and sociopaths, a future burden on society. My initial reaction to this article was one of surprise, and fear that cocaine use might somehow be viewed as benign in terms of its long-term effects on development and behavior. But my deeper reaction was in response to our moral judgements about what is legal and illegal, regardless of the real impact of harmful behaviors. Tobacco companies continue to flourish and market their products to young people in spite of the well-documented long-term effects of tobacco on the smoker, prenatally, and as a result of second hand smoke inhalation. In contrast, cancer patients and those with chronic pain continue to fight for access to medical marijuana, which is still illegal in most states. I am relieved and happy that the crack-exposed children are doing better than expected. I am also hopeful that this new information may put a fresh perspective on the dangers of prenatal alcohol and tobacco exposure and how we, as a society, deal with these issues.

2009-01-28T08:08:00.001-05:00

Infectious Mononucleosis: The Annie of Diseases?
By: Lisa Menard

In an article published on January 21, 2009, Carolyn Sayre introduced us to a teenager named Chelsea Day and her struggles with infectious mononucleosis. We soon find that Chelsea is just one of many who are affected by the disease. For the 35 to 40 percent of adolescents and young adults who develop symptoms, this disease has a major impact on their quality of life; however, according to Dr. Robert Frenck, mono is a disease that "doesn't get the respect it deserves."

Mononucleosis, or mono, is also known as "the kissing disease" because it is spread by close contact. About 95 percent of adults in the U.S. have been infected with Epstein-Barr, the herpes virus that causes mono, by age 35 to 40; however, most people who become infected with Epstein-Barr virus never develop symptoms.

Since mono is so common, some experts fear the disease has become trivialized among physicians and the research community; however, mono is anything but trivial for the young people who get it.

There is still no vaccine or antiviral drug that can ward off Epstein-Barr virus or treat the resulting infection; there simply isn’t enough demand for a vaccine to warrant expensive research. Dr. Gary Simon agreed with this mentality when he stated, “There are more serious things. In general, this is a self-limited illness; 99.9 percent of people will get better.”

On the other hand, Dr. Hank Balfour, who agrees that further research is warranted, blames big pharma for the orphan situation. According to Dr. Balfour, “If they (big pharma) don’t see it as a blockbuster, then they don’t want anything to do with it.”

I agree with Dr. Balfour's views, but only to a certain degree. Is this a disease that deserves further research? Yes. Is the study of mono an orphan situation? Yes. However, this is also the point where I tend to disagree with Dr. Balfour.

The study of the disease is not an orphan situation because of big pharma's desire for blockbuster drugs; rather it is an orphan situation because of Dr. Simon's main point; there are more serious things and 99.9 percent of the people will get better. Can we say the same for cancer, heart disease, or HIV/AIDS?

Orphan diseases are rarely studied for a reason. Teenagers such as Chelsea Day may feel that it is unjust that her suffering is trivialized; however, the decision is clear when we compare which action produces the most advantages and fewest disadvantages for the most people; this is where pharmacoeconomics comes into play.

If we are going to mention the topic of monetary value, then one must consider the cost versus benefit relationship. Money is being submersed into studies such as cancer and HIV/AIDS because these diseases have a more profound impact on the healthcare system as a whole. Think of it this way, which is greater: the cost of treating non-life threatening mono for a couple of months, or the years of treatments for cancer of HIV/AIDS?

Extending the monetary situation a little further, should orphan situations still be a topic of controversy? Incentives, such as tax credits and seven years of marketing exclusivity, make clinical research of rare diseases more feasible. In the case of mono, it may affect more than 200,000 persons in the U.S, but there is no expectation that the cost of developing a drug or vaccine will be recovered from sales; these incentives may make up the difference.

In the meantime, scientists such as Dr. Balfour are working on treatments to help patients recover faster; and last year, Belgian researchers reported the results of a mid-stage trial that limited the number of mono infections from 10 percent (control group) to 2 percent (study vaccine group). So, while the controversy still simmers, Chelsea Day and all of the future mono-sufferers can be assured that, "the sun will come out…tomorrow."

Medical Bloggers Cross Ethical Lines

2008-08-27T16:36:00.003-04:00

Is the information age providing too much of a good thing in the world of healthcare?

According to a recent study published in the Journal of General Internal Medicine, some medical blogs have crossed ethical lines by violating individual patient privacy. The report calls on doctors to use responsible tone and content in sharing their narratives with online communities.

Blogs have become increasingly popular in recent years, providing places for commentary, news, and interaction as the Web has exploded as the world’s information portal (maybe it’s appropriate, then, that this is a blog about blogs). Medical blogs are especially popular, as people use the Internet to supplement their healthcare knowledge and share opinions on medical news. In that sense, the blogs make a significant contribution to the general public.

But should formal blogging standards exist for doctors, nurses, and other healthcare professionals? Dr. Robert Centor, a regular blogger himself, doesn’t think so. Centor believes that “rules are unnessesary” because the Internet provides a place for personal expression at an individual’s own risk. However, some blogs may have crossed the line: the JGIM study found that 17% of medical blogs contain enough information for patients to identify themselves or their doctors.

In response to the ethical issues surrounding medical blogs, a coalition of bloggers formed the Healthcare Blogger Code of Ethics, which attempts to maintain a high standard of integrity in healthcare information sharing. Bloggers may place organization’s seal of approval on their sites if they meet the standards of the code, while a “blogroll” on the group’s site lists the names of code-abiding blogs.

As information explodes across the Web, it’s important to keep in mind the ethical standards of the healthcare industry. Maybe the JGIM study is just what medical bloggers needed to keep ethical issues at the front of the boom enveloping all corners of the information superhighway.

Sharing Prescriptions

2008-08-27T10:20:00.005-04:00

No Prescription? Have Some of Mine in The New York Times raised the issue of people sharing their prescription drugs with others. Reasons for sharing prescription drugs ranged from being on the same medication but not having it with them to sharing medication for pain or having similar health problems as the other person.

Another reason, not discussed in this article, that people share prescription drugs is cost. In an early post, I mentioned that my mother is currently in the Medicare prescription drug coverage doughnut hole. One way she deals with that is by borrowing medication. She and my husband are on the same prescription antidepressant--same brand, same dosage, etc. My husband, however, realized about a year ago that he never remembered to take the evening dose and seemed to be fine without it. So, over time, he ended up with a stockpile of that drug. So, when my mother mentioned her problem with having to pay out of pocket for the same drug, he started sharing his medication with her. It doesn't entirely solve her problem, but it does mean that she only has to get her prescription for that drug filled every other month.

Last month, my nephew and his girlfriend (both in their late teens and still in college) both came down with Strep throat. The girlfriend still has health insurance through her parents, so she went to urgent care and got a prescription for antibiotics. My nephew doesn't have health insurance. So, between them, they decided to share her antibiotics and recommended over-the-counter medications. Thankfully, they live with me and when I heard their plan, I explained why it wasn't a good idea. Taking half a course of antibiotics might result in neither of them fighting off the infection. So, I took my nephew to urgent care, paid out of pocket, and got him his own course of antibiotics.

And in my own experience, I've had multiple knee surgeries and have a friend who has also had knee surgery and a recent total knee replacement. Post-operatively, we've both been prescribed oxycodone for pain, which most doctors prescribe in very limited quanities because it can be addictive. Have we ever shared pain medication? Yes. After my friend's knee replacement, they sent her home with a handfull of paper prescriptions, including one for oxycodone. It took her partner several hours to get to the local pharmacy, do the paperwork, get the prescription refilled, and get back home. Meanwhile, my friend was in pain, serious pain. So, I shared my oxycodone with her--knowning that the same medication had been prescribed by her doctor but that she just didn't have it in hand yet made the decision a no brainer.

So yes, people do share prescription medications for lots of reasons--cost and need among them.

HPV Vaccine Use Controversial

2008-08-27T09:46:00.005-04:00

A recent article in The New York Times, Researchers Question Wide Use of HPV Vaccines presented some of the issues still surrounding widespread use of vaccines for the prevention of the human papillomavirus (HPV).

One concern raised in this article was whether the vaccines are worth their high cost. This is an especially important question for developing countries and even women and girls in the United States with little or no health insurance or Medicare coverage. A complete series (3 shots) of the vaccine cost between $400 and $1000 per person depending on the country and charges for doctor's office visits. Vaccines for other diseases are relatively inexpensive and save money by preventing costly diseases; however, the HPV vaccines seem to actually be costing the healthcare system money. The HPV vaccines might only be truly cost effective if they protect girls from cervical cancer for an entire lifetime. Unfortunately, there hasn't been enough research to prove that yet. For girls with sufficient healthcare coverage, there's every reason to consider vaccination to reduce the risk of cervical cancer. However, the case is not so clear where funding is scarce. Should this $400 to $1000 per girl be spent on other medical treatments or prevention that have already been proven to prevent disease and save lives? Pap smear screening and treatment in developed countries has already reduced death rates from cervical cancer to very low levels. Should funds be spent on more screening and treatment instead of HPV vaccines in developing countries untl further data is available? Would that be a better use of such limited funds for healthcare? Perhaps, at least for now.

Safe Shooting?

2008-08-27T01:45:00.003-04:00

Just five years after opening, the first legal safe injection site in North America finds itself in the crosshairs of the Canadian government.

Health Minister Tony Clement weighed in on the controversy last week, calling into question the ethics of physicians who support the harm-reduction facility. According to Clement, the “injection site undercuts the ethics of medical practice and sets a debilitating example for all physicians and nurses.”

At issue is Insite, which opened its doors in the Downtown Eastside section of Vancouver in 2003 under an exemption from federal drug laws. Clients use safe injection sites like Insite to inject their own drugs under the supervision of trained medical staff. The idea is to reduce harm to users and decrease other negative consequences of drug abuse.

Clement and the conservative Canadian government oppose Insite, citing the practice of “supervised overdoses” as unethical and claiming that the facility has done little to reduce drug overdose deaths. However, a government-appointed panel concluded otherwise in April, noting that Insite has saved money and lives and that most health officials want the service to continue.

Safe injection sites treat drug addiction as an illness rather than a crime. That distinction has stirred controversy in and around Vancouver, which went down a “drug-fueled spiral” in the years leading up to Insite’s opening. Opponents of Insite think drug users should be in rehab or behind bars, while supporters sharply criticize Clement and say the closing of the facility could result in the deaths of users.

Does Insite prevent the spread of disease and save lives? Or is it an unethical blemish on Canadian healthcare? Either way, the controversy isn’t going away anytime soon. Physicians, politicians, and drug users: stay tuned.