When can we smile at tragedy?

Posted by on April 5, 2014 Comments Off on When can we smile at tragedy?

Last week two online events occurred that stimulated this question.

First, a train jumped the track in Chicago. There were no serious injuries; anyone taken to the hospital during morning rush hour was released by noon. The event yielded the following photo:

Chicago_train_20140326

Seeing a train on an escalator, particularly when it could have taken the steps, provoked a smart ass comment from me on a friend’s Facebook posting. Another friend of hers took umbrage, saying that I should not make light of it and that I would not feel that way if I had been related to a victim.

Later that day I was on Quora.com. Someone had posted a reference to being sexually assaulted 20 years earlier. Another Quoran posted a light remark, while a third objected to making light of an assault.

These two incidents made me think: when is it appropriate to make light of tragedy, and when is it completely tacky, and, more importantly, what is the distinction between the two?

The first criterion that occurred to me was magnitude. I have only heard one joke about the Nazi Holocaust or Shoah, and I only heard it once, as an undergraduate. The size and nature of the suffering puts it beyond humor. [Digression for the joke: an old Jewish man was sitting beside the road watching the Nazis parade by during the early 1930s. He was smiling. Hitler approached and asked what he was smiling about. He replied, “When Haman tried to eliminate the Jews, we got hamentashen (pastries) and when Antiochus oppressed us, we got latkes (potato pancakes). I am wondering what kind of food we will have to commemorate your defeat.”]

However, it cannot simply be a matter of magnitude. World War II deaths as a whole were in the tens of millions, compared to the 6 million deaths attributed to the Shoah. Indeed, there were more Chinese deaths than Jewish deaths in World War II.

It might be that magnitude plus severity is a better measure. If we measure severity as a percentage of the population killed, then the percentage of the population in Lithuania, Latvia, and Poland are above 10 percent, a high level of intensity, and many of these were Jewish victims of crimes against humanity. In addition, the percentage of the Jewish population subjected to genocidal killing was much higher.

Besides the question of magnitude and severity, the question of proximity in time is pertinent. Arguably the Black Death of the 13th and 14th centuries had as profound an impact, but given that the events occurred 700 years ago, Monty Python was not criticized for making light of the plague in Monty Python and the Holy Grail. Similarly, Monty Python has done skits on the Spanish Inquisition, whose excesses are a matter of historical record. Similarly, we have heard, or can imagine hearing, someone say, “Aside from that, how was the play, Mrs. Lincoln?” We cannot imagine someone saying, “Aside from that, how was the visit to Dallas, Mrs. Kennedy?” The difference is 100 years. None of us will be there to see if the second one becomes acceptable, but even 50 years after the event, it is still too raw for humor.

In addition to proximity in time, the proximity to the event of you and the audience make a difference: if the victim of the tragedy is in your audience, humor is unlikely to be appropriate, whether the audience is live or virtual.

Considering the number of variables involved, it is not difficult to overstep a boundary, especially when the humor police are watching. Someone with a comic bent has two choices: either keep humor private, or accept the likelihood that, even considering all the angles and possibilities of sensitivity, someone will criticize.

Addiction: Twenty-first Century Style

Posted by on November 19, 2013 Comments Off on Addiction: Twenty-first Century Style

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

  1. does not evaluate the risk of nicotine exposure to the person “vaping.”
  2. notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

Burstyn report

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Competition, Cooperation, and Health Care

Posted by on October 14, 2013 Comments Off on Competition, Cooperation, and Health Care

Maybe it’s the days of endless government shutdown. Maybe it’s the days of endless rain.

Writing about any of it comes hard to me. I am uncharacteristically quiet and reflective.

We live in a society built on competition. The economic system creates wealth and rations scarce resources through competition. Democracy is a competition for the support of voters. And, no society is more sports-minded than we are, with giant arenas and stadiums for a variety of sports, each with millions of followers.

However, all of this competition occurs in the context of a society. A society implies certain shared values, a modicum of cooperation, and concern for other members of the society, if not for their own sakes, then for the sake of the society.

Consequently, a competitive society is one with built-in contradictions. At the extreme, economic competition results in great wealth, poorly distributed, and concentrated in the hands of the few. At the extreme, political competition, like sports competition, requires that victory trumps all ethical considerations, including the needs of the society or sport.

On the other extreme, a completely cooperative society, devoid of competition, sharing things equally, is unlikely to thrive. As our conservative friends point out, the incentives for wealth creation and technological progress based on expenditure are likely to be lacking. In addition, there will be free riders, people who wish to partake without producing.

The political and social pendulum in the United States often swings between competition and cooperation, between liberty and equality. At this point in time, it seems to me that we have swung a bit too far toward competition. We have a Congress that cares more about the next election and scoring political points than public policy; we have a Speaker, who should know better, but is more concerned about the challenge to his leadership than the American economy.

Behind it all are two ideologies that seem singularly unconcerned about any impact, other than how a position is measured against the yardstick of a belief system, a non-religious libertarianism allied with a particularly narrow version of Christianity, aligned together in opposition to government initiatives, despite their obvious contradictions. It is a characteristic of ideology and utopia, as Karl Mannheim called the narrow beliefs of the present and the future, that purity of belief surpasses any human need.
ideology and utopia

Combining these strong ideological commitments with the political system results in the political impasse we are experiencing. Closed belief systems can rationalize economic collapse as a necessary, ultimate good, so compromise is not only unnecessary from that perspective, but traitorous. As Eric Hoffer put it,

It is the true believer’s ability to “shut his eyes and stop his ears” to facts that do not deserve to be either seen or heard which is the source of his unequaled fortitude and constancy. He cannot be frightened by danger nor disheartened by obstacle nor baffled by contradictions because he denies their existence

So, the campaign against the program of our current President can pivot from health care to spending to entitlements, but is consistently against the President and his positions. When the economic consequences of the shutdown and the debt limit crisis are tallied, they will say, “See, we told you that the Affordable Care Act would destroy the economy.”

Politicians of all wings, parties and beliefs routinely employ spin–stretching the truth to make their points; however, at some point the distance from the truth is sufficient to call “spin” an outright falsehood. An example, in health care, was the charge that Obamacare mandated “death panels.” (Physicians routinely discuss end-of-life issues with their patients. The proposal was that they be reimbursed for the time so spent.)

As Mark Twain put it, “A lie can travel half way around the world while the truth is putting on its shoes.”

When confronted with an obvious falsehood or exaggeration, the honest person faces a dilemma: does the speaker/writer truly believe what is written, or is that person cynically exploiting the ignorance of others?

Here are some of the arguments about the Affordable Care Act that have been dragged into debate about fiscal policy, the Federal budget, and the US statutory debt limit.

  1. Congress has exempted itself from Obamacare.
    The fact is that Congressional employees will be shopping for health care on the exchanges rather than receiving employer-provided health care as would most businesses with a comparable number of employees. As employees, they will receive an employer contribution that reduces the monthly premium cost.
  2. Large enterprises have been made exempt from the mandate to provide coverage so individuals should be exempt as well.
    Large enterprises are still required to provide health insurance coverage for their employees as scheduled; however the Justice Department will not be imposing penalties immediately. Furthermore, the individual mandate is an entirely separate issue–it is the linchpin of eliminating denial of coverage for pre-existing conditions. Without it, no one would buy health insurance until they needed it, with the assurance that their health condition could not be denied.
  3. Health insurance premiums are going up because of Obamacare.
    With the exception of the past 3 years, health insurance premiums have been rising by double digit percentages each year. The rise slowed because of the deep recession we are emerging from. Health insurance premiums will continue to rise, largely driven by technology (MRIs are expensive), now that the recession is almost over. Furthermore, premiums may seem very high to individuals who have not been able to or been interested in purchasing insurance until now. Health insurance is expensive.
  4. Companies are letting full-time workers go and hiring part-time workers in their place.
    1. Many individuals choose part-time employment over full-time employment. So, the only concern should be involuntary part-time employment rather than all part-timers.
    2. There has generally been a rise in part-time employment during economic recessions. The recent recession is no different.
    3. Many new jobs are coming into the economy to help with Obamacare, as well as new hires in the private sector to meet the needs of the health care law mandates for preventive care and individual coverage.

      4. [It should be noted that individuals concerned about employment issues would never close the Federal government or permit it to be closed, since the loss of spending by Federal workers ripples through the labor market as business owners determine whether to take on new hires, and the lack of Federal issuance of permits in several areas e.g. a Vermont micro-brewery, adversely impacts employment.]

    And as I was reflecting upon the original conundrum, how to reconcile cooperation and competition, liberty and equality, while retaining the best of both, I came across a quotation from Milan Kundera,

    kundera

    “Too much faith is the worst ally. When you believe in something literally, through your faith you’ll turn it into something absurd. One who is a genuine adherent, if you like, of some political outlook, never takes its sophistries seriously, but only its practical aims, which are concealed beneath these sophistries. Political rhetoric and sophistries do not exist, after all, in order that they be believed; rather, they have to serve as a common and agreed upon alibi. Foolish people who take them in earnest sooner or later discover inconsistencies in them, begin to protest, and finish finally and infamously as heretics and apostates. No, too much faith never brings anything good…”

    The Roman playwright Terence wrote “Ne quid nimis,” alternatively translated as “Nothing in excess,” or “All things in moderation.”
    Terence

    Moderation isn’t sexy or attractive. It doesn’t cause the adrenaline rush of ideological combat. But, I think it is the medicine we need now.

    Moderation in politics, moderation in spending, moderation in punditry. Here’s to moderation!!

The US health care debate

Posted by on October 3, 2013 Comments Off on The US health care debate

Writing about the political dance in Washington, DC is not a pleasant task. I intend to skirt around the edges of it. It is marginally about health care and largely about the relative power of the two major US political parties.US_capitol

Nonetheless, since it has brought the Obama health care plan back to the top of the national political agenda, it is worth recalling some basics.

First, the principle of insurance is that a catastrophic risk is spread across as many people as possible making advanced contributions so that funds are pooled and available to any individual suffering that risk. For example, individuals buying life insurance at a young age receive a favorable premium rate and are likely to contribute for a long time, much longer than the time it would take to accumulate the death benefit, but for those individuals not so fortunate, the monies are there in a pooled risk fund to be distributed to the family of someone who dies prematurely. The risk of an expensive illness with accompanying medical costs is similar.

Second, millions of Americans have not had health insurance. Some of those are young, feel invulnerable and do not want health insurance. Others have pre-existing health impairments and have been refused health insurance. Still others do not receive insurance through their employers and cannot afford it on their own.

Third, there are negative consequences to our society for these uninsured:

  1. Those without insurance still must be treated when they get ill or have a motor vehicle accident.
  2. The young, less likely to be net expenses to a pooled risk fund, need to be part of the contributors under the principle of insurance
  3. Those denied insurance because of pre-existing conditions need to be saved from bankruptcy, and the hospitals need to be protected from having to serve them at no cost.
  4. Those who do not have insurance through their employers, who could not afford individual insurance policies, require a means to participate.

Fourth, the Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” is an honest attempt to address those concerns, as well as reining in the ever-rising costs of medical care.

Fifth, the term “socialized medicine” is easily bandied by politicians, but there are two distinct areas of government involvement in health delivery that can more accurately be called “socialized medicine,” and “socialized insurance.” The US has both. Socialized medicine occurs when the government provides access to healthcare either directly through government clinics or through social insurance used in government health facilities. In that case, the health care providers are government employees. Foreign examples are the National Health Service of the United Kingdom. NHS-logoIn the US the system of hospitals under the Department of Veterans Affairs (VA). Socialized insurance is when the government supplies health insurance but the healthcare practitioners are not government employees. Medicare is socialized insurance, as are the national health systems of Canada, France, Italy, and Germany. There are advocates for socialized insurance in the United States, under the banners “Medicare for All” and “Single-Payer.” There is no recognizable group that favors socialized medicine in the US–NONE.

Sixth, Obamacare is neither socialized medicine nor socialized insurance, because all of the providers are private, and all of the insurers are private. An early proposal to include a “public option” form of insurance was dropped. It is not surprising that Obamacare is completely privatized–it is a proposal in concept by that most conservative think tank, the Heritage Foundation. (More recently, it has taken a further turn to the Right by engaging former SC Senator Jim DeMint as President; however, it has always been quite conservative.) Its proposal was adopted, supported, and implemented by the Republican governor of Massachusetts Mitt Romney. The theory was that the accelerating costs of healthcare could be addressed by a market system, and the government assumed the role of creating the market or even playing field for the insurance companies to compete for business.

Seventh, the individual mandate, which draws a lot of the political fire, was part of the original Heritage plan by Stuart Butler in a 1989 paper, and of the Romney plan. It is essential to the effectiveness of the system in two major ways:

  1. It makes the younger, healthier citizens participants, with the benefit of their consuming less than they contribute but not being a burden when struck by accidents or rare illness.
  2. More importantly, it makes possible the elimination of pre-existing conditions. If pre-existing conditions could not prevent obtaining insurance, no one would buy insurance until contracting an illness, and would then be assured of acceptance. Because the insurance would have to cover the illness, with no reserve built up, with no spreading of risk across the entire population per the insurance principle, the insurance would be nearly unaffordable with the premiums set at the level of the average illness since it would have to cover the risk. Pregnancy benefits are often rated that way in insurance policies since the benefits being paid are nearly assured.

Eighth, there is the issue of affordability. Enterprises with over 50 employees are required to provide insurance. Most already do, but these employers are a very small segment of the workforce, perhaps 10 percent. The rest of us are self-employed or employed by smaller enterprises. If they already provide health insurance that is fine, but under the individual mandate, if they do not, then anyone working there including the executives will have to fulfill the mandate by finding insurance on the exchanges, and by shopping for the level of coverage at a premium they can afford. Both affordability and insuring the young are addressed in part by requiring adults to be eligible until age 26 for insurance under their parents’ plan.

For those at the bottom of the pay scale, those who do not qualify for Medicaid, which can have very stringent asset limitations (in California, for example, having funds over $2,000 disqualifies one from Medi-Cal), those often called “the working poor” may be eligible for government subsidies. In addition, the federal government is offering states financial incentives to expand the Medicaid program to cover more of the working poor.

Finally, there is the issue of what is health insurance coverage? If we want to require people to buy it, we need to be able to say what is and what is not acceptable coverage, to avoid individuals and businesses buying something so minimal that it complies with the law but does not address the problem of access to health care. An individual buying a policy hat pays $100 daily for hospital care has not really bought insurance. So, the government through implementing regulations has stipulated what a minimum policy contains. This has raised issues of conscience for those who do not believe in one or more aspects of medical science as applied to health care.

The religious reservations are well-known in the United States. Among them are a preference for Christian Science practitioners among Christian Scientists, an avoidance of blood transfusions among Jehovah’s Witnesses, rejection of birth control measures among Catholics, as well as rejection of pharmaceutical and surgical interventions to prevent or abort a pregnancy among numerous denominations. The law has allowed a religious exemption for churches. The point of contention has been for practitioners who participate in commerce and do not wish to compromise their religious beliefs by providing the means for something they consider murder. From a public policy view, the problem is multiple:

  1. Recognizing that right by owners of businesses and organizations may deny access to some of their employees who feel equally strongly that obtaining those treatments is their right.
  2. Recognizing those rights by one group implies, under equal protection, recognizing such objections by all groups and individuals. That places the government in the powerful and unwelcome position of determining which religious beliefs are legitimate and entitled to protection, an intrusion into religion that most Americans would find offensive.
  3. Recognizing that right with respect to abortion, would open the possibility of recognizing objections to all forms of insurance. A business owner might claim religious exemption to providing any insurance, undermining the public purpose of the law.

In order to address these concerns, the law limits religious exemptions to religious institutions, such as places of worship. There are pending court cases that may change the way this challenge is addressed in order to comply with First Amendment considerations.

One theory of American government is that the states act as laboratories for the society and the nation, trying approaches, which, if successful, can be generalized. That has occurred here, with Massachusetts providing the laboratory. As the national experiment is just beginning, it is too early to tell whether the proponents or opponents of Obamacare have correctly analyzed its impact and future. Five years from now, it will be much clearer. I look forward to seeing that day and looking around to see what worked and what did not, what needs changing, what has been correctly changed, and what has not. I have often thought that politics is America’s most engaging indoor sport, and, at this moment, Obamacare is at center court.

What we almost know

Posted by on September 25, 2013 Comments Off on What we almost know

The impact of intestinal flora on health conditions is known, thus fecal transplants for numerous conditions. Last week I wrote about an experiment with mice verifying the impact on obesity.

As a consequence, there are numerous products being marketed as “probiotic.” We have no idea whether those products are helpful, harmful, or simply benign.Bacterial flora are an instance where we know some bacteria are essential, and we know some can be added beneficially, but we do not know which ones to add. There are promising studies with lactobacillus acidophilus shown: lactobacillus We almost know about GI flora, but not quite enough yet.

There are other topics where we are at a similar place. We know a lot about what mental illness is and isn’t. We know that increasing serotonin in the interstitial spaces of the brain helps with depression and that too much serotonin is associated with schizophrenia. As of this point, however, we don’t have imaging or blood tests or biopsies that will tell us who is mentally ill–we use written testing and observation not laboratory tests to diagnosis it. When physicians attempt to treat it, it is largely a matter of trial and error. We do not know beforehand whether a particular selective serotonin re-uptake inhibitor (SSRI), such as fluoxetine or venlafaxine will work with an individual, or if any SSRI will work. Some people will do better with buproprion, which uses a different mechanism. Others will do better with a serotonin–norepinephrine reuptake inhibitor (SNRI) such as duloxetine. Others will experience no clinical effect at all. We almost know about mental illness, but not quite enough yet.

These examples lead to a more general question about what we know and do not know. It is usually phrased as “nature vs. nurture,” but it is really genetics vs. environment. I am not sure if the the “versus” between them is appropriate–something else I do not know–as it is the relative interaction of the two rather than a false choice between them that is a more likely source of the truth about who we really are.

Researchers often conduct identical twin studies, controlling for genetic variation by comparing the environmental impact of twins with nearly identical DNA. Molecular computer graphic of DNA double helix However, the studies are limited: it is intriguing if they both smoke the same brand of cigarettes or like the same foods despite very different upbringings, but it does not neatly tell us which behaviors are genetic and which are environmental.

Similarly, we know that 3/4 of children of two bi-polar parents are likely to have bi-polar disorder, which seems to indicate a Mendelian genetic inheritance, but we only almost know about the inheritability of mental illness, not quite enough.

Even where we know that a trait is inherited, we often do not know what genes or constellation of genes are associated with a given, visible trait. We almost know about the human genome, but not quite enough yet.

As scientists or those of a scientific bent, we are obligated to say what we know and what we don’t know, being able to distinguish the difference. It is not always an easy distinction to make, but is central to our effort to know more, and eventually know enough.

Learning about fat people

Posted by on September 16, 2013 Comments Off on Learning about fat people

When I was growing up, I had a first cousin who was morbidly obese, long before the efforts of the rest of the country to catch up with her. Her failure, and it was considered a failure, to lose weight was seen as evidence of a moral failing, a lack of willpower, only slightly less pejorative than the sin of gluttony in earlier times. There was some vague talk that she might have some hormonal imbalance, but it was clear that all around her considered her problem to be predominantly one of willpower.

Both alternative and scientific medicine have taken a recent interest in gastro-intestinal (GI) flora, or “gut bacteria.” The alternative medicine folks have favored “probiotic” supplements and yogurts fortified with bacteria. The probiotic movement began with Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” who believed that longevity of rural Bulgarians and Georgians could be attributed to their consumption of fermented milk products.
Metchnikoff

Consideration of the impact of GI flora on diarrhea is not really new–a half century ago I can recall being given lacto-bacillus pills to counter the gastric distress resulting from penicillin. It is the potential impact of bacteria on obesity that is notable in the current focus. Recently National Public Radio (NPR) interviewed Jeffrey Gordon, a microbiologist and director of the Center of Genome Science and Systems Biology at the Washington University School of Medicine in St. Louis.

While I hope you will either listen to the embedded audio clip (about 12 minutes) or read the interview transcript, the short version is that there the research shows a recursive feedback loop between how the bacteria impact our appetite and how what we eat impacts the bacteria that are in our intestines. By eating the right or “lean” foods, we encourage the bacteria that help us maintain our weights at a healthy level. Now, there has been some experimentation with fecal transplants, having a similar aim, but that does not seem to be for everyone–particularly those of us who would be grossed out by the very idea. Eventually, we will probably have probiotics, which, combined with proper diet (they need to be fed or cultivated in our gut), can be delivered to our intestines in pill form, or at least a suppository rather than a fecal transplant.

Over time my cousin became estranged from nearly everyone in the family and died a few years ago, not having been seen by any family members in decades. Waxing philosophically, I cannot help but wonder how different my cousin’s life might have been had she been born a half-century or better a century later. And, I wonder how different my father’s life might have been had he survived his first heart attack and lived to see statin drugs.

It seems that much of our survival depends upon living just long enough for technology to address a mortal weakness in our genome. Nonetheless, it is encouraging to note that promising approaches to obesity may make it seem like nothing more interesting than a historical healthcare statistical blip rather than the crisis it appears to be as we live with it and address it.

Three research pieces with a lot of heart

Posted by on September 10, 2013 Comments Off on Three research pieces with a lot of heart

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.
Preventable deaths by age

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Preventable deaths by race

Finally, the deaths are concentrated geographically in the South-Central Region.
Preventable deaths by region

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Polypill study

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

Herd Immunity — How vaccines avoid thinning the herd

Posted by on September 3, 2013 Comments Off on Herd Immunity — How vaccines avoid thinning the herd

Part of the difficulty in making a case for universal vaccination against dangerous disease is a lack of understanding of probability. Since there are few certainties in life, except its eventual end for individuals, we are constantly calculating probabilities. What is the probability that I will get to the other side of the street before that oncoming car arrives? What is the probability that the wheel stop on my number or that I will draw the card needed to complete my hand? What is the probability that the game I am going to attend will occur or get rained out? And, of course, what is the probability that the suggested intervention will cure my disease rather than kill me or leave me permanently debilitated?

Some probabilities are more difficult to calculate than others: what are the odds that I will die from prostate cancer, and what are the odds that the operation will leave me impotent? how do I calculate the best course when my choices are an operation with an 80 percent success rate that leaves another 15 percent paraplegic and 5 percent dead? How about the same operation with 93 percent success, 5 percent paraplegic, and 2 percent dead?

The more complex the alternatives, particularly when they are being balanced against complex outcomes from non-intervention, the more difficult it is for us to make a rational decision.

That leads to a discussion of vaccination. Let’s consider a disease such as smallpox, which has killed 100s of millions of people. Not everyone got smallpox. Not everyone who got smallpox died from it–estimates are that about 30 percent, or 3 out of every 10 died. Now, consider that not everyone who gets a vaccination gets 100 percent immunity. Some people get partial immunity. Some very small percentage may not produce antibodies in reaction to the vaccine. Some people actually die of the side effects of the vaccination.

As an individual, you might think, well, it’s not great but 70 percent odds of surviving are better than none, and maybe it will miss me altogether, so why should I vaccinate? Of course, smallpox has been eradicated, and we don’t have to make that kind of determination any more since the dangers of side effects from the vaccination exceed the danger of contracting smallpox, particularly in the United States where the last documented case appeared in 1949.

If you were a free individual, not part of a society, not part of the possible transmission stream of a disease, then no one is likely to care too much what you decide? However, if you are reading this, you are part of a society providing this message to you via a societal mechanism. As part of that society, you have obligations to others in the society, including children, yours and others, who once were considered private property but are now considered individuals with rights, albeit limited compared to adult rights.

The concept of “herd immunity” goes directly to the questions posed and to your obligations within the society.

Herd Immunity Concept

Those who are vaccinated provide a barrier to illness for those who are not:

Consider:

Assume you have 5 friends who do not know one another, and that everyone has 5 such friends.

Assume that vaccinations give almost 100% immunity and that the corresponding disease gives almost 100% probability of infection if you come in contact with a person who has it.

Now, if 80 percent of people are immunized against the disease, it is quite possible that one of your friends is not immunized. However, if 80 percent of that person’s friends are immunized, there is now only 1/5 times 1/5 or 1/25 = 4 percent chance of the disease vector reaching you. It may be that you friend’s friend has friends with 100 percent immunity, all five of them immunized, and the further you are socially from the source of infection, the lower your odds of becoming infected–even if you are not immunized. You are protected by herd immunity.

However, consider if only 60 percent of people are immunized, then 2/5 times 2/5 is 4/25 or 16 percent chance of becoming infected. That is 4 times your chance of infection from a secondary friend, as in the first example. The degree of herd immunity is a complicated calculation depending upon the percent immunized and the way the disease is transmitted. Your chance of infection depends on those factors as well as your social distance from the source of the infection.

For an animated look at the concept, click on “Play Animation” in the three scenarios of The History of Vaccines: Herd Immunity.

Here are the thresholds for different diseases as estimated by the Centers for Disease Control (CDC):

Herd Immunity Thresholds CDC

Think about flu shots for a moment:

  1. The vaccine is based upon recent mutations of the virus, so you might catch a virus that is not part of the vaccine.
  2. Not everyone gets 100 percent protection from a vaccine–it may be sufficient to protect against some strains and give partial protection against others
  3. In part, because of herd immunity, not everyone exposed to influenza is infected

So, we have friends and relatives drawing the wrong conclusions (e.g. the vaccine caused me to get influenza), based on an association of factors that are coincidental or subject to an alternative explanation, such as a new strain or partial immunity. For most young people, the flu is an occasional inconvenience rather than life-threatening; however, their failure to vaccinate exposes others whom they could be protecting by a simple annual injection. Let’s spread the word–it might not save those young individuals–just an older person, or an asthmatic standing close to them.

Vaccination–Now and Then

Posted by on August 26, 2013 Comments Off on Vaccination–Now and Then

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China. ChineseVaccination

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Child_with_Smallpox_Bangladesh

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.
Vaccination_US_thru1998