Thursday, February 24, 2011

HORROR DU JOUR: PUBLIC HEALTH IN POLITICAL HANDS


In 1854, as a cholera epidemic ravaged London, physician John Snow reasoned that it spread via contaminated water. When he created a map of cholera incidence, he discovered that most cases clustered around a public water pump on Broad Street. He talked city authorities into simply removing the pump's handle, and the epidemic ceased. It was soon found that sewage was contaminating the pump's source.

Physicians still avert disease through public health activism, but today they labor mainly in third world countries. In the United States, doctors haven't been taught much about public health; they almost exclusively wait in their offices for sick people to appear.

That leaves the issue to politicians, an abdication tantamount to letting your cat babysit your infant. With few exceptions, politicians have little education in, or even regard for, science.

Take Maine's Governor Paul LePage, for example. He said something truly remarkable yesterday about bisphenol-A, or BPA, an ingredient in plastic bottles. BPA has been identified for decades as a "xenoestrogen," a molecule that, mimicking the female hormone, causes problems in humans, especially in fetuses. 

Here's what Gov. LePage said: "If you take a plastic bottle and put it in the microwave and you heat it up, it gives off a chemical similar to estrogen. So the worst case is some women may have little beards."

Trust me, they won't have little beards, but their kids will be at risk for neurological troubles and feminization. Maybe the Governor would be more concerned if he knew women exposed to BPA might deliver boy babies with small penises.

It's not just his ignorance that disturbs me. He's laughing off the issue, ridiculing people who are justifiably concerned about a dangerous chemical. If he goes on to claim that BPA's never been undeniably proven hazardous, he'll be right, strangely enough. By its nature, science can only show likelihoods, never certainties.

Many chemicals are toxic only in the long run. They can take years to decades to make their effects known. Considering that span plus the fact that thousands of BPA's cousin molecules--in food additives, medications, cosmetics, household products, and outright pollutants--constantly act together on us, their individual culpability is extremely difficult to prove. In terms of liability, these chemicals are a manufacturer's dream.

Americans honor the principle that a defendant is innocent until proven guilty. That's just, but we perversely apply it to chemicals as well as people. Canadians see it differently, employing what they call the "precautionary principle." This legal standard states that if a chemical is suspected, even in the absence of scientific consensus, to cause harm to the public or to the environment, the burden of proof that it is not harmful falls on the manufacturer.

I recently saw a film about the hazards of herbicides. It included an interview with a member of a city council somewhere in Kansas, as I remember, who voted with a majority to ban all herbicide use in that city. He explained, "Look, if I'm right about this, then it's likely several kids won't have cancer twenty-five years from now. If I'm wrong, then there will be a few more dandelions people will have to pick by hand."

One hopes someone educates Governor LePage about values along with basic science. If, as he joked, BPA did indeed cause women to grow little beards, would that concern him, or would he feel it's more important to continue the use of BPA?

Monday, February 21, 2011

THE TOXICITY OF BURIED FEELINGS


I mentioned here just a few days ago that doctors are at risk when they don't express their feelings. Now comes a study (http://well.blogs.nytimes.com/2011/02/21/faking-happiness-may-lead-to-blues) that suggests patients are similarly jeopardized.

Some point to other cultures--say, the Italians--as overly expressive. They're hyperemotional, we claim, even gesticulating with every statement. Well, compared to Americans, this might be true. I wonder if the Italians see our culture as underexpressive.

If we are, this can beg trouble, since buried feelings are buried alive. Indeed, that's the source of Post-Traumatic Stress Disorder. Soldiers have always suffered this, and so, too, have a good number of people with cancer.

Imagine--or remember--being diagnosed with cancer. Once you hear the C word, your hearing shuts down, a sign of emotional emergency. You can't process this overload since you're also informed that treatment ought to begin ASAP, and treatment generates even more emotional activity. 

I wouldn't say it's unhealthy to submerge all this furor temporarily in order to focus on survival. But six months after treatment, when everyone around you figures your cancer is past history, you find you're inexplicably mercurial. You're depressed, you get inappropriately angry, you can't sleep. You're suffering PTSD.

Cancer-affected families often emphasize the need to be "positive." What does that mean, after all? I recall the wife of a man with lung cancer warning anyone entering their home that positivity was an absolute requirement. So it was that the place was a sea of smiles. But these smiles looked less like contentment than a pandemic of rabies or tetanus. Any casual observer would have recognized the elephant of denial in the living room. This strategy effectively keeps emotions buried but nonetheless active.

To me, "positivity" has come to mean honesty or, as one member of our support group defines it, "rigorous honesty." Genuine expression of what's happening is truly therapeutic.

We can balk, though, assuming we'll fall permanently into our current emotion. "If I start crying," some say, "I'll never stop." But that's not so, ever. When we get accustomed to expressing ourselves, we learn that every emotion is finite.

I find myself referring repeatedly to Elisabeth Kubler-Ross' On Death and Dying. What most readers take away from that book is that absorption of any bad news impels the listener into emotional "stages," the final stage being acceptance. But what Kubler-Ross actually said was that one reaches acceptance--defined as absence of emotion--once one has completely expressed whatever emotions have arisen.

Thursday, February 17, 2011

WHEN PATIENTS DIE


There's a beautiful essay in today's NY Times Well Blog (http://well.blogs.nytimes.com/2011/02/17/a-doctor-at-the-funeral/) by internist Danielle Ofri. She writes about the pain physicians feel when their patients die, and their discomfort at attending their funerals.

It made me reflect on my practice, which is limited to facilitation of cancer support groups. This work isn't clinical, but emotional, so members, including me, become close…and die regularly. I attend more memorials than most people do. A clerk at a local stationery store recently asked me why I buy so many condolence cards. And I'm often asked, "How do you handle all these deaths?"

I handle it like Dr. Ofri does: I feel punched in the gut. I cry, I'm saddened and sometimes even disoriented. That is, I believe I handle it well.

Doctors suffer as much as anyone else, but there are pressures within practice to restrict their expression of it. Failing to grieve is a path toward spiritual erosion--not to mention ill health--yet that's the only recourse available to physicians who haven't been educated in death-and-dying issues.

The principle that life is impermanent is the foundation of whole religions.. It doesn't sound so great that we'll inevitably lose everyone we love, but on the other hand, recognizing that can impel us to love one another in this moment. As Elisabeth-Kubler Ross pointed out in her classic On Death And Dying, once we choose to stop fearing death, we genuinely live.

Monday, February 14, 2011

WHY THE BRAIN IS WOODY ALLEN'S SECOND FAVORITE ORGAN


Today, Valentine's Day, I read an essay about love as a product of brain biochemistry. Rich in references to neurotransmitters, functional MRIs, the chordate nucleus and ventral tegmental area, the piece pointed out that love is literally in the head. The author, a medical colleague, states that if we knew love's physiology, then maybe we could make it occur more often. Maybe we could stop bad relationships, and make good ones last.

This is a great destination to aim at, but how we get there is a crucial matter. The brain physiology approach has the pharmaceutical industry slobbering onto its shirt. In fact, I wonder whether most brain research is done for any reason other than to design behavioral manipulation. Let's see: if we tweak the serotonin-dopamine ratio in the prefrontal cortex, then the love factor increases thirty-five percent…

In the world of philosophy, this perspective is called "reductionism." It posits that we're essentially biochemical gadgets. Forty-some years ago my physiology professor began a lecture by jumping into the air and spitting on the blackboard. It got our attention. Wiping his chin, he turned to us and said, "Jumping and spitting. That's all we can do." That is, human activity is the effort of muscles and glands, period. He met any challenge to that (e.g., "What about humor and contemplation and fear and love?") with, "You can't prove to me that even exists." In that view, what's real is what can be measured.

As the Brits say, bollocks. Reductionism shrinks us from the magical, quirky human beings we know we are down to sacks of enzymes. Even reductionists love their spouses and know when a joke is funny. If they want to believe they're impelled solely by their chemicals, that's their privilege. Sure, physicochemical manipulation of the brain can influence experience dramatically; consider the effects of surgery or LSD. But if we're to increase love in our life on an ongoing basis, we'll do it through imagination and choice, and that will drive our chemistry. A few decades ago, psychologist Robert Ornstein published a book, The Psychology of Consciousness, in which he stated he'd sought to explain the chemical basis of consciousness. Instead, to his surprise, he wrote about the consciousness basis of brain chemistry.

May we enjoy this Valentine's Day with more than our heads.

Wednesday, February 2, 2011

CONTACT AS TREATMENT


A terrific essay in the New Yorker (http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all) a couple of weeks ago, written by writer/surgeon Atul Gawande, reveals a major factor in today's surreal healthcare costs.

Gawande points out that a small fraction of patients with chronic and multiple illnesses uses a grossly disproportionate share of healthcare. For example, one percent of the patients in Camden, NJ uses thirty percent of the city's total healthcare. Many of these "superusers" are indigent, so guess who pays for their services.

This occurs all over the country. People who are too poor to pay for healthcare and can't find a doctor who accepts Medicaid (after the doc's overhead, remuneration often amounts to minimum wage) simply go to the nearest emergency department. Necessarily tooled for genuine life-and-death crises, EDs are costly to run. But most of the patients present with colds and flu and rashes, so they generate great expense for minor conditions.

Fortunately, Gawande reports, a number of experiments currently address this problem. Some people are opening care centers within housing projects and nursing homes. These low-cost operations are in some ways low-tech as well, as practitioners visit patients in their homes, offer classes, see them in groups. And it seems to work: where these strategies are tried, medical visits plummet.

Twenty-five years ago, when I worked for an agency for the disabled, we obtained a grant for a similar project. We enrolled the agency's clients--forty of them, all with disabilities--into a class that met weekly for seven weeks. Here we discussed common human processes, including disability, sickness, relationships, work, expression, spirituality, and death and dying. In other words, we just talked about life. We had inventoried participants' healthcare use before the class, did so afterward, and again six months later. Their medical visits dropped forty percent after the class, a figure that held after six months. When we reported our findings to the granting entity, we weren't believed and our grant wasn't renewed. Yet our findings paralleled what Gawande now describes.

What these interventions have in common is, I suggest, less medical than social, and that would make sense in regard to chronic illness. When you find you're sick in a way that's incurable--that's what chronic means--you need to make changes in your life to accommodate the illness. Your family and friends ache for your well-being, but often don't understand your situation (A guy in my cancer support group says, "My family doesn't speak cancer."). So if you're to make adaptive changes you'll need to consult experts, and the experts are other folks similarly afflicted.

Call it a "support group," but I believe it's more. Some call it a "navigation group." Am I doomed to see my situation as exclusively medical the rest of my life and be dependent on pills and surgeries, or is there another way to address it, too, a way that actually empowers me?

I don't know if those who do the experiments Gawande describes realize yet that their interventions are more social than medical, but they will. During these next few decades, the most effective therapy for people with chronic conditions will be compassionate, creative human contact.