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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Saturday, September 06, 2003


    (Thanks to my family practice email list-serve for the heads up.)

    posted by Sydney on 9/06/2003 08:30:00 PM 0 comments

    Abolishing the Feminine Mystique: There’s a joke in the movie In the Company of Men that, as crude as it is, explains part of the mystique of women - “Never trust anything that can bleed for seven days every month and not die.” Now medicine is poised to eliminate that mystique:

    The Food and Drug Administration yesterday approved a new type of birth control pill that enables women to skip their monthly menstrual cycle for about three months.

    It contains estrogen and progesterone, the same hormones that are in birth control pills now, but they’re taken for much longer periods of time:

    ....each packet contains 84 hormone pills instead of 21, followed by seven placebo pills, so the reproductive process is suppressed for three months instead of three weeks.

    Of course, a lot of women are going to love dispensing with their periods, although not all:

    ...In tests, Seasonale won praise from women who suffer from intense problems associated with their periods. But Seasonale also sparked debate over what is considered "natural," whether it is wise to manipulate a woman's reproductive cycle with hormones for long periods of time and whether Seasonale is a manifestation of societal biases against menstruation.

    Well, it’s easy - and justified - to be biased against menstruation, but still others see a plot by population control activists:

    In keeping with this mission, the Population Council is a leader in the development of new contraceptives. The notion that long-term contraceptive regimens should be used to stifle menstruation was originally the brainchild of Population Council researchers; in particular, former council vice president and endocrinologist Sheldon J. Segal, who co-authored the book, Is Menstruation Obsolete? with Elismar Coutinho, a Brazilian gynecologist. Segal is also a member of a council division known as the International Committee for Contraceptive Research. Almost all of the latest propaganda used to promote Seasonale comes directly from Segal and Coutinho’s book. The Population Council further pushes the concept through a plethora of recent pro-Seasonale articles from other council members, such as “reproductive health” researcher Charlotte Ellertson and Sarah L. Thompson, both quoted earlier in this article.

    Quotes from these “authorities” have helped clinch public support of Seasonale and everything it stands for. Barr and friends hope to see FDA approval of Seasonale within the year; their expectation is not far-fetched. It seems that the population control agenda is more important than the fact that long-term effects of a constant influx of synthetic hormones has barely been studied, much less proven to be safe and natural.

    Interestingly, they got their approval not within a year, but within a month. And this would be the same FDA panel that has several members who were much maligned by the press and reproductive rights activists as being too pro-life. Looks like their fears were unfounded.

    Ideology aside, however, there is reason to approach this new birth control pill with caution. Current conventional medical wisdom has it that it’s just not healthy to supress menstruation. The constant exposure to estrogen and progesterone causes the lining of the uterus to remain in its thickest phase (see days 15-28 on this illustration), causing a condition called endometrial hyperplasia. Endometrial hyperplasia, while usually benign, can increase the risk of uterine cancer. While it’s true that women who take birth control pills have a lower incidence of endometrial cancer, they also have regular periods - at least with current birth control pills.

    The pharmaceutical company says that Seasonale is as safe as other birth control pills, but their Phase III clinical trial only lasted one year, and most women take contraceptives for around fifteen to twenty years. No one knows what the long term consequences of suppressing menstruation will be. And I must say, it is odd that this is touted as a healthy intervention while estrogen and progesterone in the form of hormone replacement therapy is so widely disparaged. Fools rush in.
    posted by Sydney on 9/06/2003 05:06:00 PM 0 comments

    Depends on Who You Talk To: John Ray dissects current pop thoughts on race and IQ.
    posted by Sydney on 9/06/2003 04:44:00 PM 0 comments

    Objections: Judging from my email, a lot of people took exception to my earlier post about being "fat and happy." I was alluding to the association between "fat" and "prosperous" and between "lean" and "poor." I guess we're loosing those associations these days, since we're fortunate enough to live in a land where the poor are well-fed enough to be fat and the rich spend lots of money to keep themselves thin. But, here are the comments:

    Surely, there are other alternatives to "fat and happy" than "lean and miserable"--how about lean and happy or fat and miserable. I fear your new responsibilities are getting the better of you--I have seen thousands of patients over the years and can only recall a few who are genuinely happy being fat--they may be happy but it is in spite of being fat--obesity need not dominate your life but I can assure you that during those quiet moments, when we have only ourselves to talk with, very few feel good about being fat. Leanness guarantees nothing but leanness, but obesity is a slippery slope to many places I would not want to go.


    Well, you know as well as I do that there are choices besides "fat and happy" and "lean and miserable." I have thought a lot about walking, and I have decided that that is what we are meant to do. I am afraid of getting diabetes (I am overweight by some 30 lbs); I don't like the feeling of growing weakness; I know that if I don't get some activity, I will begin to suffer from osteoporosis.

    So, there are consequences to our sloth. Yet, I can understand full well that almost all of us (the sane ones, I think), don't move unless we have to. Thus, all those joggers and exercise buffs are always going to be in a minority.

    I saw, the other day, a tourist in Whitehorse who was horrendously overweight. I have seen a lot of that - much more than I have ever seen before - we are talking more than 50 pounds of extra weight. These people could solve this huge problem - and it is a huge health problem - by knowing that a simple walk could make all the difference- that parking the car at the far end of the parking lot; walking to see a friend (a mile is not a long way, really). Carrying one's groceries as far and as much as possible (maybe shopping for them more often, so it becomes feasible to carry them instead of putting them in the cart). You don't have to jog, or run upstairs. Just take a walk.

    I have seen people who think that walking 2 blocks is out of the question.

    And that is what the medical profession could be telling their clients!

    So there!
    posted by Sydney on 9/06/2003 04:22:00 PM 0 comments

    Tempting: Got this offer in the mail today:


    It was from the US Army. How did they know I'd be particularly vulnerable to that message at this point in my life? Coincidence or Big Brother?

    posted by Sydney on 9/06/2003 04:11:00 PM 0 comments

    Friday, September 05, 2003

    Preparedness: The government will be giving money to a group of universities to develop vaccines against bioterrorism:

    The Middle Atlantic region will receive a five-year, $42 million grant from the National Institute of Allergy and Infectious Diseases. Besides creating vaccines to guard against anthrax, smallpox and West Nile virus, they will study antibodies that could produce short-term protection.

    I didn't think anyone outside one or two senators really thought West Nile virus was the work of terrorists. But here's what they really plan to work on:

    The regional researchers will study viruses that cause hemorrhage fever, such as ebola and Marburg, and target E. coli and shigella, bacteria considered to be threats because a small amount causes severe illness.

    Researches will also design better diagnostic tests and needle-free vaccinations for fast response to a biological attack or infectious disease outbreak.


    posted by Sydney on 9/05/2003 08:53:00 AM 0 comments

    Labels: A sample of the inner workings of the autistic mind from "The Curious Incident of the Dog in the Night", a novel told from the perspective of a mildly autisitic child:

    "People think they’re not computers because they have feelings and computers don’t have feelings,” says Christopher. “But feelings are just having a picture on the screen in your head of what is going to happen tomorrow or next year, or what might have happened instead of what did happen, and if it is a happy picture they smile and if it is a sad picture they cry.

    The author, who has worked with autistic children, has this to say about our current trend to classifying every deviation from normal as a disease:

    He clearly has Asperger’s syndrome. But the term never appears in the book, and neither does the word “autistic.” If Haddon had his way, autistic wouldn’t be in the jacket copy either, though it is. “The label doesn’t add anything to your knowledge of anyone,” says the author, who would prefer it if the term “odd” were to become popular again. “In the old days you were allowed to be odd,” he says. “Too many people now who would have been odd find themselves with a label and getting sucked into some kind of system.

    Sounds like a wise man.
    posted by Sydney on 9/05/2003 07:55:00 AM 0 comments

    Thursday, September 04, 2003

    Stifling Hunger: Recent research suggests that there might be an appetite supressing hormone in our pharmaceutical future:

    In the small study, obese and lean people ate about 30 percent less from a buffet after they were given a dose of the hormone, PYY3-36, to trick the brain into thinking they had already eaten. The research also showed lower natural levels of PYY in the obese, which may explain why they overeat, Bloom said.

    The study was a small one - involving only 12 obese and 12 lean people - but the results are interesting, and could point the way to a safer drug-based approach to obesity and overeating than what we currently have. It just needs a lot more work before it’s ready for prime time.

    The hormone in question is a fragment of a hormone released by the gut, which works its magic in the brain at the hypothalamus. More than you probably want to know about it can be found here.

    posted by Sydney on 9/04/2003 09:07:00 AM 0 comments

    Myths and Misdemeanors: Writing in this week's The New Republic, Jonathan Cohn (subscription required) makes this observation:

    As you might suspect, people who don't have regular access to medical care tend to end up sicker than people who do, since it's through regular checkups that you're most likely to catch things like cancer or heart disease before they kill you. And, naturally enough, people who don't have health insurance tend to be sickest of all. So, because Hispanics in the United States are far more likely to be uninsured than the average American, it ought to follow that they're also much less healthy than the average American. But that's the paradox: They aren't. Quite the contrary: Hispanics in the United States are healthier than the rest of the country. Far healthier, in fact. According to surveys by David Hayes-Bautista, a professor at UCLA who has conducted some of the most authoritative work on the matter, the rate of heart disease among California Latinos is actually lower than for the population as a whole--this, despite the fact that Latinos are more likely to be overweight and smoke (both major risk factors for heart disease). Latinos are also less likely to have strokes or suffer from cancer. By better avoiding heart attacks, strokes, and cancer--the three leading causes of death in the United States--Latinos enjoy unusually long life expectancies. A Latina woman living in the United States, for example, will probably live longer than the average American female. 

    Do we know for sure that people who have the best access to healthcare (i.e. the most insurance benefits and easy access to doctors) are healthier? We assume they are, but we might be wrong. To be sure, someone with diabetes who has no access to medicine will be a lot sicker than a diabetic who does, but for the average person with no chronic illnesses, does it really make much of a difference if they see a doctor for regular check-ups? As much as I hate to admit it - with the exception of screening for colon cancer,cervical cancer, and diabetes - regular check-ups aren't that likely to save a life.

    Regular check-ups don’t prevent heart disease. (Even screening for cholesterol and treating it aggressively only lowers the chances of heart attacks or sudden death by a few percentage points. It doesn't prevent the aging process of the coronary arteries that is, ultimately, what's behind heart disease.) And regular check-ups aren’t likely to detect early heart disease, unless the patient’s fortunate enough to have symptoms, which means it isn’t really “early.”

    Every family doctor or internist who's practiced long enough has had the unfortunate experience of having a patient die shortly after a normal physical exam. It is humbling. We all labor under the assumption that regular check ups will find any and all malfunctioning parts - like an auto check-up would. Even those of us who should know better sometimes think this. The truth is, there’s a lot of very common disease out there that we just can’t detect at early stages. And perhaps we’ve done the public a bit of a disservice by promoting the importance of regular check-ups, as if we can predict a patient’s future by listening to their hearts and lungs, probing their every orifice, and looking deeply into their eyes. In the end, all we can really say after a check up is that there’s no obvious illness at that moment. But in the moments to come, anything goes.
    posted by Sydney on 9/04/2003 08:17:00 AM 0 comments

    More Projections: Australian blogger John Ray, and Brits Natalie Solent and Public Interest (scroll down to Sept. 2 post) take on The Guardian's psychoanalysis of George W. Bush. As Natalie Solent says, "it's a game that works on any platform."
    posted by Sydney on 9/04/2003 07:46:00 AM 0 comments

    Harry Potter's Politics: Over at Blogcritics Chris Cotner wonders about the politics of Harry Potter. Is the Order of the Phoenix a parable of modern times, or do we just project our own perceptions on literature?
    posted by Sydney on 9/04/2003 07:32:00 AM 0 comments

    Wednesday, September 03, 2003

    Avoiding Confusion: The WHO is recommending that all nations give priority to influenza vaccinations, so that the flu won't be confused with SARS:

    The influenza vaccine does not prevent other respiratory diseases and, importantly, it does not provide protection from SARS,' the WHO cautioned.

    However, 'high vaccination coverage may reduce the number of pneumonia cases caused by influenza (and) reducing pneumonia cases may also lower the possibility of misdiagnosing influenza as SARS,' the agency said.

    Flu vaccination programs should focus on the elderly and those who are already sick from other illnesses, as well as health workers, the WHO said.

    'Suspected SARS cases can result in considerable disruption of health services as well as costly precautionary measures and investigations.

    Really, there recommendations aren't any different than they have been in recent years. The same groups are urged to get it - the elderly, and those with heart or lung conditions or immune system problems. And healthcare workers. They're just trying to promote its use in countries where it isn't often used.

    posted by Sydney on 9/03/2003 08:33:00 AM 0 comments

    Shifting Blame: The Louisville Courier-Journal makes an interesting point about Kentucky OxyContin abuse and the tendency to blame the pharmaceutical companies:

    Imagine the reaction if this corporate announcement were ever made:

    "Wonder Drugs Inc. has decided to restrict distribution of its new and highly effective painkiller in rural Kentucky. Unlike the rest of America, Kentucky remains too backward to handle a powerful narcotic like ours.

    "The state's rural doctors, pharmacists and law enforcement agencies are not up to meeting their professional responsibilities or providing the public protections our medication requires and receives elsewhere. Thus, our only choice is to protect Kentuckians from themselves by restricting access to the proven pain relief that other Americans enjoy, and we urge all other manufacturers of pain medications susceptible to abuse to do the same.

    "Wonder Drugs will henceforth withhold from rural Kentucky our normal marketing, informational and distribution efforts. Corporate policy will be to treat the family physicians and community druggists of rural Kentucky not as the competent professionals the state's licensure boards claim they are, but as the clueless pill pushers the state's record of prescription drug abuse shows them to be."

    The editorial points out that Kentucky has a long history of drug problems that go far beyond OxyContin:

    In a state where sheriffs are being killed over drug corruption and doctors were able to operate a regionally famous pill outlet, Purdue Pharma's sales tactics rank low on the list of public outrages.

    Kentucky is a state that with a few exceptions, doesn't allow the sale of alcohol. There are parts of it where you have to drive for two hours to be able to buy a beer. No wonder they turn to drugs.
    posted by Sydney on 9/03/2003 08:20:00 AM 0 comments

    Blame Wal-Mart: A reader sends along these observations on spread and sprawl:

    It seems that people have been getting a lot fatter than they every did before. My theory is: in recent decades, malls have spread from outside cities to smaller population districts (eg, up here, in the Yukon, we just got Walmart.) Now, people like malls, which is why they are popular. But there is no doubt that they are built for the car, and that walking becomes less likely in this new culture.

    I would say that someone should look at the spread of the mall throughout the USA, rather than such aspects as rural vs urban, etc.

    Also, in the last generation, the car has become more accessible to more people. In the 50s and even 60s in Canada, the 2 car family was uncommon. Now, multi-car families are all over the place. And necessary: to get the kids to school (no longer do they walk to school, even a few blocks is seen as too much) - given the many cars on the road, this is realistic. To go to work. To go anywhere.

    Now, walking is the healthiest of human activities. When I was a child, in the 50s, I walked to church every Sunday with my grandmother. There was no thought that we should "drive" there. The distance was about 6 blocks one way.

    The other thing is, we don't have to carry much anymore. We wheel our purchases from the store to the car, and then there is the short walk (often from inside a garage directly into the kitchen) to the house.

    So, in other words, we have a very comfortable life style that discourages moving our bodies.


    If our prosperity is the main culprit in our epidemic of obesity - and most evidence suggests that it is - then our growing girth isn't necessarily a bad thing. Who wouldn't rather live fat and happy than lean and miserable?
    posted by Sydney on 9/03/2003 07:38:00 AM 0 comments

    Negativity: Recent research suggests that negative thoughts may inhibit our immune systems (emphasis on the "suggests" and "may"):

    Researchers at the University of Wisconsin are reporting today that the activation of brain regions associated with negative emotions appears to weaken people's immune response to a flu vaccine.

    ...In the study, 52 women, ages 57 to 60, were asked to think and write about extremely positive and extremely negative events in their lives. The women were participants in a continuing long-term study of high school graduates from the class of 1957.

    In the positive emotion condition, the women were instructed to spend one minute recalling an experience of "intense happiness or joy, specifically the best time or experience in their life," and then to spend five minutes writing about it. In the negative emotion condition, the subjects did the same for an event that inspired "intense sadness, fear or anger, the worst time or experience in their life."

    Electrical activity in the brain's prefrontal cortex — an area known to be centrally involved in emotion — was recorded by electroencephalogram while the women were thinking about their experiences and after the writing ended. Then the participants were given a flu vaccine.

    Six months later, the researchers found, the subjects who showed the most activity in the brain's right prefrontal cortex also had the lowest antibodies. Brain activation during the positive-emotions condition was not linked to differences in antibody levels.

    Interesting that positive thoughts didn't seem to make much difference. So much for the power of postive thinking. The power appears to be in the negative.

    But isn't that true in general? One person's really bad mood can make all those around them miserable, but one person's good mood rarely puts everyone else in an equally happy state.
    posted by Sydney on 9/03/2003 07:35:00 AM 0 comments

    Sunday, August 31, 2003

    Spread and Sprawl: The anti-suburb movement is gearing up to use our national obsession with obesity in their war against sprawl. An institution in Maryland called National Center for Smart Growth - as in community, not personal - says our suburbs are making us fat, and that something should be done about it. According to the lead researcher:

    "'If these results hold up, then building compact communities will become a public health imperative, given our obesity epidemic."

    Trouble is, these results don't hold up:

    People who live in the most spread-out areas spend fewer minutes each month walking and weigh about six pounds more on average than those who live in the most densely populated places. Probably as a result, they are almost as prone to high blood pressure as cigarette smokers, the researchers found.

    Six pounds up or down doesn't make much difference in the BMI of a person, unless they happen to be just on the borderline. It doesn't even make much difference in clothing size.And the correlation between sprawl and girth is even less impressive:

    A 50-point increase in the degree of sprawl was associated with an average weight gain of a little more than one pound per person, researchers found.

    But 50 points on the scrawl scale is a fairly large spread:

    The index ranged from a low of 63 for the most sprawling county -- Geauga, Ohio, just outside Cleveland -- to a high of 352 for the densest -- New York City.

    Geauga county is a county of large, expensive houses on widely separated, expansive tracts of land. It's a county of horse farms and nature preserves. (They even play polo up there, believe it or not.) New York City, on the other hand, is a place where people live right on top of one another, where the sun is obscured by buildings, and the sight of a tree is hard to come by. What are the chances that the difference in average weight is more likely to be due to comparing the average of a small number of people to the average of a large number of people? Pretty good, I'd expect. In fact, I bet if they compared the average weight of the population of South Dakota, or of Vermont, with the average weight of the population of New York City, South Dakotans and Vermonters would come out heavier - even though they live in rural areas with small towns that encourage walking and bike riding.

    Then there's that "probably" and the health effects of living in suburbia:

    While researchers found no association between sprawl and diabetes or heart disease, they did find that people who live in the least sprawling areas had a 29 percent lower risk of developing high blood pressure than those in the most sprawling areas.

    The researchers, of course, don't tell us exactly what that 29 percent reduction represents. Do 100% of people in sprawl areas have high blood pressure compared to 71% in densely populated urban areas? Or do 1% of people in sprawl areas have high blood pressure compared to 0.71% in dense urban areas? Probably somewhere in between, but much closer to the latter than the former. No way of telling, however, since the study is not available unless you're willing to pay for it. And judging by this study, it doesn't appear to be worth the money.

    And Another Thing: For years people have been blaming urban living for obesity. They argue that people living in the inner city are afraid to leave their apartments (at least in poor neighborhoods) and that children have to sit inside in front of the television because there is no place to play. But of course, looking into that connection wouldn't fit the current public health political ideology.

    UPDATE: A reader reminds me that there's another downside to urban living that's often mentioned in the media but forgotten in this particular article - the higher incidence of asthma in urban areas:

    Another point to make in the obesity and sprawl critique:

    If one compared Geauga and New York City and claims that the latter will have less weight gain, then it's only fair that we examine one other potential effect of sprawl: exposure to pollution.

    Wonder what the average particulate count, ozone concentration and NO2 concentration is at each location? Sure, it's hard to know what small differences in air quality mean to health overall, but if the National Center for Smart Growth is allowed to speculate out their heinie about the potential effects of a few pounds on health, I'm certainly allowed to speculate on the difference in a few parts per million in air quality.

    UPDATE II: Another reader says my headline sounds like a porno movie (that should help traffic) but also has these thoughts to share about the proliferation of "studies":

    I doubt that there is more misused term in this innumerate country than "study", as the vast majority of those reported in the press are nothing but data-mining, with the conclusions carefully decided beforehand. The rest are collections of breathless, but ultimately meaningless, "testimonials" for some overpriced (and probably un-needed) dietary supplement. I'm probably grumpy because I just spent twenty minutes trying to explain the difference between a real controlled "study" and these exercises in hype-by-press-release to a patient who is paying sixty dollars a quart for what is essentially sea water. "Oh, but they have lots of studies to prove it works". Went to their website- you guessed it, the "studies" page is "under construction"! HA!

    Yeah. No matter what you want to believe, there's a "study" that'll back it up. Medicine is getting to be more and more like a social science.


    posted by Sydney on 8/31/2003 08:10:00 AM 0 comments

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