Archive for the ‘Medicine’ category

The Common Inheritance, The Common Defense

March 5, 2017

A bit of self promotion here, but I’ve got a piece in today’s Boston Globe that might be of interest to some here.

It’s a look at what the idea of the commons — not just the abstract, model commons of Garrett Hardin’s famous essay, but the historical commons as actually lived and used — can tell us about current problems.  The TL:DR is that commons are not inherently prone to tragedy, but that the preservation of communal goods requires…wait for it…communal action: regulation, self-regulation.

This is, of course, exactly what the Republican Party denies — more, loathes and condemns.  With Trump, they’re getting their way, but its vital to remember that the consequences that will flow from these decisions are not down to him, or simply so: the entire Republican power structure is eager to do this, and when we pay the price, we must remember who ran up the bill.

Anyway, here’s a taste from my piece.  Head on over to the Globe’s site if you want more.

The idea of the commons is deeply woven through the history of the English countryside. Shakespeare captured this idyllic approach to nature’s wealth in “As You Like It,” when the shepherd Corin explains to the cynic Touchstone the joys of his life. “I earn that I eat, get that I wear,” he says, adding that “the greatest of my pride is to see my ewes graze and my lambs suck” — in the unowned, readily shared Forest of Arden.

There can be trouble in such an Eden, as Hardin pointed out in an influential 1968 paper. Hardin asked what would happen if access to a commons were truly unfettered — if Corin and every other villager ran as many sheep as they could there. In such cases, Hardin argued, the endgame is obvious: Too many animals would eat too much fodder, leaving the ground bare, unable to support any livestock at all.

The evolution of resistance to antibiotics fits that story perfectly. The first modern bacteria-killing drug, penicillin, came into widespread use in 1944, as American laboratories raced to produce millions of doses in time for D-Day. The next year, its discoverer, Alexander Fleming, used his Nobel Prize lecture to describe precisely how this wonder drug could lose its power, telling the sad tale of a man who came down with a strep infection. In his tale, Mr. X didn’t finish his course of penicillin, and his surviving microbes, now “educated” (Fleming’s term), infected his wife. When her course of penicillin failed to eradicate these now-resistant microbes, Mrs. X died — killed, Fleming said, by her husband’s carelessness. It took just one more year for this fable to turn into fact: In 1946, four American soldiers came down with drug-resistant gonorrhea, the first such resistance on record.

Go on — check it out.  You want to hear about the great Charnwood Forest rabbit riot.  You know you do…

Image: Jacopo da Ponte, Sheep and Lambc. 1650.

Advertisements

Be Afraid. Be Very Afraid

September 9, 2016

This is a video that will haunt your nightmares:

Go to NPR‘s story on this for a narrated version of the video — and you’ll find that what you see is a bacterial colony developing extraordinary capacities for antibiotic resistance in a shockingly short time — two weeks, or a little less, to go from a naive, wild-type strain to varieties that can resist 1,000 times or more the dosage that killed almost all of the original microbes.

The video is part of the supporting material for a paper published this week in Science .  In a way, there’s nothing new, or rather, nothing surprising here.  Microbial resistance to antibiotics is a phenomenon as old as antibiotics themselves.  (See Alexander Fleming’s Nobel Prize speech, for example).

What’s revealed in this video — and the reseach behind it, of course — is the obvious.  We ain’t going to win any war with bacteria anytime soon.  But in this political season, I’d add another thought:

There are some things at stake in this election that matter rather more than whether one candidate used a not-according-to-Hoyle email server.  Among them are matters of life and death — and not just in the usual sense of decisions about national security or similar matters.  One party, one candidate takes science seriously right now.  The other doesn’t.  Vote like your — and your kids’ — lives depend on it.

Racism Kills…And Kills…And Kills

June 15, 2016

Anger?  Heartbreak? Disbelief? Berserker rage?  Which should come first in response to this?

For forty years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black males with syphilis despite the availability of effective treatment. The study’s methods have become synonymous with exploitation and mistreatment by the medical community. We find that the historical disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.4 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men. (h/t Jesse Singal at The Science of Us)

Graveyard_in_the_Tyrol_1914-1915_JS_Sargent (1)

That’s the abstract of a paper by Stanford Medical School’s Marcella Alsan and the University of Tennessee economist Marianne Wanamaker. It’s currently in the working paper stage at the National Bureau of Economic Research (which is, despite its name, not a government research institution).

As Singal writes over at New York Magazine that means both that this is not quite the final draft of this paper (or at least, that it hasn’t yet gone through the whole journal process yet) — and that there is a host of nuance and specific contingencies that surround the Tuskeegee story.  But the central point remains:  specific acts of racial cruelty harm not just those bearing the immediate brunt, but also can — and did here — do  lasting and lethal damage to so many more.

Alsan and Wanamaker conclude:

Our findings underscore the importance of trust for economic relationships involving imperfect information. Typically the literature on trust has focused on trade settings (Greif, 1989); however, much of medical care depends on health providers and patients resolving information asymmetries. Trust, therefore, is a key component of this interaction…

Indeed.

And if we needed any more reasons to take this election seriously (we don’t) think on this:  Donald Trump’s candidacy is based on racism, on the denial of a share in American polity and society to those who look the wrong way.  There’s a breach of trust there, deep and dangerous — and in so many ways, deadly as hell.

John Singer Sergant, Graveyard in the Tyrolbetween 1914 and 1915

Your Daily Apocalypse, Outsourced Antibiotic Edition

November 21, 2013

Go read this piece by Maryn McKenna — who is, in my never humble opinion, one of the handful of very best reporters on matters of infectious disease, global health, and really scary stuff.

I was born in 1958, fifteen years into the era of clinically-available antibiotics.  I was my mother’s third child.  Had we shifted that timeline back a few years, that would have meant that there would have been a measure of luck in mom simply making it to and not through her third lying in.  As Maryn writes, before antiobiotics, five out of 1,000 births ended with the death of the mother.  No worries by the time I popped my head out into the maternity floor at Alta Bates.

But this a must read not because of any remembrance of the pre-antibiotic era, but because Maryn plausibly analyzes a post-antibiotic future.

Plaguet03

Here’s a sample:

Doctors routinely perform procedures that carry an extraordinary infection risk unless antibiotics are used. Chief among them: any treatment that requires the construction of portals into the bloodstream and gives bacteria a direct route to the heart or brain. That rules out intensive-care medicine, with its ventilators, catheters, and ports—but also something as prosaic as kidney dialysis, which mechanically filters the blood.

Next to go: surgery, especially on sites that harbor large populations of bacteria such as the intestines and the urinary tract. Those bacteria are benign in their regular homes in the body, but introduce them into the blood, as surgery can, and infections are practically guaranteed. And then implantable devices, because bacteria can form sticky films of infection on the devices’ surfaces that can be broken down only by antibiotics

Dr. Donald Fry, a member of the American College of Surgeons who finished medical school in 1972, says: “In my professional life, it has been breathtaking to watch what can be done with synthetic prosthetic materials: joints, vessels, heart valves. But in these operations, infection is a catastrophe.” British health economists with similar concerns recently calculated the costs of antibiotic resistance. To examine how it would affect surgery, they picked hip replacements, a common procedure in once-athletic Baby Boomers. They estimated that without antibiotics, one out of every six recipients of new hip joints would die.

As Maryn reports, the problem is tangled and complex — but there are clear actions that could be taken and aren’t, most obviously ending the reckless use of antibiotics in agriculture, which consumes something like 80% of the total produced.  But don’t waste time here: go read the whole thing. Get scared; get mad; call your congressfolk.

Image: Josse Lieferinxe, St. Sebastian prays for plague victims, 1497-99.

The Difference Between Democrats and Republicans

October 1, 2013

In California, a Democratic Party-run state:

Dozens of workers at a call center in the Sacramento suburb of Rancho Cordova began fielding calls after a countdown to 8 a.m. Tuesday, the time the state’s health exchange opened for business. The agency that runs the exchange, Covered California, reported on Twitter that more than 30,000 telephone calls were received during the first 90 minutes of operations. Another 1,200 were on hold and about 4 percent had hung up.

Peter Lee, executive director of Covered California…said Tuesday was just the starting point, and it was evident that exchange officials had work to do after the website and phone system were hit with a crush of inquiries.

Gov. Jerry Brown, meanwhile, announced he had signed a package of bills to help implement the new law and expand the state’s Medi-Cal program for those who are too poor to pay for the subsidized insurance.

“While extreme radicals in Washington shut down our government, here in California we’re taking action to extend decent health care to millions of families,” Brown said in a statement, referring to the impasse in Congress that has led to a partial shutdown of federal government operations.

Meanwhile, as a result of the government shut down triggered by those GOP extremists, there’s this news:

Cecil_Beaton_Photographs-_General;_China_1944,_Canadian_Mission_Hospital_in_Chengtu_IB2569C

At the National Institutes of Health, nearly three-quarters of the staff was furloughed. One result: director Francis Collins said about 200 patients who otherwise would be admitted to the NIH Clinical Center into clinical trials each week will be turned away. This includes about 30 children, most of them cancer patients, he said. (From behind the WSJ paywall via the Atlantic) (h/t a tweet from science writer extraordinaire Steve Silberman aka @stevesilberman.)

So there you have it:  Democrats strive to get sick people care (and the well, protected), and labor to fix  the bits that don’t work.

Republicans leave kids with cancer on the street.

Update:  H/t commenter Baud, it turns out   that Americans in those (GOP-led) states that have chosen to abandon their responsibility to their citizens actually do twant healthcare from the Feds (via TPM):

Nearly three million people have visited the federal health insurance marketplace created by Obamacare on its first day, according to the U.S. Department of Health and Human Services.

Since midnight, 2.8 million people have visited the website, which will serve consumers in more than 30 states, and 81,000 have called the marketplace’s call center. Those numbers were current as of late Tuesday afternoon.

Image:  Cecil Beaton, A mother resting her head on her sick child’s pillow in the Canadian Mission Hospital in Chengtu, 1944.

American Exceptionalism, Healthcare Division

September 18, 2013

With a h/t to my spouse, this piece from a couple of days ago offers a beautiful (not really the mot juste) window onto the multiple levels of fail of US medical business and (or rather, hence) practice.  The action gets going as a young physicians assistant named Andrew T. Gray describes waking up an upset stomach, which over the course of the day blossoms into really nasty pain.  Then comes the twist:

Crawling into bed, however, I realized that my pain had coalesced in the right lower quadrant of my abdomen. Could it be appendicitis?

Panic flooded me. After six weeks at my new job, I now qualified for health insurance, but I’d neglected to fill out the necessary paperwork.

Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.

“Go to the emergency room right now,” urged one of my supervising physicians.

Instead, Gray waited overnight so as to reduce the odds of insurance company shenanigans.  The next morning, though he can’t wait anymore:

Waiting for the ER doctor, I recalled that, at some point in my schooling, I’d read a Swedish study about treating appendicitis with antibiotics. Googling the study on my smartphone, I found it.

By the time the ER resident approached, I was ready.

“I don’t have health insurance,” I said calmly. “Can I be treated with antibiotics instead of surgery?”

“I doubt they’re going to let you do that here,” he said. “But keep expressing interest.”

When the ER attending physician came in, I repeated the question.

“Absolutely not,” he replied flatly. “This is America, not Sweden. If you have appendicitis, we operate.”

The story gets better — which is to say from a policy and medical care point of view, worse.  Go read the whole thing.

As to it’s relevance beyond itself. Well, Gray’s telling an anecdote, of course, a single encounter in a system that touches millions every day.  Even so, there are at least two key points I draw from it:  (a)  there are structural problems with the culture of medical practice in the US that both drive up costs and affect (not for the better) patient outcomes.  “This is America…we operate.”

Hans_Holbein_d._J._-_Henry_VIII_and_the_Barber_Surgeons_-_WGA11566

And (b):  there are lots of reasons medical costs in the US seem both arbitrary and excessive. But (a) they are and (b) it actually matters to know what happens elsewhere, because from such knowledge it finally becomes much easier to see that US health care is exceptional alright — but not how the foaming hordes raving against tyranny in the form of Obamacare would have it.  We sure do lead the world in what we pay. Just not in getting what (we think) we’re paying for.*

*This is not to say that for particular conditions in particular cities there is no better place in the world to receive care than, say, my current dwelling place, Boston.  But brilliant tertiary care available  to those clued in and covered in just the right ways doth not a system make.

Image:  Hans Holbein, Henry VIII and the Barber Surgeons, 1543.

The FSM Moves In Mysterious Ways

August 26, 2013

Presented without (much) comment:

The latest measles outbreak is in Texas, where the virus has sickened 25 people, most of whom are members or visitors of a church led by the daughter of televangelist Kenneth Copeland.

Fifteen of the measles cases are centered around Eagle Mountain International Church in Newark, Texas, whose senior pastor, Terri Pearsons, has previously been critical of measles vaccinations. [via TPM]

 

Titian_-_The_Sick_Man_-_WGA22934

The church in question understands how to deal with such awkwardness:

 We know the truth; we are healed according to Isaiah 53:4-­5 and I Peter 2:24 and are standing against any plague that would try to attack us as a body. So agree with us that this will stop now according to Matthew 18:19.

But nonetheless hedges its bets:

Kenneth Copeland Ministries’ position regarding dealing with any medical condition involving yourself or someone in your family is to first seek the wisdom of God, His Word, and appropriate medical attention from a professional that you know and trust. Apply wisdom and discernment in carrying out their recommendations for treatment. This would include:  vaccinations, immunizations, surgeries, prescriptions, or any other medical procedures.

For my part, I’d skip the other stuff and head straight for one of the greatest inventions ever in the service of human well-being, the prophylactic vaccine.

I’ll close here, without diving into any “it’s not whether you believe in evolution, it’s whether evolution believes in you” species of snark.

Image:  Titian, The Sick Man, c. 151