domingo, 30 de noviembre de 2014
Trivializing the significance of losing one’s hair during cancer treatment
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sábado, 29 de noviembre de 2014
Should hospitals manage hospitalist programs?
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Why do hospitals feed their staff so poorly?
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ACOs: Another layer of oversight for physicians?
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viernes, 28 de noviembre de 2014
How to choose a good hospital? Hint: Don’t listen to the ads.
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Sick or not sick? Handling the reality of inpatient medicine.
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Improve the lives of primary care doctors. Here’s how.
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jueves, 27 de noviembre de 2014
Having children during medical residency: 6 tips to survive
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miércoles, 26 de noviembre de 2014
EMRs remove the soul of the medical record. So, what’s next?
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Announcement: The Society for Science-Based Medicine is co-sponsoring NECSS
Steve is off today; so I thought it would be a good idea to use this space today for a little shameless self-promotion (of Science-Based Medicine and the Society for Science-Based Medicine, of course).
The Northeast Conference on Science & Skepticism will be bigger than ever in 2015 with fabulous presenters, exciting panels, and engaging workshops.
We’re thrilled to announce that NECSS 2015 will be co-sponsored by the Society for Science-Based Medicine and will expand to include a third full-day of programming! Friday’s schedule will be curated by the team at SfSBM and feature content available exclusively at NECSS 2015. Saturday and Sunday schedules will once again feature the best of science and skepticism.
NECSS weekend also includes a special evening performance on Friday, two workshop tracks on Thursday for the early-birds, our popular “Drinking Skeptically” socializers, and more!
The full NECSS speaker line up will be announced shortly, but, as always, Rationally Speaking and the Skeptics’ Guide to the Universe will record live podcasts during the conference.
We have secured discounted room rates at the Hilton Fashion District, located one block from the main conference hall. These rates are available exclusively to NECSS attendees and we will be available shortly.
Conference registration will open in December, but you can like the NECSS Facebook page or follow us on Twitter for updates.
See you in April!
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martes, 25 de noviembre de 2014
When the art of medicine gets lost in the business
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Skin Cancer Treatment and Prevention – By Dr. melvin Elson
Of all the cancers, skin cancer is by far the most common type. Although, there are many forms of skin cancer some of which are quite rare, there are 3 that account for 99% of skin cancers—basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.
The most common type of skin cancer and the most common type of cancer overall is basal cell carcinoma. It is due to sun exposure, particularly the shorter wavelength that is also the sunburn spectrum and is blocked with the use of sunscreen. There are about 1,000,000 people in the United States with this cancer and it appears in a variety of forms, but mostly as a sore that does not heal or an area of the skin that begins to bleed. It is almost exclusively located in sun exposed areas, especially the face and hands.
Early Detection of Skin Cancer
Rarely does it metastasize—go to distant parts of the body, but it is also known as a rodent ulcer, because it eats the skin away in the area. This can be especially troublesome near the eye or in a crease in the face, e.g. near the nose. Usually treatment is curative and if caught early will usually not leave a bad scar. If not caught early, it may require what is known as Moh’s surgery which can be very destructive and require reconstruction. It is so easy to prevent by using a sunscreen with SPF 15-30 on a daily basis.
Less common is squamous cell carcinoma, which arises in an area of chronically damaged skin. It can arise in a leg ulcer of long-standing duration, in an area of chronic dermatitis and the most virulent area is the lip or mouth where it comes from use of tobacco. Treatment is surgical or irradiation and usually turns out well unless the lesion is on the lip, whereas it can be deadly.
The most virulent of all skin cancers and one of the worst of all is malignant melanoma. There are about 55,000 cases a year and has a number of factors that contribute to its development. Sunburns in childhood seem to increase the chance of having one and the use of tanning beds definitely increases the chance of having one. Treatment is surgical excision with a wide margin. No other treatment is effective and if not caught in the early stage will lead to death of the patient.
As a reminder, I offer free skin cancer screening here in the office. The only requirement is that you make an appointment, so call 615 441 5227 to schedule. This could save your life.
The post Skin Cancer Treatment and Prevention – By Dr. melvin Elson appeared first on Dr. Melvin Elson - Official Website.
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What a messy house has to do with medicine today
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lunes, 24 de noviembre de 2014
The rational ignorance of Jonathan Gruber
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What is the secret sauce to digital health?
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Selective pressures on alternative medicine
(Editor’s note: I was away at Skepticon over the weekend, where I gave a talk entitled The Central Dogma of Alternative Medicine. (When the talk’s up on YouTube, I’ll provide a link, of course.) Because of all the fun and travel delays I didn’t get a chance to turn my slides and notes into a blog post yet. Also, I’m on vacation this week. However, this gives me the opportunity to resurrect a blog post from 2007 on my not-so-super-secret other blog, because I think the concept is interesting. I even use it in a slide that shows up in many of my talks (above). I’ve updated dead links and added some text to include relevant links to post written since. Enjoy, and I’ll definitely be back next week with original material, if not sooner, given that there are others here who might have the temerity to take part or all of this week off.)
I wish I had thought of this one, but I didn’t. However, I never let a little thing like not having thought of an idea first to stop me from discussing it (even if Steve Novella’s also discussed it), and this particular idea is definitely worth expanding upon because (1) it’s interesting and (2) it combines two of my interests, alternative medicine and evolution. I agree with parts of the idea, but it’s not without its shortcomings. Indeed, I’d very much welcome any of the evolutionary biologists who read this blog to chime in with their own ideas.
A colleague of mine, Martin Rundkvist over at Aardvarchaeology, has proposed a rather fascinating idea regarding the evolution of alternative medicine in which he argues that alternative medicine evolves according to certain selective pressures. As you may or may not know, evolution is not just for biology, but has been proposed as a mechanism in cultural memes, for example. Since alternative medicine is a cultural phenomenon, it is not unreasonable to look at such non-evidence-based medicine and hypothesize what might be the selective pressures that shape its popularity and evolution. After all, if we’re going to discourage the use of non-evidence-based medicine or even quackery, it’s helpful to understand it. We already know that alt-med terminology has evolved considerably into the current preferred term, “integrative medicine.” (See also the image above and my blog posts on this evolution here and here.)
Martin primarily considers what the selective pressures are on various alternative medicine modalities and comes to a startling conclusion: Namely, that the selective pressure on such modalities is primarily to select for ineffective treatments. He bases this on two primary forms of negative selection. First, he hypothesizes, there will be selective pressure against modalities that cause obvious harm. According to this concept, such modalities will tend to be eventually recognized as harmful and shied away from by alternative medical practitioners due to fear of lawsuits and government regulations. The second form of selective pressure will come from conventional medicine. In essence, alternative medical therapies that can be shown to have a reasonable degree of efficacy will risk being co-opted by us “conventional” practitioners of evidence-based medicine and thus taken out of the armamentarium of alternative practitioners, whose setting themselves apart from mainstream medicine is very important to their livelihood. This leads Martin to observe that homeopathy is the ultimate CAM therapy:
So, there is evolutionary pressure on alternative therapies to achieve near-zero effect. This is why homeopathy is still around: its main method being the administration to patients of small amounts of clean water, it’s uniquely suited to surviving indefinitely in the alternative-therapy biotope. Homeopathic remedies can neither harm nor benefit patients.
This is a fascinating and lucid insight. Clearly it has some merit. However, it is incomplete. The reason, I would argue, is that the negative selective pressures Martin identified are almost certainly not as potent as he thinks they are, as evidenced by how rare it is for an alternative medical therapy to actually go “extinct.” Indeed, I would argue that selection against harmful or potentially harmful remedies is actually fairly weak and perhaps even nonexistent. After all, black salve is still around after many decades, if not hundreds of years, and it can produce some truly horrifying complications (not for the squeamish). Even though the FDA banned importation of black salve products and they can be demonstrably harmful, they are still around and show no sign of disappearing. Another example is Laetrile. Multiple well-designed clinical trials demonstrated that Laetrile is ineffective against cancer, and it has the well-known potential complication of cyanide toxicity. It, too, shows no signs of disappearing. Of course, perhaps the most popular ineffective CAM therapy that has potentially deadly complications is chelation therapy, which remains widely used among CAM practitioners to treat cardiovascular disease and autism, despite of the extreme biological implausibility of the argument that it should work for either condition and despite there being no good evidence that it does. Indeed, back in 2006 there was even a well-publicized case of an autistic boy who died as a result of hypocalcemia as a result of chelation therapy for autism causing a fatal cardiac arrhythmia.
No, there are lots of potentially harmful CAM modalities out there that show no signs of going away.
Let’s look at the flip side of the negative selection, co-optation of “effective” alternative therapies into mainstream medicine. Once again, this is probably a weaker negative selective force than it might seem. Herbal medicines, for example, are probably the most common of the CAM-type modalities to show some evidence of efficacy in randomized clinical trials. This is mainly because they are drugs. Impure and dirty drugs with widely varying levels of active ingredient from lot to lot, but drugs nonetheless. The problem for the co-optation of these drugs by conventional medicine is that practitioners of scientific medicine do not like unpredictability in their drugs. They like drugs with a predictable effect; herbal medicines “in the raw,” so to speak, do not fit the bill, particularly when pure pharmaceutical alternatives that lack the contamination and unpredictability of herbs exist. Even if conventional medicine co-opts an herb, for example, it is usually in the form of the pure active ingredient purified from that herb. For example, if you have breast cancer, you could try to chew on the bark of the Pacific Yew tree for its anticancer properties, but you’d be a whole lot more likely to do better if you took pure Taxol derived from that bark–and took it intravenously. The example of Taxol also suggests that once conventional medicine co-opts an herbal or plant-based remedy, it usually does not supplant the original alternative therapy. After all, all of the “natural goodness” has been extracted from it during the purficiation of the active ingredient! CAM mavens would often rather take the raw herb or the herb chopped up and compressed into an herbal pill because it’s more “natural.”
As for other non-herbal CAM therapies, even when they’re co-opted by modern medicine (although it’s often arguable whether conventional medicine or CAM did the co-opting), often an “alternative” version remains. The scientific version will be stripped of all the woo, while the “alternative” version will retain it. Think massage therapy and perhaps even chiropractic, which, as I’ve said before, stripped of its woo is nothing more than physical therapy with delusions of grandeur in the form of claims of being able to cure all manner of illnesses that have nothing to do with the spine or the musculoskeletal system.
Finally, there is one last aspect of Martin’s concept that argues against it. Martin states:
Evidence-based medicine, alternative medicine and weaponry change through time because of selection pressure. This means that they evolve and produce a fossil record of discontinued methods and therapies.
Here’s the problem: There actually is no “fossil record” of discontinued CAM methods and therapies. The reason is simple: CAM does not abandon its methods, regardless of evidence and, to a large degree, regardless of harm. Yes, individual treatment modalities may wax and wane in popularity, but they never go away completely. They never go extinct. Think about it a bit. Can you think of a single “alternative medicine” treatment modality that’s ever been completely abandoned because it either doesn’t work, is too harmful, or has been co-opted by conventional medicine. I can’t. CAM is, in the words of James Randi, an “unsinkable rubber duck.” It just won’t disappear. Martin is quite correct that homeopathy, for example, has persisted 200 years despite no evidence for its efficacy. Aryuvedic medicine has persisted at least a couple of millennia, despite a similar lack of evidence. Ditto most of traditional Chinese medicine, whose real history has been conveniently retconned over the last several decades, making it more popular even outside of China than it’s ever been. Never mind that these systems were developed in a time when very little was known about how the body actually works and are infused with spiritual and religious beliefs. They are still used my many millions, if not billions, of people worldwide. They have left no “fossils.” Of course, as in evolution in biology, this selection, applied over long periods of time, may ultimately eliminate such modalities, but if I were somehow able to call the Doctor to give me a ride in his TARDIS a couple of hundred years in the future, I bet that virtually all of these CAM modalities would still be in use. Part of the reason, I suspect, is that, as Martin pointed out, most CAM modalities do little; there is usually no CAM modality that can supplant existing modalities.
In any discussion of the evolution of CAM, I would be remiss not to look at its primary competition for resources (i.e., patients) in the ecosystem of medicine, namely scientific, evidence-based medicine. EBM has been hugely successful in many areas. Indeed, it can be said to have driven back CAM to a much smaller “ecological” niche than it once occupied. These days, relatively few people rely on CAM modalities when faced with a truly life-threatening illness, such as cancer. The Katie Werneckes, Abraham Cherrixes, and the Chad Jessops of the world (if the latter even had cancer), who treat life threatening cancers with high dose vitamin C, the Hoxsey concoction, or nasty, burning goo like the infamous “black salve,” respectively, are pretty uncommon. The main ecological niches for CAM these days have contracted to two areas. First are “diseases of living.” In other words, CAM has been for the most part relegated to the treatment of what are generally vague complaints that are not exactly diseases or to self-limited conditions. Indeed, one could argue that the strongest positive selective pressure for CAM modalities is how well each one gives the appearance of doing something therapeutic for such conditions, whether it actually does anything or not. In other words, how good of a placebo is it? Or is its timing or method of administration optimally adapted to correlate with the patient’s improvement anyway, allowing the confusion of correlation with causation? The better the adaptation, the more likely a CAM modality will thrive and expand.
The other remaining ecological niche for CAM, I would argue, is in serious diseases for which conventional medicine does not have much to offer. These conditions include diseases such as terminal cancer that has passed beyond our ability to treat it, as well as any manner of chronic diseases for which conventional medicine does not have a cure, such as Parkinson’s disease, chronic pain syndromes, multiple sclerosis, etc. Conventional medicine can treat and often palliate such conditions, but it cannot cure them. In this latter niche, I would argue that the primary positive selective pressure would be how well the CAM modality can inspire belief in its practitioners and hope in its users. The two are related, of course; the more the practitioner believes in the modality the more he or she can sell the patient on it.
Of course, applying evolutionary principles to CAM only goes so far. It’s a highly complex situation, and there are a number of positive and negative selection pressures that one could postulate. Certainly, the marketplace and how much of a feel-good aspect there is to CAM therapies are important. Finally, no doubt, like evolution, there are aspects to CAM proliferation that do not depend upon selection, a CAM equivalent of genetic drift, for example. Indeed, there was a fascinating paper five years ago why quackery persists which argues for a similar hypothesis of selection for more ineffective therapies but also added a twist: That even in self-medicating or use of alternative medicine effective remedies can can be lost due to stochasticity, in other words, due to random chance. Indeed, the authors point out that most highly efficacious innovations would be predicted to be lost due to stochasticity. Indeed, my reading of this study would suggest that one reason why highly effective treatments actually do persist in our society is because scientists, physicians, and science-based medicine validate what treatments are efficacious, retaining the treatments that are and trying (but not always succeeding) in discarding the ones that aren’t. For people self-medicating, such a mechanism is not operative.
Since were using evolutionary principles now, one might also look at CAM this way with respect to its “competitors.” Perhaps CAM is adopting an evolutionary strategy not unlike that of dogs or cats. In other words, it was subsuming itself to its more successful competitor, conventional medicine, in much the same way that ancient wolves were domesticated by humans and ultimately started to speciate into dogs. The problem with that analogy, of course, is that both human and dog gain benefits from their relationship. Humans gain companionship and work from dogs; dogs gain protection and a reliable source of food and shelter. It could be argued which species gains more, human or dog (probably humans early on and dogs now), but there is little doubt that both species benefit. So, in the relationship between CAM and conventional, who benefits?
The answer is obvious: CAM. Scientific medicine does not need CAM, but these days CAM appears to need scientific medicine. Indeed, the very name CAM was adopted to allow alternative medicine to seem more palatable to practitioners of conventional medicine and ease its ability to insinuate itself into academic medicine, which, as I’ve documented extensively, is having increasing success in doing so, even to the point of finding its way into the curriculum of various medical schools.
What this tells me is that we’re looking at a “speciation” event in alternative medicine. There is a strain of alternative medicine that fits in with the whole movement towards CAM in medical schools, and there is a strain of alternative medicine that does not. Now here’s where Martin’s idea of selective pressures favoring placeboes in alternative medicine comes in. The strain of alternative medicine that either excessively credulous or cynical academicians embrace falls under exactly the sort of selection pressure that Martin discussed that favors minimal effects. The reason is simple. The two most common justifications used for including CAM in academic medical centers are (1) the patients want it and (2) the perception among academic physicians that it won’t do any harm anyway and seems to make patients feel better. Consequently, the most common varieties of CAM in such settings are massage therapy, meditation, acupuncture, yoga, and nutrition-based therapies. Oddly enough, arguing against Martin’s idea is that seldom will you see homeopathy in academic medical centers, at least in the U.S. I speculate that that is because in such settings, there is also a negative selective pressure against extreme scientific implausibility–at least upon the initial incursion. On the other hand, perhaps it’s just an odd quirk of history, culture, or whatever that makes homeopathy use less common in the US. After all, reiki is just as ridiculous as homeopathy, if not more so (my talk this weekend prominently featured reiki, for instance), but it’s everywhere these days in academic and community medical centers.
So what term best describes the relationship between CAM and academic medicine? Certainly CAM advocates would argue that it’s a symbiotic relationship. I would counter that it’s a parasitic relationship, and here’s why. Parasitism is defined as a relationship where one organism benefits and the other is harmed. CAM is indeed parasitic. It benefits from its association with academic scientific medicine by obtaining a level of plausibility and respectability that it could never obtain on its own, while it arguably harms academic medicine in the process. True evidence-based medicine is what academic medical centers are ostensibly built to promote, applying the scientific method to medical therapies in order to find more effective treatments. What academic medical centers should be doing is to educate the new generation of physicians in the scientific method, to better prepare them to be able to evaluate claims for treatment, whether they come from conventional medicine or elsewhere. This is how medicine has advanced so rapidly over the last 60 years. Blurring the line between science and non-science, evidence-based medicine and woo, through the enthusiastic promotion of CAM in medical school curricula, harms that endeavor, both by degrading the ability of physicians to think critically (thus preparing them to accept even more implausible treatments) and by wasting money and resources to study obviously highly implausible gobbledygook before there’s any good evidence that it does anything at all beyond the placebo effect that could be better used to study more promising science-based modalities. It would be one thing if CAM were being studied from a truly scientific perspective. I don’t object to that; indeed, I encourage it. A true scientific examination of the vast majority of CAM will likely find it useless, while a few gems might be pulled out of the dirt. Unfortunately, though, as I’ve mentioned before, that’s not what usually happens. What almost invariably happens is that CAM is used as a marketing tool.
Although I often disagreed with him (mainly politics) Panda Bear, MD (whose blog seems to have been hacked and has become a spam site) gets it right in describing this parasitic relationship:
Suppose I were to actually build a house. Along with a foundation it would require framing of the walls and floors, siding, wiring, glazing, plumbing and a dozen other skilled trades coordinating their efforts. The practioners of Complementary and Alternative Medicine would be like your Aunt Mildred telling you how to hang the toilet paper in the finished bathrooms and then trying to claim credit as an essential part in the construction. Complementary and alternative medicine only exists because real medicine does all of the heavy lifting leaving a risk-free enviroment in which it may ply its patent remedies. At best it’s an afterthought, something that legitimate hospitals add to their services to attract the kook money. At worst it’s a cynical ploy to fleece a little extra from the desperate, many of whom are dying and will gladly pay for another straw to grasp. In no way is it an essential part of medical therapy except that it provides entertainment to the patients and their families while medicine and nature run their courses.
He’s not quite right, at least now. These days, CAM is like Aunt Mildred claiming that the house was built by magic.
Conventional medicine fights the real battles and faces the real danger of failure, while increasingly CAM attaches itself to conventional medicine, much as the parasitic roundworm Ascaris lumbricoide finds its way into the small intestine of its host. CAM benefits from its association, but its host, conventional medicine, most definitely does not. At best it is not harmed; at worst, grave harm to scientific medicine becomes possible.
All this speculation leads me to believe that the form of CAM that increasingly thrives in academic medical centers is indeed developing into a new “species” of woo, so to speak. It’s wraps itself in scientific-sounding terminology and, for the most part, discards the more outrageously silly religious and supernatural elements that it can, all in order to become seemingly inoffensive enough that academic physicians, although they may not approve of it, remain insufficiently sufficiently alarmed by it to rise up and purge the system of this parasite. Meanwhile, the parasite grows in number and strength, continually weakening the body of academic medicine the longer it stays. Eventually, like the roundworm, it spreads its eggs where more and more academic medical centers can pick it up until it is so entrenched and self-perpetuating that it can’t be dislodged without resulting in severe injury or death to the host.
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How to survive a night float rotation
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domingo, 23 de noviembre de 2014
A diagnosis of HIV: God had nothing to do with it
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The mystery of diagnosing Lyme disease
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I will honor my patients by hearing them out
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What will future of medicine look like? Start here.
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sábado, 22 de noviembre de 2014
Reflections after the first cadaver lab
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Medicaid is Obamacare’s sleeping giant
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The attitude when it comes to treating chronic pain
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viernes, 21 de noviembre de 2014
Innovation in cardiac surgery: When doctors worked with engineers
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Is a Google pill the only hope for cardiovascular disease detection?
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When it comes to advocacy, some doctors don’t have anything left to give
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Avoid these 4 mistakes when using a computer in the exam room
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jueves, 20 de noviembre de 2014
Why cancer still evokes fear
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miércoles, 19 de noviembre de 2014
We owe it to our patients to put on our game faces
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A ritual to recover the empathy toward bodies we care for
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Gynecologic cancer: Being a part of these women’s stories
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What does a good death mean to you?
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martes, 18 de noviembre de 2014
lunes, 17 de noviembre de 2014
The religion of emergency medicine: It’s time for a reformation
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Run your emergency department like a restaurant
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5 new rules for how doctors interact with health care IT
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Walk in the shoes of a cancer patient
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Ontario fails to protect the life of a First Nations girl with cancer
A few weeks ago, Steve Novella invited me on his podcast, The Skeptics’ Guide to the Universe, to discuss a cancer case that has been in the news for several months now. The case was about an 11 year old girl with leukemia who is a member of Canada’s largest aboriginal community. Steve wrote about this case nearly a month ago. Basically, the girl’s parents are fighting for the right to use “natural healing” on their daughter after they had stopped her chemotherapy in August because of side effects. It is a profoundly disturbing case, just as all the other cases I’ve discussed in which children’s lives are sacrificed at the altar of belief in alternative medicine, but this one has a twist that I don’t recall having dealt with before: The girl’s status as part of the First Nations. Sadly, on Friday, Ontario Court Justice Gethin Edward has ruled that the parents can let their daughter die.
The First Nations consist of various Aboriginal peoples in Canada who are neither Inuit nor Métis. There are currently more than 630 recognized First Nations governments or bands in Canada, half of which are located in Ontario and British Columbia. This girl lives in Ontario, which is basically just next door to Detroit, just across the Detroit River. Unlike previous cases of minors who refuse chemotherapy or whose parents refuse chemotherapy for them that I’ve discussed, such as Sarah Hershberger, an Amish girl whose parents were taken to court by authorities in Medina County, Ohio at the behest of Akron General Hospital, where she had been treated because they stopped her chemotherapy for lymphoblastic lymphoma in favor of “natural healing,” or Daniel Hauser, a 13-year-old boy from Minnesota with Hodgkin’s lymphoma whose parents, in particular his mother, refused chemotherapy after starting his chemotherapy and suffering side effects, there’s very little information about this girl because of Canadian privacy laws. I do not know her name. I do not know anything about her case except that she has acute lymphoblastic leukemia, that she started treatment but her parents withdrew her because of side effects.
The Song Remains the Same: Parental Rights Trump Children’s Rights to Health care
All these cases that I’ve written about over the years here and elsewhere, a depressing number that includes children such as Katie Wernecke, Abraham Cherrix, Daniel Hauser, Jeremy Fraser, Jacob Stieler, Sarah Hershberger, or others, follow a very similar script. It’s a script that on many an occasion has led me to quote Elton John sadly, “I’ve seen that movie, too.” Here’s the basic script:
- A child is diagnosed with a treatable, curable pediatric cancer. (Note that most pediatric cancers are among the most curable cancers there are. Pediatric leukemias and lymphomas, for example, have gone from a virtually zero survival rate 50 years ago to survival rates that approach 90% or even more. Truly, if there is a triumph of science based medicine, it is in pediatric cancers.)
- The child begins chemotherapy, going through part of the recommended protocol, and suffers the expected side effects.
- The parents, who quite naturally have a hard time watching their child suffer, hear about some quackery or other that promises to treat their child without the side effects of chemotherapy. If they are prone to belief in “natural healing” or alternative medicine, there is a good chance that they will stop their child’s chemotherapy and opt for the promise of the “natural healing” that promises a cure without the pain.
- Doctors, alarmed at the likelihood that the child will die, report the child to the child protective service authorities, who intervene.
- There is a court case. If the court case goes against the parents, frequently they flee with the child, as Daniel Hauser’s mother did, as did the parents of Katie Wernecke, Abraham Cherrix, and Sarah Hershberger, among others.
- At this point, one of two things happens. Either the parents are persuaded or ordered to treat their child properly (as in the case of Daniel Hauser); they come to some sort of compromise that allows the child to get some treatment plus “alternative healing” (as in the case of Abraham Cherrix); or, a depressingly common outcome, they win the “right” to let their child die through medical neglect, as has just happened with this First Nations girl with lymphoma.
- Through it all, quacks leap on these stories as examples of “fascism,” and “gunpoint medicine” in order to promote their world view of “health freedom” (otherwise known to skeptics as the freedom from pesky laws and regulations outlawing fraud and quackery), as happened in virtually all these cases, but most notably recently for the case of Sarah Hershberger.
How do these stories end? Sometimes they end with the death of the child. Sometimes the child lives (I’ll explain why a little later). Ofttimes it’s very difficult to find out what happened to the child, as I’ve found out to my frustration over the years. For instance, I have not been able to find out much about Sarah Hershberger since March, when Tracy Oppenheimer of Reason.com defended her medical neglect in the name of health freedom. (What are the deaths of some children with cancer compared to health freedom, eh?)
This First Nations case adds a different spin on the subject, but the script remains more or less the same. This time around, the parents have won the right to let their daughter die a horrible death from cancer based on aboriginal rights.
Aboriginal children now have the right to refuse life-saving medical treatment in favour of traditional healing.
The Friday ruling has nothing to do with whether aboriginal medicine works.
Family court heard unequivocally in the case of a First Nations girl refusing chemotherapy that no child has survived acute lymphoblastic leukemia without treatment.
Instead, it’s about Canada’s Constitution protecting aboriginal rights.
Ontario Court Justice Gethin Edward has now expanded those rights to include traditional healing, saying “there is no question it forms an integral part.”
“This is monumental for our people all across the country,” said Six Nations Chief Ava Hill. “This is precedent-setting for us.”
No doubt this ruling is monumental and precedent-setting, but in a very bad way. So, in other words, our neighbor to the south (at least to me in southeast Michigan, which is the only place where Canada is to the south) have declared that letting children die of cancer is an “integral” part of aboriginal identity. I am not exaggerating. The court apparently didn’t even take into account whether the “natural healing” chosen by the girl’s family works. Meanwhile, Six Nations Chief Ava Hill is exulting over the ruling, apparently unconcerned that it will result in the death of an 11 year old girl. As I’ve said many times before, a competent adult should have the right to choose any form of medicine he likes or even to choose no treatment at all, but children are different. They are not capable of understanding the implications of their decision, and this girl, at 11 years old, isn’t even in the gray area of the later teen years where an argument can sometimes be made for self-determination even though the child is a minor. They need and deserve protection from such outrageously bad choices on the part of the parents.
This case is a complete failure on the part of the province of Ontario and of Canada itself to protect the lives of its most vulnerable members, children, particularly children of a minority group. Even worse, it is an indictment of Fist Nations, which, rather than seeking to protect one of the most vulnerable members of its community, a girl with a treatable, potentially curable cancer, instead glommed onto this case as a vehicle to promote its rights vis-a-vis the Canadian government. I don’t think it was cynically done; no doubt the leaders of this particular First Nations community and Six Nations Chief Ava Hill believe in their aboriginal natural healing. On the other hand, it’s hard not to think that there was some opportunism given that the parents appear not to have even chosen to use aboriginal “natural healing” techniques.
Instead, they are using the rankest quackery, which has nothing to do with aboriginal natural medicine, administered by Brian Clement in a “massage establishment” in Florida:
A Florida health resort licensed as a “massage establishment” is treating a young Ontario First Nations girl with leukemia using cold laser therapy, Vitamin C injections and a strict raw food diet, among other therapies.
The mother of the 11-year-old girl, who can not be identified because of a publication ban, says the resort’s director, Brian Clement, who goes by the title “Dr.,” told her leukemia is “not difficult to treat.”
Another First Nations girl, Makayla Sault, was also treated at Hippocrates Health Institute in West Palm Beach and is now critically ill after a relapse of her leukemia.
Somehow, I doubt that the traditional healing methods used by First Nations people have ever included cold laser therapy or vitamin C injections. Looking at Makalaya Sault, you will see the future of this First Nations girl: Relapse. But what about Brian Clement? I’ve encountered him before this case but have never actually written about him for SBM. Let me tell you about him.
Who is Brian Clement, anyway?
In brief, he is, in my opinion, a quack. If you have any doubt, start by looking at what he is quoted as saying in this news story:
He’s been giving lectures in and around both girls’ communities in recent months, including one event attended by Makayla’s family this past May.
In a video obtained by CBC News, Clement says his institute teaches people to “heal themselves” from cancer by eating raw, organic vegetables and having a positive attitude.
“We’ve had more people reverse cancer than any institute in the history of health care,” he says.“So when McGill fails or Toronto hospital fails, they come to us. Stage four (cancer), and they reverse it.”
The mother of the girl whose identity is protected says she knew as soon as her daughter was diagnosed that she wanted to seek treatment at Hippocrates, a clinic she was familiar with through a relative, but didn’t have the money to go.
After securing financial support from family, she called Clement from the hospital waiting room on the 10th day of her daughter’s chemotherapy.
The story goes on to describe how the mother called Clement while her child was receiving chemotherapy and found how “confident” he sounded. As soon as he said he could help, the mother quit the chemotherapy for her daughter.
It’s all depressingly similar to a story I encountered about a year ago. It was the story of a young mother in Ireland who had been diagnosed with stage IV breast cancer and chosen the “alternative route.” She, like the anonymous young First Nations girl and Makayla Sault, found her way to the Hippocrates Health Institute. This young woman, Stephanie O’Halloran, was only 23 years old, an age range at which breast cancer is rare, but not unheard of. Here’s how she found out about the Hippocrates Center:
Declan said: “Ann’s sister in England heard about this treatment, which centres on a diet of raw vegetable, and she met the head of the clinic, Brian Clement, in Galway about two months ago.
“He told her he could help, but not to leave it too late.
“After the meeting we did a lot of soul searching and we prayed to the Lord.
“Stephanie is a very positive person and four weeks ago, she went to Florida where she spent 21 days starting on the programme. She came home at the weekend and is still very tired after the long flight. She feels much better.”
At the time, I had never heard of the Hippocrates Health Institute (HHI) or the doctor, Dr. Brian Clement before; so, as is my wont, I went to the source, the Hippocrates Health Institute website. It didn’t take long for me to figure out that its programs were a veritable cornucopia of nearly every quackery on the planet, including at least one I hadn’t realized that people did. Let’s just start with this list described in the HHI’s “Life Transformation Program“:
- Superior nutrition through a diet of organically-grown, enzyme-rich, raw, life-giving foods
- Detoxification
- Wheatgrass therapies, green juice, juice fasting
- Colonics, enemas, implants
- Exercise, including cardio, strength training and stretching
- Far infrared saunas, steam room
- Ozone pools, including: dead sea salt, swimming, jacuzzi and cold plunge
- Weekly massages
- Bio-energy treatments
- Med-spa & therapy services
Yes, indeed, there it is: enemas, “infrared saunas,” and all manner of other quack treatments. But what are “implants”? It turns out that wheatgrass “implants” are, in actuality, wheatgrass juice enemas:
When used as a rectal implant, reverses damage from inside the lower bowel. An implant is a small amount of juice held in the lower bowel for about 20 minutes. In the case of illness, wheatgrass implants stimulate a rapid cleansing of the lower bowel and draw out accumulations of debris.
It also seems that there’s nothing that wheatgrass can’t do. If the HHI is to be believed, wheatgrass can increase red blood cell count, decrease blood pressure, cleanse the blood, organs and GI tract of “debris,” stimulate the thyroid gland, “restore alkalinity” to the blood, “detoxify” the blood, fight tumors and neutralize toxins, and many other things. Basically, boiling it all down, I found that HHI advocates raw vegan diets, wheatgrass (as part of the aforementioned raw vegan diets), and various other forms of quackery plus exercises as a cure for, well, almost everything. I’ve often said that one undeniable indication that a clinic is a quack clinic is whether it offers a certain treatment modality? The HHI offers this treatment modality. Can you guess which one? Yes, it’s the infamous “detox” footbath known as Aqua Chi.
All you need to know about this particularly ridiculous form of “detox” quackery has been written about before. Suffice to say, the “toxins” that such footbaths supposedly remove through the feet don’t exist, and the water would change color regardless of whether a customer has her feet in the water or not. Of course, detox footbaths aren’t all. Other quackery abounds, such as intravenous vitamin therapy, cranial electrotherapy stimulation, combination infrared waves plus oxygen, acupuncture, colon hydrotherapy (apparently with or without wheatgrass) and lymphatic drainage. There’s so much there, that the über-quack Joe Mercola featured Dr. Clement on his website last year:
There’s some serious, serious quackery in this interview, a transcript of which can be found here, if you can’t stand to watch a full hour plus of this stuff. For example, there are a lot of parts where Dr. Clements says stuff like this:
Photons come down in the secondary stage, they hit the earth. They transmute into different frequencies. Those frequencies are what create the physical body or the energetic body we really are. When you and I are talking and thinking and people are listening, that’s the energetic body. The physical body that you’re sitting watching us here now, that’s created by the microbial effect in the soil, which are still the protons but recycled or re-cached protons. It’s great stuff.
It’s great stuff if you are entertained by extravagant quackery, as I am. In the context of knowing that an 11 year old First Nations girl is having her cancer treated by this quack, not so much. That’s why I stopped there, as I couldn’t take any more. Neither, apparently, could Katie Drummond, who wrote a scathing takedown of the “health program” offered at HHI, who reassures us that if you’re not into wheatgrass enemas, don’t worry about it. HHI offers them “in ‘Original’ and ‘Coffee’ varieties.” Imagine my relief. Unfortunately, that relief is rapidly eliminated by learning that HHI also offers quack modalities such as “live blood cell analysis.”
Anyway, let’s move on.
Perhaps the most unusual form of quackery offered at HHI is something called colorpuncture:
Based on modern biophysics and ancient Chinese medicine, color frequencies are applied to acupuncture points using a light pen and crystal rods. This promotes hormonal balance, detoxification, lymph flow and immune support while reducing headaches and sleeplessness. Working on cellular memory where the cause of disease resides, color puncture promotes healing from within. 50 minutes $120
All of this makes me sad. Very sad. It’s because I know that, however much I might laugh at the utter ridiculousness and lack of science behind Dr. Clement’s treatments and quackbabble, I know that patients like Stephanie O’Halloran, whose story depressed me to no end when I learned of it and depresses me even more now that I’ve followed up on her case and learned that she died a few months ago, fell for this. I know that Makayla Sault, who, unlike O’Halloran, had a highly treatable tumor, fell for this. I know that a little girl from First Nations, who also has a highly treatable tumor, is being subjected to this quackery. The only thing HHI can accomplish for any of these unfortunate cancer patients is to drain their parents’ bank accounts and drive them to seek many thousands of dollars to pay for Clement’s treatments, all while giving their parents false hope. Already, the First Nations girl’s family has paid Clement $18,000 and counting.
This is the “alternative healing” that the First Nations girl’s mother has chosen instead of effective chemotherapy. In essence, the parents and First Nations petitioned Ontario courts and Justice Gethin Edward acquiesced to letting First Nations parents have the right to let their children die through medical neglect. It might well be that Justice Edward’s ruling was legally correct and he had no real choice, but the end result will be the same: The death of a girl who otherwise would have a very good chance of living a long and productive life. Worse, his reasoning included this:
But Justice Gethin Edward of the Ontario Court of Justice suggested physicians essentially want to “impose our world view on First Nation culture.” The idea of a cancer treatment being judged on the basis of statistics that quantify patients’ five-year survival rate is “completely foreign” to aboriginal ways, he said.
“Even if we say there is not one child who has been cured of acute lymphoblastic leukemia by traditional methods, is that a reason to invoke child protection?” asked Justice Edward, noting that the girl’s mother believes she is doing what is best for her daughter.
“Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to be treated with chemotherapy and to survive for that culture to have value.”
Every parent who chooses quackery over effective medicine believes she is doing what’s best for her child. Every single one of them. The same is true of parents who thought that prayer could cure pneumonia or diabetes. That’s not a reason to deny such children protection. More disturbing, however, is Justice Edward’s last sentence, in which he seems to be shrugging his shoulders and saying, “So what if a few aboriginal children die anyway? It’s just their culture.” Or, as Steve aptly put it, using human sacrifice as a reductio ad absurdum of the judge’s argument: “Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to survive infancy without being sacrificed for that culture to have value.”
It’s understandable, given Canada’s history of riding roughshod over the wishes of First Nations families, such as the case of residential schools pointed out by Arthur Schafer, that the court would want to bend over backwards to respect the wishes of the parents. However, in doing so, Justice Edward utterly failed to take the best interests of the child into proper account.
How does this sort of thing happen?
Steve also correctly noted that the outcome of such legal battles often hinge on the reasons given by the parents for refusing chemotherapy. If, for example, they simply use medical opinions as a justification (i.e., they disagree with their doctors), the state is usually pretty quick and decisive in taking action. This is the sort of situation that ruled Daniel Hauser’s case, and ultimately Hauser underwent effective chemotherapy and lived. If, on the other hand, religion or culture is used as justification for choosing quackery over effective treatment, courts seem to be much less willing to step in and see that the child receive effective treatment. For instance, in 2009 Catherine and Herbert Schaible in the Philadelphia area to choose prayer over antibiotics for pneumonia for their first child. The child died. The Schaibles received ten years probation and had to promise, in essence, that their other children, who were not removed from their care, would receive modern medical care. In 2013, a second child, who was 8 months old at the time, died the same way. It took the second death of a child before the state actually took their children away and put htem in jail. The same dynamic came into play in the case of Sarah Hershberger, where Medina County authorities were reluctant to be too harsh because they were Amish, and their culture valued “natural healing.” Clearly, the same dynamic has led to Justice Edward’s tragic decision with respect to this First Nations girl.
Also at play is an attitude that ascribes absolute rights to parents over their children. It’s a toxic attitude that is often mixed with a general distrust of government and medical authority that fails to acknowledge that children are separate beings with their own rights aside from the rights of the parents. Those rights include the right to not to suffer from medical neglect. As has been pointed out, parents don’t have the right to kill their children; they shouldn’t have the right to let them die through medical neglect, as the parents of this First Nations child are doing.
For all my railing against the medical system, what’s really critical here is understanding why parents make these choices. Having a child with cancer is a horrible, terrifying thing to go through. Having to watch a child suffer the complications of chemotherapy with the child not understanding why it’s necessary is even harder. It’s very understandable that parents with a tendency toward believing in natural medicine or with just a distrust of medical authorities in general would be tempted by the siren song of quacks claiming that they can cure the child without all the toxic side effects of chemotherapy. In particular, it’s often hard for parents to understand why, after tumors frequently shrink away to nothing after the first couple of courses of chemotherapy, more chemotherapy is needed.
Unfortunately, for most pediatric tumors it takes a lot more than just a round or two of chemotherapy, a lesson painfully learned by pioneering pediatric oncologists back in the 1960s and 1970s. For the type of tumor that, for example, Sarah Hershberger has, lymphoblastic lymphoma, the duration of one standard treatment is two years. For chemotherapy for lymphoma, there are at least three phases. The induction phase is designed to put the patient into remission. Consolidation chemotherapy is given to patients who have gone into remission and is designed to kill off any residual cancer cells that might be present, thus increasing the chance of complete cure. Maintenance chemotherapy is the ongoing, longer term use of chemotherapy to lower the risk of recurrence after a cancer has gone into remission. It’s basically lower-dose chemotherapy given for two to three years to help keep the cancer from returning. In Sarah Hershberger’s case, her oncologist recommended chemotherapy consisting of five phases: induction (5 weeks), consolidation (seven weeks), interim maintenance (eight weeks), delayed intensification (six weeks), and maintenance (90 weeks), for a total duration of two years, three months. In this First Nations girl, who has lymphoblastic leukemia, the treatment will involve at least three phases: remission induction, consolidation/intensification, and maintenance lasting a similar amount of time.
It’s thus understandable how parents, after seeing the tumor melt away during induction chemotherapy, wonder why all this additional chemotherapy is needed. It’s quite possible that after induction chemotherapy the First Nations girl had no detectable cancer. If that’s the case, it’s the chemotherapy that she’s received thus far that almost certainly caused that result, not any quackery to which Clement has been subjecting her. If the girl is apparently tumor-free, it also means that failing to consolidation and maintenance chemotherapy greatly increases the chance that her leukemia will relapse. Worse, relapsed cancer is always harder to treat. The first shot at treating cancer is always the best shot, with the best odds of eradicating the cancer. Letting cancer relapse through incomplete treatment breeds resistant tumor cells the same way that not finishing a complete course of antibiotics contributes to the development of resistant bacteria. It’s evolution in action.
Some children will be fortunate enough to have had their cancer eliminated completely after induction and will survive to become testimonials used in support of such parents’ actions, but they are the minority. Depending on when the chemotherapy is stopped relative to the complete recommended course, most will not be so lucky. Parents also often have a view that it is the chemotherapy that is the cause of the child’s suffering, believing that if they stopped the chemotherapy the suffering would stop and, even if the child dies it would not be as bad for her as the chemotherapy. Unfortunately, death from cancer is not pretty. It’s worse than chemotherapy. Stopping chemotherapy early might relieve suffering for a while, but only at the price of an ugly death later.
Somehow, there has to be a way to get such parents to see this, to teach them the very basics of cancer biology, why chemotherapy regimens for pediatric malignancies are as long as they are, and what the consequences of not finishing chemotherapy are. Remember, the parents are almost always only interested in what they believe to be best for their child, and they are suffering in a different way as they watch their child suffer the side effects of chemotherapy. When their child is crying that she can’t take it any more, when she’s vomiting and feeling very sick due to the chemotherapy, it’s very hard for parents to see that it’s worth this pain if the tumor is already gone. They need support systems to help them deal with this. Most pediatric cancer centers provide such support, but it isn’t always enough. Again, although my memory is by no means comprehensive, since I started paying attention to these cases ten years ago, I can’t recall a single case of parents who refused chemotherapy for their child until after the child had undergone at least a couple of cycles and suffered the expected side effects. I’m sure such parents probably exist, but they must be rare, because I’ve paid a lot of attention to these sorts of cases over the years, and I can’t recall one.
Finally, when faced with parents wanting to stop chemotherapy, oncologists have to be very careful not to come across as bullying, something I suspect that they sometimes do without realizing it when hearing a parent tell them she is going to stop chemotherapy. It’s understandable that physicians and nurses would react that way. Pediatric oncologists become pediatric oncologists because they want to save the lives of children with cancer, and nurses working on pediatric oncology wards work their for the same reason. It’s understandable that they react with alarm to such pronouncements by parents and might become angry or strident. After all, the child is their patient, not the parents, and the parents have just become an obstacle to saving the child’s life. When parents threaten to stop chemotherapy, it is often a cry for help; they’re telling doctors that they can’t handle seeing their child undergo chemotherapy any more. Sensitivity is required in working with them.
None of this, however, means that, if push comes to shove and the parents can’t be moved with all the understanding and empathy in the world, the interests of the child shouldn’t come first. The interests of the child must come first, and if parents can’t be persuaded to continue treatment of a highly curable tumor, then the state has a duty to step in. It’s a duty at which Ontario and Canada have failed in the case of this First Nations girl. It’s also a duty that First Nations authorities who supported the parents in filing suit have utterly failed to uphold.
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domingo, 16 de noviembre de 2014
Palliative Care in Emergency Medicine
Earlier this year I did a sabbatical in Palliative Care. I deliberately chose to work with a purely consultative service based in a tertiary teaching hospital. They did not admit under their own bed card nor was there a hospice on site to admit to. We saw patients from all across the hospital; from outpatients to ED, from ICU to slow stream rehabilitation. My aim was to gain an understanding of Palliative Care practiced in these acute settings and take some of the principles I learned back to Emergency Medicine.
Most days in our own EDs we see patients with exacerbations of COPD. We can all picture a barrel chested man in his mid-70’s wheeled into the resuscitation bay with a nebuliser running. He is sitting bolt upright, intensely focussed on his next breath which will finish with a long expiratory wheeze just like the last. There isn’t much doubt that this is an exacerbation of his COPD just every other time he has presented. He can speak in short phrases at best, but no matter as you don’t really need to speak with him to know what to do. The medicine is easy; nebulised bronchodilators, steroids, some biPAP and perhaps some antibiotics. It worked last time so well that he got by with a few days in the respiratory HDU and didn’t need to go to ICU. So there we have it; a plan of sorts. Emergency medicine is all about disposition and he has a plan of disposal. Next patient please.
But is this really what he wants or needs? This is where it gets hard for Emergency Medicine. To fully understand a patients perspective of what they want takes time, a scarce resource in ED. The task itself made even harder by the patients being so unwell that staying alive, is at the moment, a greater focus than being understood.
In your mind you expect a good early response to treatment and that he is likely to recover from this current problem of an acute exacerbation of his chronic obstructive lung disease. You tell the respiratory team that as you neatly hand him over. With what little breath he has he makes clear though, that his biggest concern at the moment is dying, and in particular dying alone. Wanting to allay his fears you tell him he needn’t worry about that. Things will be fine.
He is still too short of breath to easily engage in a long conversation with you so you go off to speak with his two daughters. You provide the usual information about what you think is going on, how you are treating him and your expectation that he will recover from this episode. For them the major concern is that he is no longer safe to look after himself at home on discharge. They provide him with a lot of support already and are not sure what else they can do. Although they recognise his illness is serious, he has got better every time so far and it is clear there has never been a discussion about prognosis or limits of care in the future. The disconnect between what your patient is saying and thinking and what is going through the minds of his family is clear.
Nearly an hour has passed since he arrived and you reassess his progress at the bedside. biPAP seems to be having some effect on his distress but you can find little objective evidence of improvement. He continues to retain carbon dioxide, is requiring oxygen around 40% to maintain a barely acceptable saturation and his gas trapping and prolonged expiratory phase remains obvious. Holding your hand he thanks you in a few words: “You said you would help my breathing and you have”. You are frustrated that this is a disease you can’t cure, while he on the other hand is thankful that some of his acute distress is being relieved.
His admission is arranged under a Respiratory team that has strong links with the Palliative Care service. The Respiratory team recognise the trajectory that this patient is on: inevitable further declines, major issues with control of dyspnoea symptoms and a likely future precipitous decline from which he will die. They have asked the palliative care team to review him soon, even though they anticipate recovery from this episode which they are going to aggressively treat in the respiratory HDU. In their experience early Palliative Care involvement not only greatly aids in symptom control but often seems to be associated with longer life expectancy.
- Disease specific and palliative treatments can comfortably co-exist
- Palliative care isn’t just about cancer care, end-of-life care or care of the imminently dying
- Palliative care is best introduced early, not at the end of an illness
- An active palliative approach may actually prolong life while controlling symptoms at the same time
Palliative Care review your patient in ED and their first orders from are for hourly PRN midazolam 2.5mg SC and/or morphine 2.5mg SC. Your ED nurses are a little bit perturbed, even when told this is common Palliative Care prescribing. Surely benzodiazepines and opiates aren’t going to do much good for this man’s essential respiratory drive? Their order seems to be at odds with spontaneous ventilation on biPAP.
You can see that he is likely to improve from this episode but can also see that in the short-term things could go horribly wrong, whether from progressive Type II respiratory failure, severe pneumonia or a pneumothorax. The family now seem to understand the gravity of the situation but look to you for a more accurate assessment of his immediate prognosis. Your first instinct is to avoid this conversation but you recognise they have a real need to have this information as they come to terms with their father’s mortality.
Looking back through the notes you realise that this is the third time that you have treated this man in ED over the past 2 years. He has had other ED attendances in addition to those. Although he has recovered each time and ultimately been discharged home, there is an obvious trend of increasingly severe exacerbations occurring at shorter and shorter intervals. There is clearly no prospect of a cure and while he currently continues to live with his disease it is anticipated that in the future he is likely to die from it. The conversations you have had with him, his daughters and the Palliative Care team have brought this into focus for you. One day he will die of his COPD and it isn’t hard to imagine that you might be the ED clinician who has to provide care for him as he is imminently dying. As a rule you try to put a professional distance between you and your patients but it isn’t always possible. He reminds you of your own father and many of his friends. Accepting you might “lose” him even while you are actively treating him isn’t easy.
- Be self-preserving when providing palliative care. It is necessary to give yourself permission to grieve the patients you will lose
- Recognise the privilege of providing attentive and reverential care to the dying
And the last thought that I really want to finish with, one that has been the focus of Palliative Care Australia’s public advocacy campaigns and my real motivation in writing this post is that it is no longer right to avoid discussing palliative care. It is something that we all need to consider openly and honestly. It truly should be part of Emergency Medicine practice
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Communication is key between physicians and EHR programmers
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What a student learned: Medicine’s hidden curriculum
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Pathographies: Step into our patients’ lives
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sábado, 15 de noviembre de 2014
Patients: Accept your fate as a hamburger
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Ebola, the Perfect Political Pathogen
An enveloped, filamentous virus with a negative stranded RNA genome is doing the rounds in a distant part of the world. Spread by close bodily contact, this mode of transmission poses an impediment to the virus’ dissemination, in spite its high viral titres. Cultural practices and poor health infrastructure were the only allies of the virus in West Africa.
Despite its difficulty in transmitting, ebola hysteria has been blown completely beyond any rational proportion. Ebola essentially represents our fear of the unknown. An exotic unfamiliar virus that stereotypically manifests in uncontrolled bleeding and a very unpleasant way to die. To date, single cases of ebola have accidentally slipped through into the US and Australia, and as a result only a handful of people have become infected. However, the clinical outcomes couldn’t be more divergent from our fear, in the first world setting none of these secondary cases have died. The virus is realistically a non-issue, but these facts will not assuage the public’s primal fear of the unknown. Despite not claiming or realistically being able to claim as many lives as respiratory pathogens in our developed society, our lack of personal familiarity with hemorrhagic fevers drives our fears. Unfortunately, fear sells stories that audiences read, in turns this creates and confirms fears ; the cycle continues.
Fear creates opportunities for others to exploit. Electoral politics is the art of posturing and appearing strong in the face of threats. Unfortunately, our disproportionate fear of ebola has played into the hands of political opportunists. Unjustified ebola panic has given reactionary “tough on ebola” hardliners political capital to push measures that may well prove counter-productive to control efforts at home and overseas. These measures include border closures and mandatory quarantines. The simplicity of such policies is that logically, if all comply, they should work. The reality is that overly tough measures risk sacrificing the only ally of contact and case tracing, cooperation and compliance. We’re in an interconnected, international community with many means of entering and exiting countries. Sacrificing compliance risks exacerbating ebola’s spread and limits our ability to trace contacts, and that would be a public health nightmare.
The negatives of these policies do not outweigh the positives these measures provide to decision makers, votes. This is the perfect issue to politicise, proposed policies here and in the US are bandaids, measures that makes it seem you’re tackling a large concern. In this case our concern is a hard to transmit; rarely encountered disease. Because of the rarity of each event (secondary cases at home), there can be no metric to test how effective these measures would be above a baseline. This is in essence, the very epitome of a perfect political policy: one that will appear successful, but ultimately the same result would have been achieved without the intervention.
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The Holocaust: Bereavement takes a different course
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Terrifying truths about health care IT
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Fear mongering about vaccines as “racist population control” in Kenya
There are many conspiracy theories about vaccines that circulate almost continuously. Some are relatively new, but most are at least a few years ago. They all tend to fall into several defined types, such as the “CDC whistleblower” story, which posits that the “CDC knew” all these years that vaccines cause autism but covered it up, even going so far as to commit scientific fraud to do so. Of the many other myths about vaccines that stubbornly persist despite all evidence showing them not only to be untrue but to be risibly, pseudoscientifically untrue, among whose number are myths that vaccines cause autism, sudden infant death syndrome, and a syndrome that so resembles shaken baby syndrome (more correctly called abusive head trauma) that shaken baby syndrome is a misdiagnosis for vaccine injury, the antivaccine conspiracy theory that vaccines are being used for population control is one of the most persistent. In this myth, vaccines are not designed to protect populations of impoverished nations against diseases like the measles, which still kills hundreds of thousands of people a year outside of developed countries. Oh, no. Rather, according to this myth, vaccines are in fact a surreptitious instrument of population control designed to render people sterile, for whatever nefarious reasons the powers that be want to control population.
You might recall how a few years ago antivaccinationists leaped on a statement by Bill Gates that “if we do a really great job on new vaccines, health care, reproductive health services, we could lower that [population] by perhaps 10 or 15 percent.” They used it to accuse Gates of being a eugenicist and that vaccines were in actuality an instrument of global depopulation. It was a ridiculous charge of course. In context, it was clear that Gates was referring to how the expected population increase from 6.8 billion to 9 billion could be blunted by providing good health care, including reproductive care and vaccines, to impoverished people in regions where the population increases are expected to be greatest. He was clearly referring to decreasing the expected population increase by 10% or 15%, meaning that instead of going up to 9 billion the population would only increase to between 7.65 and 8.1 billion. In other words, he was referring to how good health care could decrease the expected rate of population growth, not how vaccines could be used to depopulate the world. However, because of the prevalence of the myth that vaccines are sterilizing agents intended for global depopulation, the charge that Gates is a eugenicist, as obviously off base as it is to reasonable people, resonated in the anti-science world of antivaccinationists. Similar claims, namely that there is “something” in vaccines that results in infertility and sterilization, have been unfortunately very effective in frightening people in Third World countries and have played a major role in antivaccine campaigns that have delayed the eradication of polio.
Of late, there’s been a new variant of this particularly pernicious bit of misinformation going around the usual social media sources. Naturally, the first place I saw this story was on the site of über-quack and conspiracy theorist Mike Adams, who proclaimed in his usual hyperbole-filled way vaccine Tetanus vaccines found spiked with sterilization chemical to carry out race-based genocide against Africans:
Tetanus vaccines given to millions of young women in Kenya have been confirmed by laboratories to contain a sterilization chemical that causes miscarriages, reports the Kenya Catholic Doctors Association, a pro-vaccine organization.
A whopping 2.3 million young girls and women are in the process of being given the vaccine, pushed by UNICEF and the World Health Organization.
“We sent six samples from around Kenya to laboratories in South Africa. They tested positive for the HCG antigen,” Dr. Muhame Ngare of the Mercy Medical Centre in Nairobi told LifeSiteNews. “They were all laced with HCG.”
Another such story, by Celeste McGovern (who, if you look at her articles, is obviously very antivaccine) at the ever-quacky GreenMedInfo site entitled Vaccine Conspiracy or Racist Population Control Campaign: The Kenyan Tetanus Shot:
When Catholic bishops in Kenya issued a press release last month questioning their government’s internationally-funded tetanus vaccine campaign directed at women and girls and warned that it might be laced with an experimental contraceptive that makes them miscarry their babies, it was barely mentioned by the mainstream media outside of Kenya. The BBC carried a brief story that dismissed the allegations as “unfounded” and suggested that even raising such questions was dangerous as it could frighten people from a “safe and certified” lifesaving vaccine.
Elsewhere, the John Rappaport has also flogged this nonsense in a story called Depopulation vaccine in Kenya and beyond:
“Dr. Ngare, spokesman for the Kenya Catholic Doctors Association, stated in a bulletin released November 4, “This proved right our worst fears; that this WHO campaign is not about eradicating neonatal tetanus but a well-coordinated forceful population control mass sterilization exercise using a proven fertility regulating vaccine. This evidence was presented to the Ministry of Health before the third round of immunization but was ignored.”
(“Mass Sterilization: Kenyan Doctors Find Anti-Fertility Agent in UN Tetanus Vaccine,” November 8, 2014, by Steve Weatherbe, earth-heal.com)
You have to understand that every promoted so-called “pandemic” is an extended sales pitch for vaccines.
And not just a vaccine against the “killer germ” of the moment. We’re talking about a psyop to condition the population to vaccines in general.
There is much available literature on vaccines used for depopulation experiments. The research is ongoing. Undoubtedly, we only know a fraction of what is happening behind closed laboratory doors.
This story has been popping up all over the usual antivaccine social media sites. From here in the comfortable confines of our First World nations, it’s mainly a curiosity, something that gets the antivaccine contingent here riled up, but in Kenya and other Third World countries, where neonatal tetanus is a real concern, this myth has been popping up since the 1990s, causing great harm to vaccine programs.
So here is the basic outline of the myth that is going around this time. A group known as the Kenya Catholic Doctors Association (KCDA) has claimed to have tested several vials of tetanus vaccine. Why did the KCDA test these vaccines? Who knows? Actually, for some reason, due to the persistence of the common myth that vaccines are being used for sterilization and depopulation, this group of doctors apparently felt obligated to test this vaccine. In actuality, the KCDA is an arm of the Kenyan Catholic Church, created less than a year ago by John Cardinal Njue, Chairman of the the Kenya Conference of Catholic Bishops, for this purpose outlined in a speech by Cardinal Njue dated Christmas Eve, 2013:
The Sanctity of Life and its fundamental principle, .Life begins at the Conception and ends with natural death‚ are under threat from worldly forces devoid of faith.
The Catholic Church calls upon her faithful and all people of good will to appreciate the gift of life and safeguard it from the moment of conception to natural death. The Catholic Church will therefore continue to urge its Professionals especially in the medical and health care areas to be vigilant and to stand up for the moral principles and standards, as willed by God and promoted by the One, Holy, Catholic and Apostolic Church, The perfect teacher in matters of Faith and morals
Which leads Njue to proclaim:
It is therefore a good reason to celebrate as we Launch such an Association, the Kenya Catholic Doctors Association, bringing together Catholic Doctors to enable them walk the journey of faith in their profession and in Communion with each other and the Church. The Church in the Spirit of Christ invites all the Catholic Doctors to find in this Association, an opportunity to live the invitation of Christ.
And finally:
Dear Catholic Doctors, allow yourselves to be enlightened by the Gospel so that your eyes of faith may penetrate the misleading attraction of the World that proclaims anti-life principles and courageously stand and be counted.
In other words, the Kenya Catholic Doctors Association is a recently formed, wholly owned subsidiary of the Catholic Church in Kenya, to which doctors have been recruited to uphold Catholic teachings in medicine, particularly with respect to reproductive health. No wonder the Kenyan Catholic bishops and the KCDA are working so closely together on this!
Before you can understand the why the claim that hCG is in the tetanus vaccine would produce fear that the vaccine is in reality a sterilization agent, you need to know about a previous experimental vaccine. hCG is what is commonly referred to as the “pregnancy hormone.” Pregnancy tests are based on detecting hCG, which can first be detected about 11 days after conception and whose levels rise rapidly thereafter, peaking in the first 8-11 weeks of pregnancy. In the past, attempts have been made to produce a vaccine that targets hCG and thus results in the inability to conceive a child. It is a technique that falls under the category of immunocontraception. It takes little more than a quick trip to Wikipedia (among other sources) to learn that as far back as the 1970s, hCG was conjugated to tetanus toxoid in order to make a vaccine against hCG, because hCG itself did not provoke enough of an immune response. It’s not necessary to know all the details and history. From the 1970s on, there have been clinical trials of such vaccine contraceptives using hCG, and it is possible to prevent pregnancy by this approach, although antibody response against hCG declines with time.
This brings us back to the claims being made, described in an editorial by Dr. Wahome Ngare for the KCDA that appeared in Kenya Today. According to this article, the WHO had embarked on a vaccination program against tetanus that somehow had aroused the ire and suspicion of the Catholic Church because it was aimed at girls and women. The reason, of course, is because in Kenya there is a high risk of acquiring tetanus during childbirth, but the Catholic Church saw more nefarious motives:
Our concern and the subject of this discussion is the WHO/UNICEF sponsored tetanus immunization campaign launched last year in October ostensibly to eradicate neonatal tetanus. It is targeted at girls and women between the ages of 14 – 49 (child bearing age) and in 60 specific districts spread all around the country. The tetanus vaccine being used in this campaign has been imported into the country specifically for this purpose and bears a different batch number from the regular TT. So far, 3 doses have been given – the first in October 2013, the second in March 2014 and the third in October 2014. It is highly possible that there are two more doses to go.
Unlike other mass vaccination exercise, this particular WHO/UNICEF organized and sponsored tetanus vaccination campaign was launched at the New Stanley Hotel in Nairobi which is extremely unusual for a public campaign. For this reason, many people, including health professional did not know about the campaign until the matter was addressed by the Catholic Bishops.
Of course, the reason the vaccination campaign is targeted at women of reproductive age is because its primary purpose is to prevent neonatal tetanus. Targeting women of reproductive age leads to immunity in these women and the prevention of tetanus in their newborn babies. As the WHO stated in its response, these campaigns are very much targeted to districts where the highest incidence of neonatal tetanus has been observed. None of this stopped the KCDA:
With the help of Catholic faithful’s who put their own lives at risk, the Kenya Catholic Doctors Association managed to access the tetanus vaccine used during the WHO/UNICEF immunization campaign in March 2014 and subjected them to testing. The unfortunate truth is that the vaccine was laced with HCG just like the one used in the South American cases! Further, none of the girls and women given the vaccination were informed of its contraceptive effect.
This proved right our worst fears; that this WHO/UNICEF campaign is not about eradicating neonatal tetanus but is a well-coordinated, forceful, population control, mass sterilization exercise using a proven fertility regulating vaccine.
None of these charges are new. This is a conspiracy theory that’s been around at least since the 1990s and appeared in nations such as Mexico, Tanzania, Nicaragua, and the Philippines. No evidence of mass-sterilization was ever found, but these rumors did adversely impact vaccination programs in those countries.
It also sounds like an awful lot of cloak and dagger on the part of the KCDA just to get their hands on some tetanus vaccine. Much is made of the reluctance of WHO/UNICEF to provide the Catholic Church with vials of vaccine to test, but given the unreliability and dissembling demonstrated by the KCDA, it’s hard to imagine why the WHO would not want to provide vials of vaccine for them to test. Moreover, every vial wasted in this process would be one less potentially life-saving vial that could be administered to a Kenyan woman to prevent neonatal tetanus in her baby. In any case, somehow the KCDA obtained vials to test. It’s not clear how they got them or even whether they actually did get them, but they claim to have obtained six vials. The test they subjected them to appears to be the same test used to measure hCG in blood samples for pregnancy tests. If one takes Dr. Ngare’s story at face value, it sure sounds damning. The Kenyan government is even launching an investigation.
There’s just one problem.
The WHO has investigated already and found nothing wrong. Ngare’s claims are, to put it bluntly, completely without merit. As it pointed out:
There is a situation where ant- β-HCG antibodies can be produced by the body and that can act as a contraceptive, however, this requires the administration of at-least 100 to 500 micrograms of HCG bound to tetanus vaccine (about 11,904,000
1 World to 59,520,000 mIU/ml of the same hormone where currently less than 1 mIU-ml has been reported from the lab results.
As UNICEF also points out, there is no laboratory in Kenya capable of accurately making these sorts of measurements on non-human samples (such as vaccines):
The tests were done in hospital laboratories in Kenya. The staff in these laboratories could not however tell whether the samples were vaccines or not, as this was not declared to the testing laboratories by the Catholic Doctors Association. The laboratories tested the samples for hCG using analyzers used for testing human samples like blood and urine for pregnancy. There is no laboratory in Kenya with the capacity to test non-human samples like vaccine for hCG.
It’s also been noted that these values might have been the results of a reaction between the preservatives in a standard tetanus toxoid vaccine and a serum/urine HCG test kit. They are too low to be considered a significant threat when compared to the millions of times. Also, the vaccine in which hCG was linked to the tetanus toxoid is 20 years out of date. Indeed, in an e-mail interview, the original scientist who developed the hCG-tetanus toxoid vaccine even said that a different carrier, LTB, has been used, to avoid the very misinformation that has been associated with the valuable tetanus vaccination. Also, as the WHO and others responding to this rumor have noted, contraceptive vaccines based on hCG don’t last very long. Antibody titers against hCG decline rapidly after around three months.
In other words, there’s no evidence to support the claims of the KCDA, and they aren’t even plausible, given what is known about the history of vaccines using hCG coupled to tetanus toxoid. Quite simply, such vaccine linking hCG to tetanus toxin are basically history, long abandoned. They didn’t even work very well as long term contraceptive, with their effect fading after three months, much less as permanent inducers of sterility. The Catholic Church and the Kenya Catholic Doctors Association are thus engaging in fear mongering. They might believe they are doing good, but they are engaging in activity that could very well lead to the preventable deaths of Kenyan babies, as young women are frightened away from receiving the tetanus vaccine by their rhetoric and highly dubious laboratory results.
None of this, of course, has stopped Mike Adams from proclaiming this “vaccination genocide and “medical crimes against humanity”:
What is happening in Kenya is a crime against humanity, and it is a crime committed with deliberate racial discrimination. Normally, the liberal media in the United States would be all over a story involving racial discrimination and genocide — or even a single police shooting of a black teenager — but because this genocide is being committed with vaccines, the entire mainstream media excuses it. Apparently, medical crimes against black people are perfectly acceptable to the liberal media as long as vaccines are used as the weapon.
As this story clearly demonstrates, “vaccine violence” is very real in our world.
No, what this story clearly demonstrates is how utterly out of touch with reality many of the people making these claims in the US are. If you doubt me, just take a look at some of Adams’ other claims, namely that there are five vectors for what he calls the “science-based genocidal assault on humanity”:
- Vaccines
- Viruses
- Food
- Water
- Chemtrails (i.e. atmospheric deployment of chemicals)
Chemtrails? Yes, chemtrails. If you want any further evidence of just how far gone the cranks who argue that the tetanus vaccination program in Kenya is a racist depopulation program, look no further.
Lest you think that this obsession over vaccination as a cause of infertility is limited to Kenya and other Third World countries, consider this. The very same theme frequently appears in antivaccine rants against Gardasil, which has been blamed without evidence for premature ovarian failure. Another favorite antivaccine trope is that polysorbate-80, which is used in some vaccines, causes infertility. Yes, we in the “advanced” First World nations are nearly as prone to falling for this sort of misinformation as Kenyans. Never forget that.
Also, never forget just how far antivaccine activists like Mike Adams and John Rappaport will go to demonize the object of their hatred: Vaccines.
via Medicine Joint Channels