Sunday, May 12, 2019

Measles Update

I'm interrupting my series on herbal and nutritional medicine to update my audience on the measles outbreak. Now the Centers for Disease Control reports 764 cases in 22 states.
How this compares to recent years...
And, writing this on a Sunday morning, I just heard that NPR's Hidden Brain will be running an episode on how we know what's "true", one story featuring a woman who was an "anti-vaxxer" and now has come around to the view that vaccines are important and that they work. In Washington State, New York City, and elsewhere health authorities and legislatures are tightening restrictions on both public-space access for the unvaccinated and exemptions to vaccination.

Interestingly--and despite the warning that measles is "deadly" and causes "severe complications"--the CDC reports that no deaths or encephalitis cases have been filed from any location in the U.S. There were 66 hospitalizations, and these include 3 cases of pneumonia. 71% of cases through April 2019 were in unvaccinated persons. 25% were in infants too young to be immunized with the MMR vaccine. And another 24% were too young to have been fully immunized (2 doses) at age 4. The remaining 51% were distributed among adolescents and adults.

One way to look at this is that 628 people who were unvaccinated or whose immunity status was unknown are now immunized against measles. Another interesting conclusion is that 11 cases of measles were in people who were fully immunized, much smaller than the number suggested by published reports of 98-99% long term protection in those who are immunized (that's good, right?). CDC data also suggest that the peak of this outbreak was in the 3rd week of March; by the end of April, measles had dropped to about 11 new cases nationwide. This is consistent with how most infectious disease outbreaks trend. Eventually, the epidemic fades.

I've written before (1, 2, 3, others) about what I believe are the real issues in the "vaccine controversy" or "vaccine debate" or whatever you want to call it, so I won't repeat all that here. But I thought that under the circumstances it might be a useful time to share snapshot of the reality of the current episode.

This outbreak is being sold as a failure. It's a failure of parents who don't "believe" in the science. It's a failure of doctors and nurses to sufficiently coerce parents into getting their kids immunized. It's a failure of state governments to restrict vaccine exemptions to only the most extreme circumstances (like an actual medical allergy). It's a failure of our society to "get on board" with this public health measure.

I think it is a failure too. For me it's a failure of our society to have a more effective conversation about health, disease, and health care. For anti-vaxxers whose kids just got over the measles without anything catastrophic happening, it just confirms what they already believed: measles isn't a very bad disease, and their kids turned out okay without the use of measles immunization. This news will spread throughout social media and further serve to undermine the messages of public health authorities, nurses, and doctors who promote immunization.

Stalemate.

What won't be discussed is that the reason this outbreak--so far--hasn't caused a wave of medical calamity (deaths, brain damage), is that this isn't a very serious disease. Older doctors who report how "devastating" measles was in the past, causing deafness, mental retardation, and of course death, don't address how much different public health and medical care were 40 or 50 years ago. That measles tends to cause complications in the poor, the undernourished, is not discussed. I have stated before that poverty, nutrition, safety, and hygiene are known to be key reasons for health problems and deaths that can occur from even simple illnesses like the flu, measles, or infant diarrhea.

This allows us to ignore the disparities in society. We can turn our sights away from systemic, societal problems--like racism, poverty, and hunger--and attribute disease outbreaks to stubborn parents who refuse to follow along in the hymnal like the rest of us righteous folk.

From NPR and ABC
Recently, I saw this report on how actress Maureen McCormick and other former cast members of The Brady Bunch are upset that the episode "Is There a Doctor in the House?" is being viewed by people who avoid vaccinating their kids as confirmation of the non-seriousness of measles. In that episode, the kids get the measles, and home-bound hijinks ensue (cue laugh track).

Interesting too is the story's report on how Merck Co. helped to shift the public's perception of the mildness of measles through educational campaigns like "Mission: Measles--The Story of a Vaccine." Of course, this was good for Merck. More immunizations = more dollars; witness this story from the New York Times about ever-higher vaccine costs.

I remember this episode of The Brady Bunch (we were a family of eight too, so we saw ourselves in that show), and although it can be argued that in the 1960s, there were worse diseases that did make measles seem less serious (smallpox, polio), maybe the impulse to make all diseases seem serious--no matter how little their real risk--does society a disservice. Maybe it distracts us from what we ought to be paying attention to, from what social and political policies really need to be changed.

And with that, I wish you all good health!

Monday, May 6, 2019

Herbs and Nutritionals Series: Allergies

The University's local Commencement was Saturday. As the graduates commence their journey forward, I commence with summer break. I'll start with some writing. Recently I promised a series on herbal medicines, so I'll start there.

Spring brings with it high pollen counts and if you are sensitive to it, it can be pretty miserable. I suffered from allergies (in the fall) for years, but no longer. I find the best treatment for allergies is a carefully-selected homeopathic remedy. If you're not quite there though, or still in the need-for-support stage, here are some things that can help. Caveat: This piece is educational and is no substitute for personalized medical advice.

Vitamin C
In high doses this vitamin is anti-inflammatory. "High" means several thousand milligrams a day. I learned that naturopaths prescribe this "to bowel tolerance" meaning you keep upping the dose until the bowels become a bit loose. However I find that 3,000-6,000 mg per day is often helpful. I tell patients to take it in "divided doses"--meaning one spreads that out over the course of the day, for example 1,000 mg three times a day. 

Quercetin
This is a naturally-occurring nutrient found in grapes, cherries, berries, kale, tomatoes, and broccoli, among others. Quercetin is a component of cell-walls, and having a diet with enough of this nutrient ensures that cell walls have all they need. The thinking is that strong cell walls means that they're less likely to break. "Mast cells" are in the body to protect against certain kinds of infections. When organisms try to get into the body, mast cells break open to release histamine which brings white blood cells to the area. Some studies have found that taking quercetin reduces the "breakability" of mast cells just enough to reduce histamine release. You can get this from foods or from supplements. The latter will often be compounded with plant-based digestive enzymes like bromelain or papain to help the quercetin be absorbed.

Image result for neti potNasal Lavage ("neti pot")
This is a nice, "nursey" hygiene measure. The neti pot is a specially-designed pot so the user can washout the nasal passages.
 It's been in use for thousands of years, and can wash away the inhaled pollen and collected mucus that leads to symptoms. There's lots of stuff on the internet one can look up for the details, but I always emphasize with my patients that the pot should be cleaned with hot water with each use, to reduce the risk of sinus infection. The washing solution is salt water, and there are premixed solutions available, or a person can make their own. I also emphasize lukewarm water! Very hot or cold water can cause problems. Saline nasal sprays are a less messy means to achieve the same "wash out", but may not be as effective.

Image result for stinging nettlesStinging Nettles (Urtica dioica)
This is a plant that actually suppresses T-cell function, which is one of the main causes of allergies. Without getting into too many details, T-cells are a type of cell that "memorizes" allergy and initiates the reaction that pops mast cells. 

One has to be a little careful with this one for two reasons. First, the plant must be picked and processed at a certain part of its life cycle to avoid the "cystoliths"--tiny hard bits of calcium carbonate--that are said to cause kidney and liver damage. Some sources dispute this, but it isn't hard to stick to young plants that are pretty much cystolith-free, so why take the chance? For my patients, I always recommend verified professional-quality nettles.

Second--and this is not in dispute--is that this stuff actually works to get at the source of allergy symptoms. T-cell suppression isn't as strong as some of the drugs that also do this (as in drugs for autoimmune diseases), but I have observed that when used for too long, sometimes the user will actually catch a cold! So for my patients, I tell them to limit daily use to only a couple of weeks at a time.

That's it for now. Look for a few more highlights of various herbs and nutritionals in this series.

Sunday, March 24, 2019

A Wave From the Fast Lane

This is one of my busiest times of the year, but I felt the need to reach out and just let all of you know I'm still here. We're coming to the last month of the semester, spring yard work season has just begun, and there's a lot going on. So here's a few things going on in science and medicine--just to keep you in the loop.

The Cannabis Debate Heats Up

In just a few short months since Governor Wolf's re-election, when he said recreational weed was off the agenda for the moment, to now, where Lt. Governor Fetterman has undertaken a "listening tour" to get a real sense of how Pennsylvanians come down on this matter, the debate has resisted being put "on hold."

Intuitively, a lot of us cleave to the notion that adding more intoxicating substances to the social mix just has to be a bad idea. Others of us choose a more libertarian way: let grown-ups do whatever they want, as long as it's properly regulated for the sake of the safety of the general public. What one thinks is one's personal view and is formed from any number of influences, including one's own experiences and reflections, as well as the resulting personal politics and spirituality.

But there's also a scientific debate and it's broader than just medical science, and includes criminal justice, sociology, psychology, economics, and political science. That's all over the place right now! One example currently flooding the internet is the link between schizophrenia and marijuana use. I'm seeing a lot of this on Facebook right now. I addressed this in great detail in my previous blog entry, so I won't do so further here. I will place this debate in the framework of a new debate that's emerged this week.

What is Science, Really?

The new debate is around the real meaning of positive or, by extension, negative results in scientific studies. In a piece published last week in Nature Valentin Amrhein and colleagues--as well as over 800 other scientists--argue that it's time to retire the concept of statistical significance. A discussion of this concept is nicely done in this article in Vox, so I won't get deeply into it here. But a very short version of the whole thing is that the culture of science has grown dependent on this very complicated and subtle concept. They argue that statistical significance has led us to many unsupported conclusions, conflicting study results that perplex the public, and a false dichotomy that suggests that a thing either "works" or it doesn't, that a thing is "there" or "not there."

I see this in my office when people come in and say something like "Last year medical science said that a little red wine is good for my heart. But last week I heard that it's bad for your heart. Which is it?" This is often followed by either throwing up of the hands as if to say "I give up!" or by a kind of defeated reconciliation that "nobody really knows what's true, so why should I care?"

Having taught research methods for many years, I can say that I heartily agree with Amrhein's group: there's too little nuance in interpreting scientific results, but good news bites require that nuance be tossed out the window. Click bait has no time for Deep Thought.

I find that one of the most useful services I provide for my patients, and my students, is to help them understand how to sort this all out. I'm not sure how this change of heart will play out over the next decade, but I like the direction we're heading. Science isn't a destination; it's a journey.

The Complicated Fabric of Science and Society

So there's other science-y stuff in the news: genetically engineered babies in a Chinese research lab, new data about daily aspirin use in people who have never had a heart attack or stroke, climate change and whether or not we should pursue or abandon nuclear power...as well as the whole medical/recreational marijuana thing. We are interested in science for its own sake, just the sheer beauty of understanding our world. We are interested in it because it leads to technologies that can improve our lives. And of course we are interested in it because it helps us make public policy.

It's on this last point that I'd like to emphasize that in policy matters, people have opinions that are wholly personal, religious, or aesthetic. A technocracy is governance based purely on objectively good science with a utilitarian aim. Alternatively such a government might serve an agreed-to philosophical or political good. Historian Loren R. Graham reported that nearly 90% of Soviet Politburo members were engineers--science in the service of a communist ideal was their aim.

While much of the world doesn't operate with technocratic governance, science is still used to tell us things about how fossil fuel use affects our climate, how vaccines affect public health, what sorts of medicine are effective for what uses, how to grow food, how markets work, and so on. It is what's in our hearts that determines how science is then used to inform what actions we take as a society. It is important to note that knowledge is constantly evolving. We learn new things. We develop better methods of "knowing" the truth of the world we live in. All the while, our hearts moderate the incoming information, and color our opinions of it with our personal views.

Knowing that's the case, and explicitly acknowledging that in any conversation about objective scientific information, could really improve our public discourse. And knowing that what we know now is only the best estimation of the objective truth right now, might remind us to reserve a little skepticism about what the future might hold.

Peace...and happy springtime!
Image: G. Hodan in public domain search

Sunday, February 3, 2019

Legal Marijuana--Is this a good idea?

My dad sent me an article from a little magazine, Imprimus, a publication of Hillsdale College, a private liberal-arts college in Michigan. I've linked its Wikipedia entry here, but I'll summarize two points here: first, that it's a true liberal arts college, with a curriculum based on the so-called "Great Books" of Western civilization (Ref 1), and second it has "worked to establish ties to the conservative political establishment" (Politico, cited in Ref 2). This latter fact alone doesn't negate arguments Hillsdale publishes, but it provides context.

The writer is a journalist, formerly of the New York Times, and more recently an author of spy and corporate thrillers. The article is from a speech he gave at Hillsdale this year.

In it he shares how he shares what he learned from his wife, a psychiatrist who formerly worked with severe mental illness among incarcerated inmates at a hospital for the criminally insane in New York. In a discussion, she off-handedly notes that all of the inmates smoke marijuana, and the conclusion to be inferred was that marijuana use led to their insanity. 

The author--a libertarian who admits that he was generally pro-legalization of drugs--investigated and came to the conclusion that marijuana use causes violence, and a lot of it, and he implies that the "elite media" (whatever that is) conspires to keep this fact out of the news, and further, that legalization moves us toward a more violent society. It's a pretty nicely written piece.

Except that like a lot of opinion pieces about cannabis, it cherry-picks data and draws unsupported conclusions from available research. So what's really the case?

Marijuana and Schizophrenia

As early as 1977 a scientific review by Ernest Abel published in the APA's Psychological Bulletin found that while the majority of people using cannabis are not prone to violence, a few susceptible individuals, and subject to certain situations of set and setting (Ref 3), marijuana use may result in violence. More recently a number of studies have found a correlation between marijuana use and schizophrenia, a condition in which people's brains falter, leading to psychosis. Psychosis includes hearing voices, hallucinations, and disturbances of thought that can include paranoia, altered perception of reality, and catatonia. It's a pretty serious psychiatric illness, and in some it does lead to violence, either reactive violence (acting out when feeling threatened) or proactive violence (homicide, suicide).

More recently there have been a number of studies that confirm an association but not a causation between marijuana use and schizophrenia. That is, yes, it does seem people with this illness use marijuana more, but does that cause the problem, or is it merely part of a multi-factor stage upon which this problem is built? Some researchers admit that those with schizophrenia may be using marijuana to self-medicate. Others note that the complex factors that can precipitate schizophrenia are simply also associated with marijuana availability and use. An example would be a poor person from a violent neighborhood where drugs are plentiful: Did the plentiful marijuana cause the disease, or was it caused by the surrounding violence and resulting fear, or is it a combination of several factors, including a local lack of mental health services?

A more recent article in Scandinavian Journal of Public Health found that for every 10% increase in cannabis use, they can project a 0.4% increase in violence. That's not the disease schizophrenia, but hey, we're probably all on the same page and agree that more violence in society is undesirable. On this argument, maintaining marijuana's status as illegal makes sense. 

But What Is It Really?

Is this all the just the interaction of a chemical--or chemicals--in marijuana causing a direct and predictable violence reaction in all humans? 

I'll begin by saying the author of the Imprimus article, Alex Berenson, is not equipped by background or education to decode scientific studies. That doesn't mean he can't read them and begin to draw some conclusions, but to be fair he should be more sensitive to his own level of training in this before drawing what end up being pretty dire conclusions. His wife, a physician, should know better, but as a clinician myself who has dealt with many people using drugs and also having mental illness, I'll admit that--in the trenches--it's easy to start seeing the whole world in one color.

Next, I'll note that almost all of the sound research out there on this freely admits that there's a lot we don't know. One example pertinent to this topic is a 2018 study in Molecular Psychiatry that demonstrated a link between variants in the serotonin 2B receptor gene and risk for psychotic reactions to THC, the psychoactive chemical in marijuana that gets people high.

I teach a class on drugs and drug abuse at Penn State, and one of the things I try to get across to my students is that yes, drugs have predictable effects, but only to a point. Some people will experience untoward effects, unpleasant symptoms, or even permanent damage from certain drugs. In my pharmacology class, I teach my students that pharmacogenetics--the science of studying genetic variations in how people respond to drugs--is still a very young science, but one that will certainly influence their future careers as nurses.

I use pharmacogenetic testing in my practice now, but there's still a lack of consensus on when and how it should be used. Indeed the vast majority of our allopathic drug prescriptions are written on the basis of a vague faith that most patients will respond as predicted. Only a handful of drugs in US have genetic testing routines that guide what we will prescribe, and the fastest-growing class of drugs in which this testing has been studied is among cancer treatment drugs.

Then Why Is Marijuana Legalization Expanding?

THC is a chemical very similar to the neurotransmitter anandamide, which is naturally occurring in humans, and bonds to special receptors in the brain--cannabis receptors! (CB1 and CB2) "Anandamide" comes from the Sanskrit word for bliss. People use cannabis because it makes them feel good, blissful, happy, whatever. Roughly a hundred years of tightening restrictions on all psychoactive drugs, marijuana included, have not led to significant declines in drug use or the criminality that defines its black market. I show my class a couple of diagrams, based on the science, of drug use harms. 
From: w:de:Benutzer:Dosenfant [Public domain], via Wikimedia Commons

From: Pmillerrhodes [Public domain], from Wikimedia Commons
As one can see from the above diagrams, none of these drugs is harmless, and none comes without some risks to society, but there is a definable scale of harms. Interestingly, caffeine, the most widely used drug on the planet (Starbucks, anyone?) isn't listed in either diagram, but does cause dependence and in some people causes physical symptoms, and rarely actual danger (mostly cardiac).

Marijuana legalization is expanding for several reasons.
  • It's fun, and people--voters--like to have fun. But this is nothing without the second reason.
  • It's not harmless, but demonstrably less harmful than other, legal, drugs in ours and other cultures.
  • It's not especially deadly--in fact no case of direct fatal overdose from cannabis alone has been reported. (This may change with novel delivery systems, and increasing cannabis potency.)
  • And as I tell my students: "Don't tell people drugs will kill them. If they try a drug, and it doesn't kill them, then they'll just think you're a propagandist and liar." Marijuana simply didn't live up to it's hype as "deadly" and "a gateway" to other drug use. 
  • And of course, there's the money. I put this last because for a long time, the money was there. It's why there was a multibillion dollar black market in cannabis. If the other reasons didn't obtain, we wouldn't be having this conversation.
In the textbook I use to teach my "Drugs of Abuse" course, the authors propose a theory of holistic self-awareness, which argues that the best way to be in the world is drug free, open and tuned in to all the sensations, thoughts, and experiences the world has to offer. I think this is an admirable argument, but ignores the tremendous variety in human bodies, human experience, and human potential. It is an ascetic argument. That's valid on its face, but only if one accepts it as so. It does not logically follow that it must be the only way to exist in the world.

I try to get my students to understand that the use of mind-altering drugs is very personal. I also try to help them understand that regulating a society is more complicated than simply saying "drugs are bad" or by arguing that all drugs are equally harmful, or that even the small harms from some drugs outweigh the benefits of particular drugs to some people. 

There is commonsense regulation available. Young brains are more adversely affected by cannabis than older brains. Driving while intoxicated is hazardous. And some people using drugs might benefit more if we redesigned our health care system such that people didn't feel compelled to self-medicate. Would a legal market improve the drugs we use (a wider variety of marijuana potencies, rather than the only very potent stuff on the black market now)? Could regulation and product testing improve safety?

As I tell my students, all mental health drugs can cause weird, unpredictable reactions in some patients. If they didn't, medical psychiatry would be way better than it is now. All mental health drugs come with a downside--which is why some people stop taking them (sometimes with tragic results!) but we don't outlaw those drugs. In a similar vein, why must we treat all, currently-illegal, mind-altering drugs with the same level of fear, disdain, and criminal sanction? 

Recreational marijuana is coming now. Almost a century of restriction is one cause of our relative lack of good, impartial data about how now-illegal drugs can be harmful and helpful. A century of political coddling and regulatory exclusivity given to the pharmaceutical industry has come with its own disappointments. I look forward to the new age of openness and hope that we can have a productive conversation about how to balance personal freedom and social safety, how to balance the possibilities in psychopharmacology and ethical regulation. 

Now go out and enjoy this glorious(ly not too freezing) day!
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Reference 1: "Great Books", at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Great_books.
Reference 2: "Hillsdale College" , at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Hillsdale_College.
Reference 3: "Set" is the mental state the user is in at the time of drug use. "Setting" is where and when the drug is used. Example: A person using cannabis to calm down before a stressful event has the mental set "This will calm me down" in the setting "before my stressful event." I'm not stating whether this is healthy or not, but as a way to understand the way mind-altering drugs work.


Sunday, January 13, 2019

Ethics & Medicine: A Philosophy Lesson

Ok, the title sounds a little pedantic, but the lesson doesn't have to be. Anyway, thanks to all who follow this, for your patience while I've been taking care of some business during the holiday break. The semester just began, so I'm back!

Photo credit CDC/Judy Schmidt
The inspiration here is an article I read online back around Thanksgiving Update on the Ethics of Mandating HPV [human papilloma virus] Vaccination. HPV is a virus that comes in many strains, and a few strains can increase risk for cervical cancer. Women, especially, will appreciate it as a concern that has driven regular check-ups--"Pap tests"--over their adult lives. Catching the cancerous changes early has a 100% cure rate, and numerous studies over the decades showed that regular Pap tests reduced the rate of cervical cancer to a rarity. HPV vaccines were introduced in 2006, and public health experts pronounced that this was "the first vaccine that prevents cancer" and that it should be used throughout the population.

In the following 12+ years there have been arguments pro and con. I shared the former above. The con arguments ran to these...

  • Use of the vaccine would lead young people to conclude that sexual activity outside of marriage is ok.
  • The vaccine probably had hidden dangers that would not be known for years "and my kid's not going to be a guinea pig!"
  • Big Pharma was making up reasons to sell us more pharmaceuticals.
  • The vaccine was too expensive.
  • Once again we're targeting women's sexuality for "treatment"--a feminist argument.
...and so on. Use of the vaccine languished for a number of years. Some state legislatures tried to mandate that HPV vaccine be included in the required immunizations for attendance at public school. That didn't always go over well with parents who were also voters. Since then, the Centers for Disease Control report that immunization rates have increased. There's more acceptance of it, and its use has been expanded to include boys. (After all, girls have to get the virus from somewhere!) 

From Merck, Inc.
Advertising helped. Check out this ad from Merck in which adorable young people ask their parents if they knew about this vaccine that can "prevent...cancers". I mean, what parent wouldn't feel guilty about not paying whatever it costs to immunize their kid against cancer? (In fairness: many insurance companies now cover the cost of HPV vaccination.) But this article is about the ethics of medical technology and medical decision-making, so let's go there next.

Ethical Theory

Our sense of right and wrong is governed by two things: ethics and morals. Morality is a personal framework for the determination of right and wrong, and guides us in how we should act in society. It may include our religious or spiritual beliefs, and so its application may be limited by some circumstances. For example, some Christians believe that God rules against abortion, and so for those folks, abortion is wrong. Someone who doesn't subscribe to that religious view may believe that abortion is a suitable choice in some circumstances, and what circumstances permit that choice may also vary among individuals based on even more specific values. Morality is determined by culture, religion, psychology, and a variety of other factors.

Ethics has a similar dictionary definition, but more precisely it's a body of theory that attempts to help people choose right from wrong using broader social and historical bases. It's a branch of philosophy and so it's unbound by any specific religion. Here are a few examples of ethical theories, some of which the reader may be familiar with, but this list is not exhaustive--just some examples!

Utilitarianism: the theory that suggests that we should do the thing that does the greatest good for the greatest number of people.

Duty: philosophers will recognize this as "deontology", the theory that suggests that formal rules of conduct--the laws of a society--determine what is right or wrong.

Contractarian: and if you recognize the word "contract" in there, you can see that this would be the theory that argues that what is right and wrong is based on what everyone involved agrees is right or wrong.

Making an argument on ethics means making an argument within a theoretical framework, and there are parts to that framework. Autonomy is something that most of us in America feel is an important feature of our personhood. Being able to "be ourselves", to pursue "life, liberty, and...happiness" is a thread that runs through medical decisions. We should be able to choose medical therapies based on what we want, not what we are told to do by a doctor or a nurse. In mainstream American ethical thinking, autonomy is very important. In some cultures, not so much. For example, some of my colleagues at Hershey Medical Center work with many Amish, and in some situations Amish families may decline life-saving medical treatment because the "greater good" (utilitarianism) is better served by foregoing expensive treatment that seems to go against God's will and can cost the community a lot of money, when that money could better used elsewhere. You get the idea.

Ethical Tension in the Immunization Debate

As I've suggested elsewhere in this blog, a lot of the passion about whether or not to immunize comes down to different ethical approaches to this issue of what's right and wrong. In the article I referenced above in Infectious Disease Advisor, lawyer and professor of medicine at Georgetown University, Lawrence Gostin, states "I think that mandating the vaccine has public health benefits far beyond the small intrusion on individual rights. Thus, a mandate should be in place for all recipients recommended by the CDC unless there is a genuine religious objection — that exemption should be quite narrow." 

Gostin is making a utilitarian argument. What's better for all should be chosen over what's thought by some to be better for themselves. He argues that giving up a little bit of personal autonomy is more right than wrong because it is in the "best interest of the children receiving it"--although I'll be quick to note that neither Gostin nor the article's author provides statistical estimates of just how many people would benefit. However, I dug around a bit and found that a team did use mathematical modeling to estimate how much disease and death could be prevented (Van Kreikinge, 2014). 















Here, I've just shared one part of one of the results they share that's relevant to Americans. Basically it says that the more people you vaccinate, the more lives are saved. I have a couple of problems with this estimation. First, I used to do gynecology and examined (literally) over a thousand women for cervical cancer surveillance. What I found was that if women were poor, without insurance, or otherwise limited in capacity for self-care, they could get full-blown cervical cancer. Women with good education, good health care, reasonable hope for a prosperous future, and so on would not get past the very early stages of cancerous change. Simple outpatient treatment was 100% effective.

Second, two of the study's authors are paid employees of Merck, Inc. Think there's any financial incentive to create a rosy mathematical model that underscores the importance of getting immunized? Do you think that the study included in its estimates the impacts of wealth inequality, war, food insecurity, unfair labor practices, or any of the host of social and economic factors that also have an effect on what kind of health girls--or boys--receive? It did not.

"Ethical" Pronouncements as an Excuse for Ethical Truth

I get it. Doctors, nurses, public health advocates and policy makers all want to believe they are doing the right thing. They take one little thing they can run with, whether that's vaccines, or medicines like statins, or healthy eating or whatever, and they use it as a pivot to make the argument that people should do this because it's the "right thing", and it may be small, but it will help.

Where this goes wrong is the argument that follows on: if you aren't doing this, then you are wrong. It's the same argument that doctors use to vilify alternative medicine practitioners. It is unethical to use homeopathy with patients, or to recommend supplements, or to suggest vaping over smoking. "There's no evidence" (well, there often is, but it's not "enough" evidence). 

Really, this is all just an excuse for moralizing over someone else's choices, when the evidence for harm from such things may be minimal. Ethical truth is a personal, moral state of thoughtful calculation that considers the autonomy of another person, and the importance of valuing imagination and cooperation, over a static moral framework and its use to dominate others in order to feel superior. 

While I am aware of the value of HPV vaccine in preventing some cancers in susceptible persons--as the author of the article I shared notes--I do not agree with the ethical calculus. I would argue that it's an excuse to avoid talking about bigger social problems that lead to the deaths they would like to prevent. Further, it's an excuse to write a prescription in a few seconds, rather than to work with people to understand and help them build upon their own health choices.

Be well!
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Reference: Van Kreikinge et al., 2014 in Vaccine, Feb 3;32(6):733-9. doi: 10.1016/j.vaccine.2013.11.049. Epub 2013 Nov 26.

Monday, November 19, 2018



Do We Have Free Will?

This might seem like a question for philosophers, and in fact it has been for millennia. It really is a question for all of us. Do we choose? Or are our choices chosen for us, perhaps by a creator, perhaps by biology? On Saturday the radio program This American Life aired an episode that focused on will. The will to make a thing happen. Acts of volition. The first couple of segments were stories that spoke to how people exercised their will to achieve or change something. The last segment flipped the thing on its head. In talking with neuroscientists at Harvard and elsewhere  journalist David Kastenbaum heard the argument that we, our acts, our behaviors, are the mostly-deterministic result of firing neurons, action potentials, and the electro-chemical currents of the brain-machine.

In short, you think no thoughts that are yours, inasmuch as you cannot anticipate the origin of a thought.

Ok, that sounds a bit crazy. Let me try again. Let us say that you think a thought, like, "I am thinking now.” Where and when did your thought start? We intuitively feel that we are thinking, coming up with ideas, making decisions. Neuroscientists argue that measurements of thought and action don’t support this view. They aregue that to think is to work a biomachine called a brain. But what started it working? Mapping the function of the brain has led scientists to question a fundamental belief of what it means to be human: that we originate our thoughts.

Now that we've mapped this--and I'm not saying anyone claims to understand it--it has become increasing evident that "thoughts" must spring into existence unbidden. A thought had to have been preceded by a prior thought, and so on. The only logical interpretation, these scientists argue, is that at no time have we initiated anything. All thought, all decision, is a burst of neural activity that we did not—even could not—have decided upon beforehand. The implication: We choose nothing. Each of us is a slave to an unfolding sequence of electrical action potentials that snap from one to the other, not always in a straight line, and in fact mostly in bursts, clusters, and linked tracks that would resemble the chaining of a series of fireworks, each burst seeming to set off another burst elsewhere, but none of it truly under our control.

Makes a cool mental picture, but the implications are profound for who we are. Stick with me here. I know this is dense, but I’m going somewhere with it.

One can make an argument based in religion or metaphysics. But metaphysics by their nature are unknowable and therefore untestable. What I'm talking about here neither proves nor negates religion or religious spirituality. So maybe we are aware of ourselves, maybe we have free will, because a god wills it. I'm not equipped to tackle this, and anyway, it's not necessary.

I do think this is a medically important question, and a relevant question in any healing work. Determinism, and that's what we're talking about here, can persuade both the sick and the healthy to decide that there's little that can be done. It induces inertia and guilt. "I am the product of my genes, of connected neural impulses. I have no control." Worse, it suggests that any sense of control is itself an illusion of control.

So back to the radio show.

These scientists were all kind of on the same page. The evidence points in this direction. The conclusion is inevitable. (And if this sounds like kind of depressing, yeah, it is.) But here's what's wrong with this thinking.

We've seen it before. At the end of the 19th century, classical physics had developed to the point to which it was believed possible that we could know everything. They believed the universe unfolded like a clock. It was mechanical, followed rules, and was ultimately deterministic. However, in the background, the math was falling apart, and this would lead to Einstein's and Planck's theories in the early 20th century. Those theories, later experimentally validated, suggest that the very small world of atomic physics is full of things that wink into and out of existence, and perhaps even travel backward or forward in time. Weird stuff.

The guests on TAL acknowledged the random, probablistic nature of quantum physics, as perhaps the origin of something, maybe thoughts, maybe consciousness. One guest posed the "quack like a duck" argument. We know free will exists because it seems like it does. "If it walks like a duck, and quacks like a duck, it is a duck." It just seems intuitively right that we have the will to choose.

Yet their digression at that point only serves to underscore my own argument. Why must the physiology of the brain necessarily point to only one possible conclusion about where thoughts come from? Earlier I proposed that this is "machine thinking", that the human body is a machine. The brain itself is a machine. This has implications that reach deeply into our conception of self, and touch upon something that is profoundly reassuring to all of us. If we are machines, then we can be "fixed". Everything can be fixed, if we just understand how the machine works. This is important, because the notion is framed by our shared sense of the tools we feel we have available to us: drugs, surgery, counseling and behavioral therapies, physical and occupational therapies, prosthetics, and so on. These available tools fit with a machine-based conception of human life very well.

This way of thinking about human consciousness is quite binary. We have free will or we don’t. We are machines or we aren’t.

We love binary choices. Nature versus nurture. Determinism versus free will. It is essentially a mechanic's choice. How to fix the world? Turn a screw here. Add some some solder there. Connect a few wires. It's done, and we can cure diseases, increase our food supply, and clean our world. It is the conceit of people who need to know there's an answer that they are equipped to understand.

I believe this is a fundamentally faulty approach to the question of consciousness. My proposition is based on the idea that we don’t yet know what we don’t know. We therefore choose to frame such questions in terms of only what we know now. That doesn’t make the unknowable less real, just farther out of reach. The experimental evidence suggests to some that “thought” is a sequence or cascade of spontaneous “origin thoughts” that we don’t come up with on our own. We behave, in a sense, like animals. I argue that we should be more imaginative about these findings.

What if free will is the aggregated electrical impulses of spontaneous “origin thoughts” but then these coalesce into a “consciousness experience” that is both intuitive and creates feedback that can control the general direction of subsequent thoughts? This would violate neither the sense that we can think and choose, nor the experimental evidence about how brains function in real time.

It could be that. Or it could be something else. In either case, it is the failure to step outside of classical frameworks of scientific understanding that hold us back. This failure leads to really interesting findings in the physical world of experimental study becoming very limiting philosophical conclusions that solve nothing. In medicine, a more imaginative view of this evidence can lead us to more imaginative conceptions of health and disease. For individuals, we might recognize that we are at once subject to spontaneous impulses that arise from the deep recesses of our brains, but at the same time, this activity itself creates a field effect, a force, or self-regulating effort that returns to us some control, some will.

Monday, November 12, 2018

The Annual Flu Freakout

It's that time of year again, when doctors, nurses, pharmacies, and pretty much everyone including your grandma is advising to "Get your flu shot!" News stories breathlessly warn of flu seasons that are "terrible" and "alarming" and sure to bring death upon the unprotected masses. I've written elsewhere about the flu, flu shots, and even about some home remedies one can try to shorten the flu and make it less uncomfortable. In this short piece I'd like to just share some of the things that I think are important to know and remember about this annual viral pest.

First, "Do I need a flu shot?" Well it depends on your what you consider important. Most years the flu shot isn't terribly effective, but it still does protect some people from getting the flu. You can't "get" the flu from it, but you could get something like the flu that's caused by something else, or you could get the flu because the vaccine didn't have enough time (usually at least a week) to help you build up antibodies to the virus. So the main downside: it may not work.

Next "Can the flu shot cause me to have problems?" The mainstream answer to this is "Mostly no, and the really bad stuff is rare." This is true, sort of. In homeopathy, we observe that exposing the system to any infection can in some people cause unusual problems. Certainly when I am treating someone constitutionally, I find that flu shots can sometimes cause people to backslide, relapsing into what we were successfully treating, whether that's migraines, ADHD, Lyme, or whatever. I have seen cases in which a simple flu vaccine seemed to be connected to issues that are difficult to fix after the fact. The science doesn't show this because vaccine safety studies aren't designed to find this sort of thing.

"Isn't the flu deadly? That's what they say on the news." Well, I know it certainly makes one feel like one is dying! And it does kill people--but the vast majority of deaths are in persons over 80. Basically, even a self-limiting disease can cause death in people who are very compromised. Most people do not die of the flu.

In short, the reality doesn't live up to the hype.

In my practice I have three bits of advice. Risk of getting the flu can be greatly reduced by good hand hygiene. Getting a flu shot may provide additional protection and in many cases won't cause new problems, but its value is way overstated. Finally, if you are leery of getting a flu shot, just remember that there are ways to reduce its impact if you should come into contact with it.

What's interesting is that one way to reduce its impact is to take your constitutional remedy. I find that people in constitutional homeopathic treatment are less likely to get sick, and when do get sick, it's usually not as bad. Elsewhere in my blog I talk about the use of some herbs to help boost immunity and soothe the soreness that comes with the flu. Any treatment for any sort of viral illness like the flu is best done early! So if you start feeling poorly, start your echinacea and call for a consult at your earliest opportunity.

We know it's coming, and there's a lot one can do to prepare. So stock up on your herbs and enjoy the good stuff that comes along this time of the year. Yes, it's flu season, but it's also The Holidays, so stay healthy and have some fun with friends and family.
Be well!

Don't know where to turn for professional quality herbs without calling me? Now you can order directly at my Wellevate Store at Emerson Ecologics. For a limited time, all products are 10% off!

Sunday, September 9, 2018

What do the Numbers Mean? A Story of Measles and Measles Vaccine

As I have mentioned previously, I'm getting email blasts every day from various medical news outlets I am connected to (some on purpose, some just come to me unbidden!), and this thing about "deaths from measles vaccines exceed deaths from measles in the U.S" plopped into my inbox at the end of August.

So I read it. Seemed like an "antivaxer" point of view so I fact checked it at a site called Ballotpedia, a source for fact-checking claims made by politicians and people running for office. The data are real, but the author points out that while there were 12 reported deaths between 2000 and 2016 from measles in the U.S., only 2 were verified as caused by the disease. In the same period, 104 deaths were reportedly caused after receiving the vaccine. However, they note, verification is sketchy because the Vaccine Adverse Event Reporting System (VAERS) takes reports from anyone, including lay-persons, and verification depends in large part on the contents of the individual reports.

This basically means we have numbers but no context. I'll try to provide some.

Measles is a leading cause of death among children worldwide. What this doesn't tell you is that measles deaths are connected to the level of development. Less development (clean water, good food, access to health care) is connected to a higher death rate. In simple terms it can be said that if you are poor, hungry, and exposed to lots of germs in your water source, or around untreated human waste, or exposed to high levels of pollution, and you are without access to doctors and nurses, you have a higher chance of dying from this infectious disease.

VAERS reporting just says that one thing happened (a vaccine) and then another thing happened (in this example, a death). By digging into each report, it is possible to sort out likelier cases of vaccine-caused-death and less likely ones, perhaps events that were linked in time to some extent, but there were other factors to consider as the real cause of the death.

In this, Ballotpedia is right, and so are doctors and public health experts. The Centers for Disease Control discusses this weakness right on the VAERS website. However, the difference between 2-12 deaths from measles and 104 deaths from the vaccine--no matter what the flaws in the VAERS reporting--is a big difference!

To antivaxers, these data would suggest that the "cure is worse than the disease", although that would be leaving out the millions of kids who were vaccinated without dying afterwards.

To vaccine advocates, this suggests that the vaccine-caused-death data are flawed, and even so, the disease is worse than the cure. Clinicians share horror stories of "unnecessary" measles deaths to drive the point home.

To me, both sides are wrong.

It is easy to blame a childhood death from a disease like measles on unruly parents who refuse to see the light of science, when it's possible that in any given case, there may have been other factors at work. Most measles deaths are caused by encephalitis, an inflammation of the brain, a condition difficult to treat with today's approaches (mainly steroids or immune globulins). It still works 95% of the time in kids and 75% of the time adults. Homeopathy has a number of remedies that may be helpful--although they don't get used much because most doctors don't "waste time" on such approaches. Belladonna (first stages), Stramonium, and Gelsemium are three remedies that have been used to good effect.

Measles encephalitis (ME) isn't the only potential cause of death, and ME itself can occur because of the direct effects of the virus or from the indirect effects of the immune system going crazy from the virus. Death can also ensue from pneumonia, shock, or other causes made worse by the measles infection. An early study found nearly 1/5th of deaths from measles were seen in persons with an underlying medical condition. Makes sense: if you're already sick, measles might make you sicker.

It is easy to blame a sequel, like death, on a vaccine if one thing (the vaccine) happened, and then another thing (death) happened, regardless of what mysterious process was actually going on underneath it all. The survivors of a death need a point of blame for the loss.

As many of you know, I'm not against vaccines. I'm not pro-vaccine either. For a lot of nurses and doctors, the broad strokes of the science and the potential for believing that one's work (i.e., immunizing large numbers of children) makes the world a safer, better place is enough to quiet any misgivings that arise from what are actually pretty isolated events. It is easy to see why doctors and nurses argue so urgently for scheduled vaccinations.

Parents, on the other hand, see only one kid--their own, and this focus can't accept the broad brush, the science of millions of other kids' experience with vaccines (other kids who are not their own). They want to untangle the matter, and if they cannot do so, it seems safer to avoid injecting their child with a product to prevent a disease they may never see. It is easy to see why some parents resist the pressure to vaccinate.

The email blast that started this blog entry is evidence that we aren't moving past this stage of the debate. It's still the same old thing. One side says the science is sound and that the aggregate good to the population outweighs the occasional catastrophe. The other side says, "Nope, not if that catastrophe might be my kid."

Interestingly, in a commercial for Bexsero, the moms argue that not vaccinating against meningitis-B "isn't a risk I'm willing to take." I commented on this in detail elsewhere in this blog. You know, when it comes to your kid, one's point of view could go either way. So whether one chooses the immunization route or not seems largely to depend on what risks, what threats, seem most immediate and dangerous.

This is the problem with this debate over vaccines.

I have yet to hear any public health advocates, politicians, parents, doctors, or nurses openly argue that individualizing approaches to immunization is a viable medical option. I have yet to hear any of these people argue that improving wealth equity, environmental science, and access to health care for all would also improve outcomes in measles--or any other of the many diseases we vaccinate against.

I suppose it is easier to carry on this fruitless argument than it is to come together to improve the foundational aspects of health that are so inequitably distributed in our world.


Sunday, September 2, 2018

Diets

Diets

People often ask me what sort of diet they should eat. Dr Samuel Hahnemann, the discoverer of homeopathy, had little to say on this matter. After all, considering how things were in the Eighteenth Century, just having enough food and clean water were significant enough issues. He hardly could have foreseen the glut of available food we have in the West today!

Florence Nightingale, founder of modern Nursing and head of the nursing staff at the field hospital at Scutari, Crimea during the Nineteenth Century, observed that food should be as fresh as was practical to obtain, and consist of good meat, starches, and the usual fruits or vegetables available at the time. Recovering soldiers who ate decent food recovered better.

When patients ask me about diet, I don't have a whole lot to say. Part of this is the practical matter of the visit: just taking a homeopathic case uses up the available time. But I suppose I could create a patient teaching tool about what constitutes a "good" or "healthy" diet. The problem with such an approach is that it's also important to know how a person eats now compared to what they think of as a goal diet. This is compounded by other issues.

What is their culture? Foods that may be culturally appropriate to one person clash with the culture of another. When I practiced HIV medicine in Reading, I had a lot of Puerto Rican patients, and I learned that the diet of Puerto Rico tends to be somewhat high in fats. That doesn't make it bad; it does present a different set of advisements about how to make such a diet healthier.

What comforts us? Doughnuts are not exactly health food, but once a week, on Sunday, I allow myself one, because I like doughnuts and they make me happy. Limiting my "doughnut happiness" to once a week has not harmed my mood, and has contributed to me maintaining a healthy weight. Foods we were raised on--back when the health of food consisted of just having what we thought was a "balanced diet"--nevertheless can evoke good memories and a good mood.

So for me, if a patient wants dietary advice, and depending on any existing medical conditions like diabetes or high blood pressure, I generally refer them to a registered dietician (insurance sometimes pays for this service) or a naturopath, if they want something more aggressively "alternative". The latter often involves avoiding certain things like gluten, whey protein or dairy, or a wholesale changeover to whole grains, raw vegetables and so on.

Having reviewed a lot of the scientific literature on this approach, I can safely say that...

1) Such radical dietary changes really work well for some people, and
2) They also don't seem to work well for everyone.

Part of the reason is purely practical. I often tell patients that "You've eaten a certain way your whole life. It's a hard thing to change when that is what you are are used to." And it's not just liking the food. It's finding it, preparing it--changing the very way you shop for and cook your food. It's a big change!

I've also run across countless specialty diets. Atkins, ketogenic, Zone, high-protein, Frances Lappe's Diet for a Small Planet--diets even come with political and social agendas! Such is the state of affairs in a society that has plenty of food (arguably too much food), and so much that is processed in factories, themselves fed by an industrial agriculture that relies on pesticides, herbicides, feedlot meat production, and genetic engineering.

What prompted this blog is an article I saw in The Atlantic about professor and speaker Jordan Peterson and his daughter's "all meat" diet, in which they eat literally nothing but beef and water. It's actually not the strangest thing I've ever heard of in that realm. Several years ago there was a fad of eating spoiled meat to relieve the symptoms of arthritis and other conditions. Spoiled meat stinks, so of course eating it indoors often posed a problem! An example is this report from Vice News. I gotta say, the guy doesn't look all that healthy to me, but if he feels it's working...

Anyway, I like the advice of author Michael Pollan: "Eat food. Not too much. Mostly plants." I don't follow it strictly, but it has guided me to reduce the kinds of things I was raised on and learned to love (burgers, doughnuts) and my diet has gradually become healthier. I'll add that it has taken years of little changes (and the help of my wife, whose diet is better than mine). Another author I like to emulate is Dr. Andrew Weil, whose advice generally points to a Mediterranean diet of more and varied grains, fruits and vegetables, smaller amounts of meat, and reduction of sugars, artificial fats, and foods that have been processed or raised with a lot of poisonous chemicals.

I've tried some of the "faddier" diets. Haven't stuck with a single one. I like the variety of a diet that borrows more from Mediterranean, Asian, and Central American cultures, who are less meat-focused. I've never tried a gluten free diet--I'm Southern Italian and the avoidance of really good artisanal breads and real Durham wheat pasta just doesn't fit. There's that "culture" thing again!

When patients tell me they feel better on a diet, especially avoidance diets (like gluten free, dairy free, etc.) I'm fine with it. In our society it's almost impossible to not have adequate nutrition if you supplement where needed with whatever's missing (vitamin D, vitamin C, etc.), so why criticize the diet if it makes people feel better. It's a trickier conversation whenever it is clear that the thing or things avoided are causing a person to feel unhappy, restricted, and afflicted though.

Take scallops, for example. For some reason they really make me ill. I avoid them. I can eat all other sorts of seafood like oysters, shrimp, and fish. Do I miss scallops? Maybe a little sometimes. Does it make me sad I can't eat them? Not really. But a nice loaf of handmade Italian bread? A hot, buttery croissant? A fresh baguette with goat cheese? If I started avoiding those things my life would feel like it's missing something. If I felt bad enough, I might reconsider, but I'd rather find another way to beat the problem.

Homeopathy takes another approach. Its theory and practice implies that we are, generally, genetically equipped to eat whatever we choose, and what we choose tends to be what we need--if we pay attention. Food allergies, food sensitivities, we propose, may owe more to regulatory imbalances that, in the absence of genetically-driven conditions like true lactose intolerance, if given the right homeopathic remedy, will resolve, leaving the person to eat as we were meant to.

Eating food. Not too much. And mostly plants.
Bon apetit!

Monday, August 20, 2018

Vice-shaming and the Burden of Being Wealthy

I think I may have coined a new term. I looked it up on Google and didn't see anyone else having ever used it.

The other day I was talking with my wife about how people often say disparaging things about others' bad habits. Not major things, little things. A bit of dessert. A cigarette smoked at a party. Gluten.

So I said "We like vice-shaming people." Cutting people down because they do things we think no one should do. "You give your child soda?" one cries out, alarmed. "You eat meat?"

I looked it up to see if it hits in a search, and it doesn't, so I hereby claim invention of the term vice-shaming: the act of disparaging, publicly or privately, the minor vices of others.

There are other terms that do exist, like "fat-shaming" or "body-shaming"--those are popular right now. And the thing is with these: there's sanctimony on both sides of it. On the one hand you could say, "You know, being overweight is unhealthy." And the target of that comment could respond "You know, shaming people you don't know anything about for its own sake is kinda mean." So I guess, the shamer and the shamed can both claim the moral high ground here!

I've been thinking about this for a few days, and here's what I've been working with.

Medically, shame is a loser. If one of my students tells a patient something like "You know smoking is bad for you, right?" I'm liable to take her aside and shame her a little, "You know, there's no evidence that line works to get anyone to change their behavior, right?" Of course the patient knows that, everybody knows that. (Or almost everybody...but there are better ways to figure that out.)

Shame is how we in society let others know they are doing something shameful, like being mean to puppies, or throwing litter on the street, or saying awful things in public. It's a form of social control. It lets people know there are standards of behavior and that they need to get in line.

But what works for, say, getting the government to change its policy regarding family detention (that is, the use of shame), won't work and isn't applicable to the private behaviors of individuals. More to the point, not all standards apply to all people at all times. For example, if a patient tells me he uses e-cigarettes, because it helped him quit smoking real cigarettes...what? I'm supposed to criticize that?

I've had students say things like, "I work in the ER and I see these people come in and they're fat and they're all eating McDonald's while they're waiting for the doctor to come in."

I might ask the student: How do you know this isn't the first time that person has eaten all day? How do you know this person can afford--or even find--better food in their urban neighborhood? How do you know this isn't all that person could afford, both in time and money, as he sits here waiting for a doctor who makes $175,000 a year, while he misses time at his second (minimum wage) job because of this injury or illness?

So people have vices. Big deal. Yes, it's our job as health care professionals to guide them into thinking about ways they might be able to minimize the impact of those vices on their lives. Some vices are more harmful than others. Some things aren't really vices at all; the category of "vice" changes with the times. Medical research into things doesn't always clarify. So a "vice" can be a judgement call.

I've had doctors (mostly in alternative medicine) call into question meat, wheat, corn, corn syrup, sugar, salt, alcohol, grocery store vegetables (pesticides), saturated fats, unsaturated fats, any fat, anything but fat and protein, snacks and "junk food", candy, donuts, fast-food...anyway, you get the idea.

Now I'm not here to tell anyone that a Big Mac is a-ok. But neither is one Big Mac the end of health as you know it. But to anyone who reads my blog even semi-regularly, that's probably obvious by now. Stuff-that's-not-great-for-you is also not stuff that is going to kill you if you indulge once in a while.

But this whole line of thought got me wondering about vice, and what we think of as vices, from both the standpoint of the person engaging in what they term a vice and from the standpoint of the person labeling another's behavior as such.

I'm not going to go into real vices here: chronic cigarette smoking, uncontrolled gambling, alcoholism, heavy drug use, sexual addiction and so forth. These are vices in the classic sense: repeated, habitual, obviously-harmful behaviors that reliably lead to severe medical compromise, and harm others around the person who engages the vice.

What I started thinking about is how we have begun to label things that cause little evident harm or at least ought not to, as "harmful" or vice-like. As I noted earlier, gluten, one of the protein fractions of wheat and related grains, has taken on the cast of a "vice" in recent years. Now I will be the first to note that I have had patients state to me that their avoidance of gluten has led to improvements in their symptoms--although if it were just that, they certainly wouldn't be seeing me at all, right? These folks tell me about how much they miss, by avoiding gluten. And I have to ask: This is food, right? How is it that our food causes us this much complaint?

Google this or talk to your friends or natruropathic (and some regular) docs and they will tell you. It's...
  • The way wheat is bred and grown today
  • Additives
  • Allergies
  • (unspecified) "toxins" either in the food supply or in the general environment...
...and so on. But I find the evidence for these causes unconvincing. Of course, I certainly advocate for a cleaner, healthier, more sustainable food supply, but I also have to question how it is that in one of the wealthiest societies the world has ever seen, we have to start treating everything we love as a "vice"--a harmful habit that must be broken. 

On the website HealthLine the author warns about acrylamides in potatoes--so we're not supposed to eat cooked potatoes? He pans white bread--failing to distinguish soft, gooey Wonder Bread from stout, delicious baguettes from the bakery--in favor of "less bad" wheat breads and even ezekial bread. I've had ezekial bread. It's not a food that makes me enjoy eating bread. Maybe that's the point.

Maybe that is the point. In our great wealth and ease, have we somehow translated this into physical ailments that arise from the fruit of that wealth and ease?

That may sound silly, but I recently had a French patient of mine tell me there's no talk of peanut allergies in France. It's not a thing. My wife edited this entry and said "Is that true, or is that just her view point?" So I looked it up. Yeah, it's mostly true. Peanut allergy occurs most in developed countries like the US, but not uniformly. It is less to non-existent in many developed countries, and appears now in some developing countries. The distribution doesn't make sense.

So let us suspend for a moment the belief that every physical complaint or disease must have a material cause.

Is it possible that many ailments--even very physical ones--stem from psychic imbalances? This is well-known to practitioners in homeopathy, Chinese medicine, and Indian (Ayurvedic) medicine, as well as wise healers, shamans, and others who admit to the possibility of both individual and social causes of disease that are energetic or psychic in origin.

I'm not saying "it's all in people's minds." That would be mean, true, but worse, it would miss the real understanding: that perhaps society itself can alter the way our bodies and our minds respond to that society, both its riches and its "vices". Suddenly the things we love become our enemies, poisons similar to chronic tobacco use, heroin, and unprotected promiscuity.

I know this sounds bizarre. But I think it is important to explore the question, because I think it is reasonable to imagine that both individual and collective thought can create physical disease. That seems pretty "magical", I know. And I have no proof of this--actually, I'm not trying to prove it here, although there are instances of this occurring, detailed in such sources as the New England Journal of Medicine, American Family Physician, and scholar Rebecca Kukla, but there are many others.

Accepting this for a moment as a thought experiment, we can ask several questions:

Does wealth and ease lead to physical illness beyond the material influence of the things we ingest? That is, does collective guilt or boredom cause our bodies to react in new ways, giving rise to new "diseases"?

As these emotions grow among us and become more common, shared among many, is one possible reaction for members of that society to begin to "shame" others on their engagement in what should be otherwise neutral impacts to the body (vice-shaming)?

In health care, can this translate into a collective professional culture that shames people for things human beings ought to normally tolerate well, like eating peanuts, or gluten, or even modest amounts of sugar?

I don't have answers to these questions, but in Nursing, we recognize that human beings are unitary beings of body-mind-spirit, and as such we can admit the possibility that the rise of "new diseases" might be less a product of material things alone (like "toxins") and maybe a product of less material origins, like fear, boredom, stress, guilt, and so on. Extending that, it is also possible to imagine that among many individuals, similar physical problems could be collectively shared.

It sounds kinda crazy, but my research into the connections between the body's immune system and the mind suggest it might not be so crazy. This is an idea in development, and I would welcome the thoughts of readers or this blog, patients, and friends on this matter.