Oxy-Addiction-Nonsense Goes on

When I began writing these musings on the general idiocies going on all about us I wrote something to the effect of, “well, somebody has to say something”. (see ‘thin line between genius and insanity‘). Too true. So. In recent weeks you may have noticed some rumblings about Oxycontin, an opioid painkiller being discontinued; the replacement drug is similar but apparently less easy to abuse (OxyNeo).

The drug manufacturer has kept the price the same. Government health plans do not appear to have been as circumspect; my understanding is that there are plans afoot to delist the new drug and make it harder for people with chronic pain to have their pain meds covered. Terrific.

Just as noxious is the addiction narrative that has taken over all discussion around this subject – with all its moralistic, judgemental overtones. I keep waiting for a nice Puritan gentleman in a stove top hat to mince up and stick a big red A on someone.

A promo for the CBC’s Fifth Estate proclaims that addiction to Oxycontin costs us all, as taxpayers, untold amounts and they’re shocked, shocked, that this has been going on for so long.

Um, exactly what nefarious something has been going on? People in pain had some access to a medication that could provide a bit of relief? People in hospital who’d had surgeries and procedures were able to survive without being in agony? How did pain become a crime – and that tiny fraction of people who take a drug for purposes other than what it was intended for turn into such objects of scorn?

So yet again, another abbreviated history lesson. About 50 years ago we began to realize that how medicine treated pain was stuck in the Dark Ages. How that happened was some physicians who realized their post-surgical pain relief was a giant joke. (And being doctors didn’t give them any special status – which must have come as a real shock). They realized what patients went through, being accused of faking or exaggerating or being drug seeking addicts when all they had was pain.

Medicine’s treatment of pain was a “cool and callous disgrace” according to one doctor writing at the time.

With time things gradually changed, a bit. There was research and Melzack and Wall’s seminal book on pain and major scientific effort (see the International Association for the Study of Pain, IASP, site for more.) We began to understand that if acute pain was well controlled the odds of it becoming chronic went down. That sometimes chronic pain happened – sometimes for no reason (hence the term ‘idiopathic’ which essentially means who-the-hell-knows) and sometimes because of underlying conditions like rheumatoid arthritis or scar tissue from a former injury. (Occasionally even as a result of iatrogenesis – caused by medical intervention, in other words. Some test or procedure gone wrong.)

Heck, we didn’t even realize until maybe 45 years ago that children felt pain. Infants. Which explains those bone chilling videos from some years ago where baby boys’ screams as they were being circumcised were simply attributed to, I don’t know. Joie de vivre?

We didn’t even concede that post surgical and post traumatic pain was worse at the start (right after the surgery) and better a few days later. Hence PCA – patient controlled analgesia – where individuals can give themselves a programmed amount of medication when they feel pain rather than waiting for the requisite number of hours to have passed before the nurse could give them a dose.

We even realized that we could give the dying a modicum of dignity and autonomy by controlling their pain. Because really, who on earth would care if a dying person got ‘addicted’ to morphine? Which they don’t but that’s another story.

Most important we began to realize that there’s nothing ennobling about pain. Pain just hurts.

Not that you’d realize it these past weeks as the moralistic jingoistic nonsense carries on in the media with the Oxycontin issue. Nope, the real issue is addiction. Tsk tsk.

Lost in all this is any sophisticated thinking or mature discussion as we forget the complexities of pain; how physical pain is exacerbated by stress and fatigue and hunger and other conditions. So that phrase we bandy about: ‘most common in northern communities’ might actually have its basis in what actually goes on in those northern communities.

First Nations reserves without gobs of mineral reserves and cash where individuals live socio-economic conditions most of the rest of Canada would find unacceptable. After all, if your community and your culture are not valued; if your hopes are few and your living environment horrid – perhaps addiction might be the natural result. So Sherlock, perhaps addiction is the symptom, not the underlying “disease” (if we wanted to reduce our argument to mere medical parametres).

For a lot of people opioids (oxycontin, morphine, methadone, codeine or the synthetic variants like demerol and fentanyl) - especially in conjunction with other techniques like exercise, self hypnosis, pacing oneself and other such things – allow people with chronic pain to function. Unfortunately, pain clinics that give people that broader perspective and help them learn not to rely solely on drugs have slowly been disbanded over the years (we prefer spending money on high tech toys) so now more people rely solely on medication to help them cope with pain.

I had thought, erroneously as it turns out, that we had matured somewhat when it came to our attitudes towards pain; that we understood that pain is the one condition that unites us all – wherever we live, whoever we are. But I suppose all that thinking was giving us a headache, and without any Oxycontin on hand ….

(to be continued)

PowerPointless*

Published on February 6, 2012 in Cranky Comments. 0 Comments

There’s a moment (usually) around week four or thereabouts of teaching that I begin to glimpse a teensy glimmer, perhaps even a glint of comprehension. In cartoon lingo one of those little light bulbs, though often it’s kind of dim and dusty like the light at some tacky hotel you didn’t really want to stay at but you missed the train and it’s all you could find at that hour of night. And at least it seemed like it didn’t rent by the hour.

So interesting I can't stay awake

I can’t take it for granted yet because I’ve learned that critical thinking, even though it’s one of those buzz phrases always used to describe higher learning, is not the cornerstone of higher education. Heck, probably isn’t even the balcony railing.

Of course it may never have been, whatever us oldies like to think of our own brilliant youth. Talking to a philosopher friend who taught at undergrads some 25 years ago, I have the sense that his students weren’t much better – in fact he says he once just gave up; the blank, stolid looks unnerved him and he just up and left. Simply told them he was available in his office if anyone wanted to discuss the material.

It’s a great idea, except I don’t really have an office – as a sessional prof I have an ugly desk in a cubicle; one of many in a large, ugly, locked room that would make Dilbert weep. I just use it to store my coat on the days I teach. And if I actually expected any students to drop by I’d have to lurk by the door to let them in, since they can’t seem me way off in the back and the door is locked. And that would be creepy. I gather it’s really not about the learning anyway, certainly not that undergraduate thing. It’s what Jane Jacobs called ‘credentialing’.

As nearly as I can make out, reductionist thinking, dull and linear, wanders the hall like some ghost of sleepy hollow – and the reverence for expertise and white coats and science and anything that smacks of authority is put up on a pedestal so high it’s bound to fall off and hurt something. Then again, what does one expect when everything from ridiculous commercials for face cream to mattresses professes to have research (clinical trials no less) backing up their claims that their product improved people’s lives 83%?

How one would know such things always fascinates me. Questionnaires? Surveys? PR thingies? You know the ones I mean, the little sheets of paper someone with a clipboard thrusts into your hands as you’re trying not to dislocate a joint finding some leg room in that airplane seat or you’re racing from one thing to another trying to find your keys. Whereupon a painfully cheerful person asks if you’d mind answering some questions about that soggy sandwich you just ate or what you think of a new strip mall they’re thinking of building where your favorite dry cleaner now resides. Er, if I’d I’d known there was going to be a quiz I’d have studied. As it stands I haven’t the foggiest. (And even if I did, would my opinion make a damn bit of difference? Likely story. It never has before. But I’m not bitter.) Numeric reasoning at present seems to take precedence over all else, including common sense.

I blame Powerpoint.

That’s right. The program we all love even if it’s made by that Darth Vader of software, Microsoft. (Apple has a variant as well I’m sure – it’s just that their ads are hipper and their numbers are smaller so it doesn’t face the brunt of our ire.)

Powerpoint’s given form to our function, our enchantment with linear thinking. And as a speaker or teacher you can even print up your cute little bullet points so nobody has to take notes. Or listen for that matter.

What I teach doesn’t lend itself to bullet points or decision trees. When I leave the class my white board looks like a hyperactive monkey was trying to write MacBeth: a mess of words that makes zero sense to anyone who hasn’t been there to hear me talk about the interconnectedness of everything or realize that those arrows actually mean something.

A/V loves me because I leave them alone. Students, well, that remains to be seen. But, sessional or no, I refuse to reduce the complexities of science and medicine into a series of bullet points. Call me crazy, but I still believe that even these texting, smartphone addled students are capable of – and even glad to be asked to engage in – thinking. Critically. Creatively. Contextually.

They’re capable of rising to the occasion if we’d just raise our expectations of them a jot. After all, they’re our kids. Surely they’re smarter than we’ve been giving them credit for.

* I wish I could take credit for the term but it was a title from the online version of The Economist – so kudos to whomever thought it up.

Inflammatory Remarks

Published on January 17, 2012 in Cranky Comments and Medicine and Health. 0 Comments

Not long after I had managed to hurl myself down the Canada Line stairs (thankfully, not headlong) last week; even as I nursed giant multicolour bruises and a lump below my knee I found myself reflecting on the extraordinary, combined, resilience and fragility of the human body.

like that ..

On the one hand, practically before my eyes, the immune system response was set in motion by the trauma: a lump the size of a goose egg beneath the knee that felt rock hard but was clearly filled with fluid; puffiness, tenderness, redness … Well, you get the picture. We’ve all been there at some point or another.

That basic inflammatory reaction was described nearly 2000 years by a Roman observer, Celsus, who – in the best empiric tradition circa 30 AD – listed the characteristics tubor (swelling), rubor (redness), calor (heat) and dolor (pain). In response to the cellular debris that the blow had dislodged the immune system dispatches macrophages, neutrophils and various and sundry immune compounds to begin “eating” them. (The term phage was coined by a late 19^th century Ukrainian immunologist, Metchnikoff, whose real expertise was food and digestion; when he observed that even a starfish ‘defended’ itself from a thorn by sending along these tiny immune substances what he saw looked like eating so he called them big eaters, macro-phages.)

The heat is generated by increased blood flow to the affected region and the redness is due to dilated blood vessels. Meanwhile, the pain serves a very useful purpose: it keeps you off the leg (or arm or what-have-you). Of course the inflammation itself is a source of pain as it acts on the nerve endings – and tugs at the skin which becomes tender as a result.

All this many years later we’ve only managed to add one more characteristic to Celsus’s, namely loss of function which is pretty damn obvious. When something’s swollen and red and painful, you tend not to favour it, and, as I found out with the leg I came down fairly hard on, it keeps you from overusing it which allows the immune system to do its thing. Bloody clever of physiology, don’t you think, creating its own splint?

The body’s resilience, adaptability and sheer cleverness never cease to amaze me. The immediate gastric response to something bad we’ve eaten, often accompanied by nausea, vomiting and diarrhea that in essence expels whatever is overtly causing the problem. The sneezing and sore throat that’s a response to a viral infection. The immediate skin response when it’s been broken and bacteria have become lodged within. Of course the immune response can also go haywire and maladaptive, as in rheumatoid arthritis which is inflammation in response to nothing. But that’s the price we pay for having this self-adjusting system inside that keeps us ‘safe’; anything that’s designed to kill can also turn on the host. As in friendly fire.

I have tried, incidentally, to put many of my military metaphors in quotes because I’m only too well aware that the immune system’s real response is not conflictive or militaristic but an attempt to achieve balance within the body. We are all a giant morass of bacteria and viruses and parasites and microbes; it is only at those times when something overwhelms that the reaction spirals out of control. In my recent case, that fall down the stairs. But that’s also why we succumb to a cold when we’re stressed or not sleeping or grieving or generally below par. It is not the virus “attacking” but our immune system not able to stay within its normal homeostatis.

(A brilliant, fairly old, book for anyone who’s interested in this idea is The Tao of Immunology by Mark Lappe, which I recommend highly.)

On the flip side of that resilience is also immense fragility. It would have been simplicity itself, had my fall taken a different turn, to imagine a broken bone or worse – brain damage, cognitive impairment, seizures, even death. I can list off without too much thought several people I’ve known to whom this has happened.

Years ago there was an ad, a simple print one, that showed an empty wheelchair and had as a tag line something to the effect of “it only takes an instant to change a life”. Which of course is true. One split second of inattention at the wheel – or on a set of stairs at the train station – or a simple glance at a text message can irrevocably change one’s life. Forever. All those cool new prosthetics and potential advances in neuroscience and this and that notwithstanding.

This is why I simply do not understand why we are so ready, so willing, so damn trusting when it comes to subjecting ourselves to screenings, such as colonoscopies, that can go sideways, nick the bowel and have one in ICU. Or willingly line up to take our radiation with a CT scan (which, I would remind you, emits up to 400 times as much radiation as an x-ray depending on the vintage of the machine) only to hear that the knee will get better on its own and if it doesn’t we’ll eventually need surgery. Um, and you needed a picture to tell you that?

Bad things can happen and inattention – that multitasking of which we are so proud – occasionally means mishaps. But when people essentially feel perfectly fine; when a person has the means and wherewithal to eat reasonably well and exercise; when we have enough money to do some of the things we like to do not to mention procure the basics of life, why on earth must we be so hypochondriacal as to always worry about possible future ill health? Especially when all those dire (and erroneous) statistics like ‘one woman in four’ will end up with osteoporosis turned upside down means that three women in four will not?

How did we all become such neurotics anyway?

And the mammogram nonsense goes on …

Published on December 5, 2011 in Medicine and Health. 0 Comments

Given my previous curmudgeonly rants about the general uselessness of mammograms I was pleased, nay, delighted when when the Canadian Task Force on Preventive Health Care issued new guidelines – ever-so-gently suggesting that perhaps this pop culture myth that ‘mammograms save lives”, especially that of younger women, is a crock. Naturally they phrased it in dry, epidemiologic language, but you’d thought the poor geezers had suggested women shouldn’t be allowed to vote.

The response, anecdotal, I’ll grant you but shrill, emotive and generally overwhelming was: Well! How dare you condemn women to death you dreadful guideline-writing scum you. Letters poured into newspapers and editorials pilloried the Task Force – the inevitable line was “having a mammogram saved my life”.

Politically incorrect and uwomanly of me it may be, but my first thought was, ‘Really?! How do you know? Given that a teensy mass that couldn’t even fill the head of a pin is now called a cancer and the person who’s had it a survivor?’

Perhaps less vocal people felt relieved that the Task Force had articulated what they had thought all along, that it may not be such a splendid thing to squish your breasts between two metal plates once a year even as you ended up dosed with radiation but I don’t know.

As far as I’m concerned the Task Force didn’t go far enough. They clearly stated that women who had the BRCA1 and 2 genes or had a family history continue to have regular mammograms, even as early as 40 and added that older women, those over 70, should also be screened. They politely did not say, trust us, if you have cancer you’ll know it. Ideally, a mammogram will find a fast-growing cancer early. By and large, it won’t. What it will find is what all those cancers that don’t want to be found, the bits and pieces of slightly abnormal tissue we all have – and which will be found if we go looking for trouble. Which is essentially what screening is.

Alas, screening is all too often confused with ‘cure’. Or ‘treatment’. Which screening simply cannot be. Screening is a way to make obvious something that was there that we didn’t know about, theoretically to ‘catch’ something dangerous early. As if.

But, hey, we’ve got the runs for the cure and all those pretty celebrities (and nonentities) going on the telly to lecture us on how we should all be focused on preventive care and take our radiation. Or have someone thrust a sharp object up our colon. Yes, sharp. The kind of thing that can slip and perforate the bowel and have you in the ICU faster than you can say colonoscopy.

But I wax incoherent.

So, once again, a brief lesson in how cancerous cells evolve. Cells divide over the course of their and our lives; with each division the odds of a ‘mistake’ increases. Which is why cancer is generally a disease of old age. The more those cells divide the greater the odds that something will go askew and result in what, if found, we will call cancer or pre-cancer or some damn fool thing. (Of course as we get older our cells divide more slowly which is why most older people die with cancer not of it.)

Then we attack what we’ve found with all the tools of the early 20^th century: radiation, surgery and harsh drugs. True, a handful of cancers are actually treatable with some new meds, usually fairly rare cancers, and a few drugs can increase life span. We are better at targeting and focusing and not killing quite so many non-cancerous cells. But the reality remains that we’re still focused on zapping and poisoning and cutting out cancers, just as they were in close to a hundred years ago and, barring the smoking/lung cancer connection, no closer to understanding why some people get cancer and others don’t.

That’s the question we should be asking and flinging money at, not mammograms.

Of course why the guidelines come as a shock to anybody I do not know, since we’ve known, definitively, since the 90′s that mammography is a crude screening tool at best. Plus, for women under 50 the risk benefit ratio is beyond ridiculous. (What we really mean by that, of course, is women who have not yet gone through menopause not women under 50 but we do love our decimal groupings – maybe it’s that counting-on-ten-fingers thing, so much easier). In other words, the number of false positives, biopsies to confirm one does not have cancer and actual false diagnoses are phenomenally high. (That last one, by the bye, simply refers to the women who end up being told they have cancer when they do not and end up in that most dismal of all “treatment” regimens for no reason at all.)

We have also known for a long time that not all cancers want to be found; that in fact over-diagnosing and over-treatment are rife when public policy institutionalizes screening, whether it’s PSA testing or colonscopies or mammograms.

But the emotional anecdotes continue to mount as individuals tearfully ask why the rest of us (and that nasty Task Force) would condemn them to death. Ah, easy there sport. Nobody’s condemning you to anything. Yes, women do get breast cancer. We have all had a friend or relative die of the disease. (Yes, including me. I sat with her as she died.) But simply because something happens does not mean it’s an epidemic or a scourge.

Finally, health policy is not clinical practice. Policy, guidelines, are simply a way for institutions to recommend what appears to be best practice. This does not mean that individual women cannot have mammograms or that individual doctors cannot counsel individual patients to have them. It simply means that a blanket policy recommending all women over a certain age undergo a procedure that is neither benign nor risk free is not a good idea.

Furthermore, something the Task Force did not mention, probably because they did not know it, is that women prior to menopause go through a phrase of life called perimenopause. Perhaps you’ve heard of it. It’s the years leading up to the cessation of the menstrual cycle when some women have hot flushes and mood swings and can get depressed and irritable. Estrogen levels fluctuate during this time and estrogen, boys and girls, is a hormone that causes cells to proliferate. It does that in the uterus during the menstrual cycle and also in the breast. So, the risk of a false positive raises commensurately for perimenopausal women because higher estrogen = lumpy breasts. More often than not these will resolve, go away, with time as an elegant Scandinavian study demonstrated some years ago.

So tell me again why women in their 40′s would want to subject themselves to this? Oh yes, because they believe in the medical model and the linear nature of physiology. Worst, we have all been subjected to such a barrage of pink ribbons and nonsense about prevention that women honestly believe the dratted technology actually works.

For my part, a certain weariness sets in as I watched this play out, not to mention the inevitable expert huffily saying, look, it’s science and you can’t argue with that. Actually I can. But this is one time the best-guess statistics, hypothesis testing, and empirical data all back up the physiology and common sense.

But I guess a lot of women have decided that the Forces of Evil want to take their mammograms away. How does one explain the Forces of Evil have a lot more on their mind these days than women’s breasts?

No Genius, Just Insanity

Published on November 16, 2011 in Uncategorized. 0 Comments

Yesterday, sitting with my friend Joan, who is American but has been living in Paris for some twelve years, talk turned to the U.S. and Obama and the Republicans and the general insanity that appears to have taken over American politics. And all one could do is shake one’s head. Today, Joan sent me this link from the Huffington Post – the bit she wanted me to see was the video, her friend Jake, talking about his take on Obama – and I have to admit Jake’s points are well made. Certainly, were I American, Obama’s calmness and intelligence would seem a right treat given the general craziness of the Bush years.

Still, there’s a part of me, I admit, that wants Obama to blast the Republicans; lose some of that civility and tell them they’re bloody idiots. Not to mention the part of me that’s just so damn irritated by these voodoo economics the Republican are espousing that I think, fine, go ahead, do it. Destroy your lousy economy and your country. That’ll teach you. Of course that’s like the depressed person who wants to kill themselves and thinks, that’ll show them.What exactly it would show ‘them’ is unclear.

It just seems so ridiculous. Why would raising taxes on corporations and on those earning huge incomes be such a bad thing? How is it that Warren Buffet is willing to pay a larger portion of his considerable income in taxes but the party that ought to be his natural ally refuses to countenance it? And finally, what kind of bonehead actually believes that an economic downturn, a recession – with unemployment hovering around 10% – can be “fixed” with harsh cuts in government spending? Even The Economist, bastion of open markets and general right winged-ness for nearly two centuries, warns against austerity during a time when the economy is grinding to a halt.

Neither national budgets nor global finance are comparable to domestic ones any more. Once upon a time one could argue that well, you take in so much in taxes, you spend so much (more or less) and things generally work out. That’s when governments were small and things weren’t so interconnected, complex and debt-ridden. Virtually all countries, even those who have weathered the recession reasonably well, like Canada, have borrowed large sums of money and the lucky ones are the ones whose debts are intra-national (in other words, the money isn’t owed to another country).

But no doubt I’m preaching to the choir here. The people who agree with me already do that and the ones who don’t wouldn’t be caught dead reading this. Not that I think there’re that many people, dead or alive, who are reading this. Voice in the wilderness etc.

Still, as I tell my students, life will go on; shops will still sell things and people will still go to work and school and day care and so on. Markets may fall at bad news from the euro but markets aren’t economies. Markets are just a bunch of jittery folks who follow the crowd(s) and are bears of very little brain.

Too bad the politicans are too.

The Wrong Stuff

Published on October 17, 2011 in Cranky Comments. 0 Comments

So the dishwasher broke. Again. It wasn’t the first or even the second time it had broken down but this time it hadn’t even been a year – the last time took two weeks for the part and over $300 to fix. It seemed time for a new one.

The new one is from Asia somewhere, possibly South Korea (though, who knows, the South Koreans may well be outsourcing to China now). And it will probably work for a year. That’s how the nice man at Sears explained it and he made perfect sense. You buy a washer/dryer, he pointed out, and the manufacturer gives you a ten-year warranty. A dishwasher? That comes with a one-year guarantee – which means that is how long the manufacturer actually expects the dratted thing to work. I was much struck by the obvious obviousness of this as it had no occurred to me before.

(In humour it’s called simple, unexpected truth. “Why do you think you lost the election, Senator?” “Too few votes.” A response so basic it surprises, and makes one laugh. Or perhaps cry.)

Hence, the truth about this brand new stainless steel dishwasher is that even though it ended up costing a whisper below a thousand dollars it was built, manufactured, to last 365 days. I’d heard of planned obsolescence but surely this is ridiculous.

Meanwhile, we are exhorted to reduce, reuse, recycle and just say no to carbon. Problem is, the one thing that life in the 21^st century is not about is conserving, keeping things, reducing waste. It’s about that dishwasher, built to last a year and ending up in a landfill.

As a woman I met recently said, in our parents’ day appliances were, granted, bulky and less than beautiful but they lasted. Once you bought that new stove or washing machine or dishwasher you could relax. If it broke down (which it rarely did) you called the repairman who’d call, have the part on him and that was that. Another decade would go by without any trouble.

Today we have smug self-satisfied little stickers on our appliances and dozens of pretty buttons that let us delay start and auto this or powersave that, that’s if the damn thing actually remembers how to work.

A few years later it ends up in a landfill having forgotten how to do the job it was designed for and not worth fixing. It never was too big to fail; rather it was too small to bother. But hey, it did its tour of duty – after all, t was only expected to work for a year.

So we discard, buy the latest version and toss yet another well-made, solid piece of engineering in favour of a pretty plastic device that looks new for six months then falls apart. Is it any wonder protestors are occupying Wall Street and Robson Street and Bloor Street; people are cranky and wondering why they can’t get the jobs their parents had, the middle class lives they could aspire to or their hope for the future.

What d’you expect, when you can’t even get the dishwasher they had? In the grand scheme of things a broken dishwasher is beyond irrelevant, especially when people are losing their jobs and homes and there are people in the world without a roof over their head or enough food to eat. But it seems emblematic of the mess that we’ve made of so much. Well, I use the term “we” metaphorically since I don’t recall anyone asking me about outsourcing or globalization or corporations being people and most of the time the people I vote for don’t get in.

That dishwasher seems like a sad little paradigm for the hypocrisy of the whole thing. So go Wall Street/Bloor Street demonstrators. At least let the man know we’re tired of this nonsense.

And while you’re at it – could you ask about my dishwasher?

Mental Health Misunderstood. Again.

Published on September 15, 2011 in Health Care and Medicine and Health. 0 Comments

According to yesterday’s Globe and Mail, a report from the Vancouver Police Department identifies the deinstitutionalization of the mentally ill as a major problem for police, who have become de facto mental health workers.

“We certainly have identified individuals that we wonder whether it would be healthier – both for themselves and the community – if they were in institutional care,” Vancouver Police Department Inspector Scott Thompson is quoted as saying at a press conference. “The difficulty,” he added, “is that [that] is a medical question. That’s not within the realm of policing.”

Ah, but there’s the rub. It’s not a medical question or medical issue or even a medical decision. It’s a political and economic and sociocultural one.

When the decision was made to – for all intents and purposes – shut down the single major institution this province had for the mentally ill, Riverview, it had nothing to do with the doctors and nurses and social workers; it was a decision made at the Ministry of Health and provincial and federal level. It had to do with the general tenor of the times, notions of autonomy and individual rights – not to mention a way to save cold, hard cash.

Riverview, once upon a time

To some extent it was in reaction to the authoritarian, pseudo eugenics-type of position taken in earlier decades where the mentally ill were forcibly sterilized, forced to undergo horrible procedures (like frontal lobotomies – driven by the enthusiasm of a single nutty doctor incidentally) and unethical experiments on prisoners and others considered somehow lesser human than the rest of us.

Now the chickens have come home to roost. The downtown east side is a morass of misery and it is the police and the justice system who increasingly have to deal with people who are incapable of making rational choices for themselves. People who live next door to drug addicts and pushers and pimps.

Yes, it is a disgrace and yes, many of the people are sick and would do far better in the wooded confines of Riverview Hospital. But we’re closing Riverview (the scuttlebutt is that the land is worth a mint and that plays a major role as well)

Many years ago I wrote a document for and on Riverview; I spent a few days wandering the grounds and halls, talking to psych nurses and doctors and patients and all kinds of people. I watched as mentally ill individuals happily wandered through the garden and attended art therapy and crafts workshops. If they had a bad episode there were medical professionals on hand to help.

But.

As a society we decided a long time ago that we couldn’t afford it, that it wasn’t a viable alternative, that it wasn’t the way to do things.

Now the police are unhappy about how it’s all unfolded and most of us don’t like it much either. But it’s not a medical decision. Or even a personal one – talk to the families of schizophrenics or people who feel fine on meds and decide they don’t need them any more, become psychotic and head for the hills. Even if the hills are only in their mind.

Mental illness is complex and misunderstood – but it’s not medicine that’s let us down. It’s ourselves.

9/11 revisited, again and again

Published on September 10, 2011 in Uncategorized. 0 Comments

Many years ago when I was young, idealistic and – not to put too fine a point on it – an idiot, I truly believed that ideas, beliefs (like democracy) could drive action, states, life. I thought that if you had the right attitude then, by golly, the right institutions and governments would follow. As I said, I was an idiot. Most 17-year-olds are.

I now know that it is lives and who we are, how we are, how we live that drives the systems we adhere to. What does that mean? Well, it means that the Bush Doctrine of heading into Iraq post 9-11 to bring democracy into the region – democracy deprived as those poor Iraqis were – then all would fall into place, like a jigsaw puzzle opening up into its full splendour of a sunset over the Rockies.

But it’s not like that.

People’s lives, whether they have enough to eat, a place to live; whether their children can go to school, safely, and come home after without being blown up; it is having decent work under reasonable conditions, living in a place where you can make a life for yourself: it is these that then give rise to political and moral beliefs.

Years ago a psychologist by the name of Kohler (I think that was his name, my lamentable memory) spoke of the slow process through which true moral understanding develops. Another psychologist, Maslowe, spoke of the hierarchy of needs and how it is only after the fundamentals are satisfied is one able to concern oneself with abstract concepts like ethical societies or an ecological metaphor for life. One can only become a person with genuine global, ecological concerns required living in a world where one’s other more basic needs like food and shelter are met.

But we don’t talk much of development or developmental processes these days. Early education is under attack (no matter how much the school day is extended) and our reverence is focused on the gene and its so-called blueprint. Well, if you believe that it’s all there, ready to go, in your genes then why the hell would you even think about development, learning, the ways in which an individual evolves into that wonderful Jewish notion of a mensch?

To care about things larger than oneself one needs to have the basics and the knowledge that more is out there if one applies oneself. This is what the Arab Spring is about and this is what the guardians of terror and nitpickers at airports do not get. As long as entire regions of the globe only see the good life in movies downloaded from the internet or from satellite television – never in their own lives – there will be terrorism and people willing to die because they have nothing to lose.

That was the real lesson of 9/11. Or ought to have been.

The clinical arts made clear

Published on August 19, 2011 in Health Care and Medicine and Health. 0 Comments

For years I have been whinging on about the overuse of medical technologies, in my writing, teaching, speaking (occasionally stooping so low as to corner a hapless victim at some dull cocktail party who’s made the mistake of innocently asking me what I do/am working on). And finally, the Archives of Internal Medicine has backed me up with a new, elegantly designed study from a group of physicians in Israel.

(Oh North America, why do you ignore the nuanced questions? Why is it that American and Canadian researchers confine themselves to reductionist questions like Pax2-dependent transcription activation and other such unpronounceable minutae, leaving the critique and analysis to the Israelis and Finns and Norwegians and Dutch and so on?)

Then again, it is not just researchers but us on this large continent, we who believe in high tech and guidelines, rules and benchmarks. We has seen the enemy and he is us, to coin a phrase. Our cultural template, our social world, our beliefs and values predispose us to believing in the power or science and technology; we love our smartphones so medical technologies – those lovely acronyms like MRI, CT and PET – must also be the royal road to answers. So we push push the doctor to send us for “tests” so we too can receive our god-given right to radiation.

What we inevitably forget (or just don’t know) is that what medical technologies measure are, at best, only pale imitations at best of the complexities of disease and illness.

When I remind students – seniors, undergraduates, their ages don’t matter – that “an MRI or CT scan can’t tell if that lump is benign; it’s a person, a human being who makes that determination” I can see that shock in their faces. Because the seem to have forgotten that it is a fallible human being, prone to errors and fatigue and over- and lack of confidence who figures out the test, not the computer/technology. And people can miss things, over- or under-report; people can exaggerate a problem because they’ve been sued or are in a hurry to get home and get to their child’s soccer game. (Came as a shock to you too, didn’t it? You kind of thought technology trumped clinical judgement as well.)

Back to the Israeli study done by Liza Paley, MD along with physician colleagues Zornitzki, Cohen, Fredman, Kozak, and Schattner. They examined newly admitted patients to the emerg for 53 days, checking to see if the various tests and scans and so on ultimately aided in the final diagnosis. Sure enough, and wonderfully confirming my own cranky comments, they found that “more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool”. In other words, with only a handful of old, cheap lab tests (which were found to be “crucial”) plus a detailed history and decent clinical skills, you could narrow down the diagnosis and figure out how to treat the patient.

In fact, up to 90 percent of correct diagnoses were the result of history, exam plus some basic blood work (hematology and chemistry, urinalysis, EEG chest x-ray – which, I would remind you, contains anywhere from a tenth to 1/400^th of the radiation of a CT scan.

These are not the tests we associate with medical high tech though. These are old tech, based on boring old 20^th century research. No genetic tests, no cool monitors or flashy gadgets.

“Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation,” wrote the authors in the Archives.

Of course our complicity in all this, particularly in community medicine, was a not a part of this study; neither was our belief, our faith in the power of the technology; superhuman, infinitely superior to the biological brain and, of course, infallible. Stemming from our belief that disease somehow has an independent reality – that it is the “other”, evinced by our metaphors (“killing” the cancer, “fighting the disease) and attitudes – that is observable through “scientific” means, ergo technology.

In fact disease and illness are nothing of the sort. A manifestation of human frailty, highly individual and affected by everything about us and around us: who we are, who we were, our personal and family history; our lives and fears; our environment and social biases – all the many stresses and strains we’ve been exposed to, from what we ingested to what we’ve invested. Ultimately, what matters isn’t that label, that diagnosis, however much it might provide us with comfort, but the care we receive.

And that, boys and girls, is the art of medicine without which the science hasn’t got a chance.

Riotous Living

Published on July 17, 2011 in Cranky Comments. 0 Comments

Coming at things a bit late – no surprise there, particularly in the summer when I teach and run around like a crazy person – so it’s taken me a bit of time to get to that Stanley Cup riot thing.

Fahrenheit 451?

Like a lot of people I watched it evolve with fascinated horror on CBC television; struck by the destruction and sheer, wanton glee in those fires and general mayhem. The restraint shown by the VPD also impressed me – and since I have been critical of heavy police presence in the past this did strike me as … civilized. A camera crew caught one particular young man in mid rant as he poked and yelled at a couple of cops who calmly ignored him. Poke the bear with a sharp stick why don’t you, I thought. Later, quite a bit later actually, I saw him being arrested. Frankly, I’d not have displayed such forbearance with a drunk kid having a tantrum if I was holding a baton.

Restraint aside, one did have to wonder why nobody seemed to even consider that this was a a problem in the making, A Situation, what with the number of people downtown, the amount of alcohol consumed and the sheer intensity with which this city greeted that Stanley Cup final. Feelings ran so high that last week you could cut the air with a knife, even in stores just going about your business, as I was. And it didn’t occur to anyone that trapping a whole bunch of people in a five block radius might be a bad idea? Just asking.

Then the immediate analysis that of course it was really a vile bunch of outsiders, no doubt lurking in the wings waiting for their chance to wreak havoc. Like movie extras, just waiting for their five minutes of fame (and a chance to wear those balaclavas).

Ah yes, the outsider theory. Which, as anyone who’s ever read an Agatha Christie knows, is never the case. For in the immortal words of whatshisname, we have met the enemy, sir, and he is us.

But we are fond of that notion of the outsider and hate to give it up, be it in terms of disease or terrorism or anything else. We don’t like thinking that our friends, neighbours, colleagues and those nice people living around the corner have it in them to behave so badly. Most importantly, we don’t like to believe that we have it in ourselves.

Yet that’s why we have police and judges and juries and international courts. Individuals, once tossed into a group, lose all decorum and – for the most part – are reduced to their lowest common denominator. And that all too often is all that is loutish, cruel, and bloody inelegant..

As with disease we prefer to think of the problem as somehow external to us, not our own cells turning rogue, with cancer, or our own immune system becoming destructive as in rheumatoid arthritis or lupus. Far better to believe in the metaphorical infectious disease, the tuberculosis bacterium, the smallpox virus, the malaria parasite transmitted by mosquito. Even swine or bird flu. Identifiable and on the outside, attacking and therefore something we can attack, mobilize forces against, fight – be it through an analysis of its genome or killing it with chemotherapy.

Comforting thought that – that we can somehow protect ourselves if we just put our minds to it. The problem is that it’s not the way even a microbial disease behaves, given that a virus or bacterium or parasite is always, in epidemiological terms, necessary but not sufficient. The immuno-competence of the host, his or her life, diet, life circumstances and a host of other factors go into determining whether or not we get ill.

Think on that the next time you try to “fight off “ a cold or hear someone say they won’t let the cancer win. There are no winners or losers in physiology, any more than there were any winners in that Vancouver riot. We all pay for the broken windows and stolen property and we all have to deal with the moral, aesthetic and social consequences.

Maybe if we recognized that to begin with we’d be better equipped to face it in the first place. And wouldn’t have to run around setting fires and losing our heads.