The Rise and Fall of Heart Disease

Heart disease was once the number one killer in rich countries. Maybe it still is. Huge amounts of time and money have gone into trying to reduce it — statins, risk factor measurement (e.g., cholesterol measurement), telling people to “eat healthy” and exercise more, and so on. Unfortunately for the poor souls who follow the advice (e.g., take statins), the advice givers, such as doctors, never make clear how little they know about what causes heart disease. Maybe they don’t realize how little they know. Continue reading “The Rise and Fall of Heart Disease”

Assorted Links

Thanks to Phil Alexander and Casey Manion.

Resistance to Fecal Transplants as Treatment for C. diff. Infection

One of the worst infections you can get in a hospital is C. difficile. It is notoriously unpleasant and hard to get rid of. It has recently been discovered that fecal transplants are highly effective against this infection. Here’s what happened next:

The Food & Drug Administration (FDA) [decided] to require an Investigational New Drug (IND) application for stool transplants—formally known as “fecal microbiota transplants (FMT)”—for the treatment of C. difficile colitis. “C. diff,” as it is known, is a severe inflammation of the bowel . . .

Over the last 10 years of my practice, I saw a change in the patients I treated for C. diff. More patients were affected, they were generally more severely ill, and the infection became increasingly difficult to treat. . . . often being refractory to therapy. . . . I also began to see patients floridly septic from C. diff, occasionally needing emergency surgery to remove their colon (colectomy). [I began] to wonder whether we shouldn’t be treating severe cases of acute C. diff with stool transplants. I reasoned that it was a better alternative to an emergency colectomy. . . .

There are barriers to doing so, however:

First, there is the “ick” factor. Thus far, resistance to transplants I have recommended has not come from patients or their families, who are desperate for relief. It has come from other health care workers, especially physicians, who seem to find the idea particularly distasteful. [emphasis added. This article supports the idea that doctors are a major source of resistance to this treatment.]

There is cost and time—while the “medicine” is inexpensive and readily available, current recommendations are that the stool donor be tested for a variety of infectious diseases at a cost of $1500-2000. There might be a week’s delay, while the donor is tested for hepatitis and other infections. . . . And now there is the new FDA requirement for an IND, which will be the coup de grace for this treatment. . . . INDs are incredibly burdensome, time-consuming, and expensive for an independent practitioner to obtain. They involve hours of paperwork (my office practice consisted of me and 1-1.5 secretaries; who has time?).

Given the awfulness and danger of this infection, I think it is fair to say that the home-treatment approach (via enema) is very easy. The author of this post, Dr. Judy Stone, complains about home treatment:

Then the sole data will come from some ambitious citizen science group [which is terrible because . . . ? — Seth], and acutely or seriously ill hospitalized patients, too ill to be treated at home, will be deprived of potentially life-saving treatment.

Dr. Stone is serious — deadly serious, you could say. According to this article, “more than 9% of C. diff-related hospitalizations end in death.” Fecal transplants are very effective. Stone predicts that patients will die because “hours of paperwork” are too much trouble, at least for her (“who has time?”). A more persuasive article would have explained why patients who need this treatment cannot be sent to doctors who decide that “hours of paperwork” are doable if that is what it takes to save lives.

Thanks to Paul Nash.

“The $2.7 Trillion Medical Bill”

The New York Times has started a series called Paying Till It Hurts about high medical costs. quite recently.) The most extreme example is that a certain (unspecified) amount of lipitor costs $124 in the United States and $6 in New Zealand. Other treatments that cost much more in the United States include hip replacements and MRI scans.

This series might be a turning point, leading to government regulation of what health care providers can charge, which is how other countries control health care costs. To read the huge number of comments (already > 1000) is to see the suffering caused by these prices. One comment: “An acne medication was over $550 for a small tube of ointment. The [prescribing] Dr. had no idea it was that expensive.”

The high prices are the tip of the iceberg of American health care dysfunction. Less obvious is the poor research that sustains them. Acne is an example. It surely has environmental causes (probably diet). If we knew what those are, you wouldn’t have to pay anything to cure acne.

Assorted Links

Thanks to Nick Gibb.

“Because It Costs More”: An Example of Medical Reasoning

Melody McLaren, a friend of mine, lives in London. Her husband has Parkinson’s Disease and receives treatment through the National Health Service. His treatment has included “deep brain stimulation” — implantation of an electrical device that stimulates subcortical brain areas. It is a standard treatment for Parkinson’s. It cost the National Health Service about £35,000.

She was surprised to discover that in the United States, the same procedure involved implantation of two batteries, one for each side of the brain. The device implanted in England has only one battery. It worked fine. My friend wondered why two batteries were used in the United States. She asked her husband’s neurologist, a French woman practicing in London. “Because it costs more,” she said. There was no other reason.

At the San Mateo Maker’s Faire a few weeks ago, I heard a talk by a doctor named Amy Baxter, who had developed a device for pediatricians that makes shots hurt less. (She had a child and noticed the problem.) She went to considerable trouble to develop a product that could be used by working doctors and presented the product several times to potential buyers. Again and again she was told It has to be disposable. Meaning one use per package. Nothing else will fit the supply chain. She did not say why she was told this, but the obvious reason was that disposable products are more profitable.

Steven Brill’s cover story in Time two months ago was about one way American health care takes advantage of sick people with little choice — hospitals, including nonprofits, charge patients for products and services far more than what they cost the hospital. This is another way.

Hospitals and Their Employees: Stuck in the 1800s

An article in the New York Times describes how difficult it has been for hospital administrators to get their employees to wash their hands. Hospital-acquired infections are an enormous problem and cause many deaths, yet “studies [in the last 10 years] have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients.” Hospitals are now — just now — trying all sorts of things to increase the hand-washing rate. The germ theory of disease dates from the 1800s. Ignasz Semmelweis did his pioneering work, showing that hand-washing dramatically reduced death rate (from 18% to 2%), in 1847.

So hospitals are only now (in the last few years) grasping the implications of facts and a well-established theory from the 1800s. What goes unsaid in the usual discussion of how awful this is — how dare doctors refuse to wash their hands!, a sentiment with which I agree — is how backward both sides of the discussion are. A discussion in which many lives are at stake.

The Times article now has 209 comments, many by doctors and nurses. The doctors, of course, went to medical school and passed a rigorous test about medicine (“board-certified”). Yet they don’t know basic things about infection. (One doctor, in the comments, calls hand-washing “this current fad“.) They appear to have no idea that it is possible to improve the body’s ability to resist infection. I read all the comments. Not one mentioned two easy cheap low-tech ways to reduce hospital infections:

1. Allow patients to sleep well. The body fights off infection during sleep, but hospitals are notoriously bad places to sleep. Patients are woken up by nurses, for example. You might think that everyone knows sleep helps fight infection . . . but apparently not hospital administrators nor the doctors and nurses who commented on the Times article. It was in the interest of these doctors and nurses to suggest alternative solutions because they dislike washing their hands.

2. Feed patients fermented foods (or probiotics). Fermented foods help you fight off infections. I believe this is because the bacteria on fermented food are perfectly safe yet  successfully compete with dangerous bacteria. In any case, plenty of studies show that probiotics and fermented foods reduce hospital infections. In one study, “use of probiotics reduced the new cases of C. difficile-associated diarrhea by two thirds (66 per cent), with no serious adverse events attributable to probiotics.” Maybe this just-published article (Probiotics: a new frontier for infection control”) will bring a few people who work in hospitals into the 21st century.

That hospital administrators and their doctors and nurses — and, in this discussion, their critics — are stuck in the 1800s is clear enough. What is slightly less clear is that our understanding is better now than it was in the 1800s and some of the new knowledge is useful.

Thanks to Bryan Castañeda.

Assorted Links

Thanks to Bryan Castañeda and Andy.

Oral Rehydration Therapy For Diarrhea

Oral rehydration therapy (ORT) is given to people (usually children) suffering from diarrhea, which before ORT was often fatal. It is very simple: The sufferer drinks water with sugar and salt ad libitum (as much as they want). You probably haven’t heard of ORT — at least, I hadn’t. Everyone has heard of antibiotics. Yet “in 10 years [ORT] saved more lives than penicillin had in 40.” Infant diarrhea was once (and may still be) the main cause of death in poor countries.

A history of its discovery supports several things I’ve said on this blog. One is Thorstein Veblen’s point about the disdain among professional scientists for useful research:

ORT might also have been developed long before 1968 but for the attitudes of the dominant medical establishment toward practical experimentation, which the Cholera Research Laboratory and the National Institutes for Health shared. Nalin believes that “the people at the lab … got kudos for the extent to which [their] work was not practical. As soon as it became practical it was discarded like a soiled towel–it was too common, too hands-on… so the prestige went to people who measured trans-intestinal fluxes or electrical currents”.

No one who has attended an elite law school, medical school, or graduate program in education will be surprised by this.

Another is the great resistance among the medical establishment to cheap and effective solutions:

The formidable and persistent ignorance of the Western medical establishment, which continues over twenty-five years after the discovery of ORT, is phenomenal. While its refusal to advocate ORT may be due in part to the notion that ORT is only necessary for people in the developing world, its actions appear to be driven also by financial considerations. Most hospitals do not train physicians in the use of ORT since they have no financial reason to do so. [I think “since” overstates what is known — Seth] The use of intravenous therapy, which often involves keeping a dehydrated child overnight, assures [greater] insurance reimbursement. Sending children home with ORT would [reduce] profits. Furthermore, recent studies show that diarrhoeal illness among the elderly may incur even greater health care costs that could also be reduced by the use of ORT. At a time of heated discussion about cost-containment in health care, it seems all the more ironic and egregious that a superior, cheap, and proven therapy [fails to replace] a far more expensive one. Estimates based on the cost of hospitalizations and physician visits suggest that ORT could save billions of dollars annually.

As an example of the resistance of American doctors to a better therapy, an ORT researcher, who had used it on Apache reservations in America, told this story:

I had an anthropologist friend who adopted an Apache child from the [Arizona] reservation where we were working. He used to be the anthropologist on the reservation. And then he [left the reservation and] went to Arkansas to teach and the Apache child came down with severe diarrhea and he called me up and he said desperately, “Look, my son’s in the hospital and they’re giving him all sorts of intravenous fluids. The diarrhea’s not stopping, he’s losing weight, they’re not feeding him. I know that you did this work in Arizona [on the reservation] and it didn’t look like that. . . . Would you call this professor of pediatrics and just collegiately talk to him?” So I called up the professor and told him that in our experience with Apache children this is what we found and here’s the publication and so on. And he said to me, “Doctor, doctor, our [Arkansas] children are not the same as your [reservation] children”. He was treating an Apache child from the same reservation.

Shades of Downton Abbey (where Lady Sybil died because a London doctor was listened to instead of a rural doctor).

First Make Yourself Healthy Meetup April 24 (Wed)

Encouraged by the success of the Quantified Self Meetup group, I have started a Meetup group called Make Yourself Healthy. It is about how non-experts — the rest of us — can improve on expert advice about health. The first meeting will be April 24 (Wed.) in the meeting room of the North Branch of the Berkeley Public Library, 6:00 pm to 7:30 pm.

The group is about solving your health problems yourself, before or after mainstream medicine fails to help or provides inferior solutions. Access to health information via the Internet makes this more and more possible; so does new technology, which make it easier to measure health problems.

The first important practitioner of Make Yourself Healthy was Richard Bernstein, a New York engineer with diabetes, who in the 1960s bought a new machine that could measure blood sugar with only a single drop of blood. Bernstein used it to measure his own blood sugar many times per day — in contrast to getting it measured once a month at a lab. What he learned from frequent measurements allowed him to stabilize his blood sugar level, which doctors’ advice had never managed to. His health greatly improved. His promotion of what he had done led to the glucometers you can find in any drugstore. Nowadays diabetics take self-measurement for granted.

I have managed to improve my health in many non-standard ways. Acne, sleep, mood, weight, and brain function, especially. On the face of it, you might think: He did a lot of self-experimentation and discovered cool stuff. At first, that’s how it looked to me. I wrote a paper called “Self-experimentation as a source of new ideas“.  But that’s misleading. Self-experimentation wasn’t new, it was ancient. Yet my discoveries were quite new — quite different from what people already believed. What really led to my successes was: 1. Better information. Before the Internet, I spent thousands of dollars on a UC Berkeley library service called BAKER, which photocopied journal articles that I requested by phone and delivered the copies to my campus mailbox. Xerox machines made this possible. 2. The prison of professional science. There are so many things that professional scientists (such as medical school professors) cannot do. There are so many ideas they cannot test. They have left a lot to be discovered and it turns out that non-scientists (such as me — I was not a sleep researcher, a mood researcher, etc.) can discover at least some of it. In other words, I wasn’t successful just because I did self-experimentation, I was successful because I did wise self-experimentation. I chose wisely what to do.

Behind this Meetup group is my belief that anyone who does this — tries to do better than expert advice — probably can teach and learn from other people trying to do the same thing, even if their health issue is different from yours.

If you are coming to this Meetup and have experience (successful or unsuccessful) trying to improve on expert health advice, and are willing to share your experience, please contact me.

 

 

Assorted Links

Thanks to Greg Pomerantz and Casey Manion.

Speech Pathology Confidential

Bryan Castañeda told me the following:

I was talking to a good friend of mine who’s a speech pathologist. He works for a woman who runs a private practice in Connecticut. Says that a third of his patients require the amount of treatment his boss recommends, a third require treatment but less than she recommends, and a third require no treatment at all. But his boss is skilled at preying on parents’ insecurities (and their clientele has a lot of money), so she makes a killing. He agreed with your advice that people should be more skeptical of the claims of medical professionals and do their own research to evaluate to those claims.

The woman who runs the practice has a Master’s in speech pathology, same as Bryan’s friend. I asked about the treatments. Bryan’s friend replied:

It depends on the diagnosis. If it’s a speech disorder, we do articulation therapy. Articulation therapy usually consists of drills, correcting erred sounds by shaping the articulators appropriately and then having the client produce the sound in isolation, at the word, phrase, and sentence levels, and then in reading aloud and in conversation until they’ve reached 100% or close to 100% accuracy.

If it’s a language disorder, we do language therapy. Language therapy is a little more complicated. We target specific language areas based on the results of previous testing. It can vary a lot, but some of the more common things I do is read passages and have the client answer questions about it, teach grammar, work on formulating sentences appropriately, teach vocabulary, and word classification activities. A lot of worksheets and games too — materials that my boss writes off at tax time. We bill by the hour, so more hours certainly equals more pay for her,” he says. “We are all salaried, so the tighter she crams our schedules the more she gets to keep at the end of the day.

At least the unhelpful treatments are harmless, in contrast to a large fraction of mainstream medicine, where children have their tonsils removed, and so on.

Assorted Links

Thanks to Nandalal and Bryan Castañeda.

Assorted Links

  • An Epidemic of Absence (book about allergies and autism)
  • Professor of medicine who studies medical error loses a leg due to medical error. “Despite calls to action by patient advocates and the adoption of safety programs, there is no sign that the numbers of errors, injuries and deaths [due to errors] have improved.” Nothing about consequences for the person who made the error that caused him to lose a leg.
  • Doubts about spending a huge amount of research money on a single project (brain mapping). Which has yet to produce even one useful result.
  • Cancer diagnosis innovation by somebody without a job (a 15-year-old)
  • Someone named Rob Rhinehart has greatly reduced the time and money he spends on food by drinking something he thinks contains all essential nutrients. Someone pointed out to him that he needs bacteria, which he doesn’t have. (No doubt several types of bacteria are best.) He doesn’t realize that Vitamin K has several forms. I suspect he’s getting too little omega-3. This reminds me of a man who greatly reduced how much he slept by sleeping 15 minutes every 3 hours. It didn’t work out well for him (his creativity vanished and he became bored and unhappy). In Rhinehart’s case, I can’t predict what will happen so it’s fascinating. When something goes wrong, however, I’ll be surprised if he can figure out what caused the problem.

Thanks to Amish Mukharji.

Assorted Links

Bitter Pill: Why Medical Costs Are Killing Us by Steven Brill

Steven Brill has a great article in Time called Bitter Pill: Why Medical Costs are Killing Us. I found it nauseating and terrifying — and I have health insurance. It is nauseating that helpless sick people are billed huge amounts of money that bear little relation to costs. It is terrifying that our government has failed to protect us from this.

Brill’s article is about the details of health care costs in America, especially hospital costs. Markups are huge. One example is a test strip for measuring blood sugar. The patient was charged $18 for each strip. On Amazon, the strips cost $0.50 each. The patient had no choice and was not told the wildly-inflated price. Brill gives many examples of similar markups. Hospitals, including nonprofit hospitals, are large prosperous businesses with very well paid CEO’s (e.g., $1 million/year). Yet Americans pay far more for health care than people in any other country and, judged by life expectancy, get worse results than people in about 40 countries. Brill’s article begins to explain the discrepancy.

Asked to explain their prices, many hospitals refused. One of them, MD Andersen in Houston, gave a statement that Brill quotes in part:

The issues related to health care finance are complex for patients, health care providers, payers and government entities alike . . . MD Anderson’s clinical billing and collection practices are similar to those of other major hospitals and academic medical centers.

Judging from the widespread refusals to explain and answers like this (“everyone does it”), the prices are indefensible.

The term stagnation — America is in the grip of profound stagnation — may be misleading because it makes it sound like things are staying the same. People point to a lack of increase in the median income over the last 30 years as indicating “stagnation”. Beneath stagnation is problems stacking up unsolved. (When they are solved, spread of the solutions produces an increase in income.) The problems aren’t staying the same: They’re getting worse. Health care costs are a good example. Health care costs have gone up faster than inflation for a long time, with plenty of signs that the American excess (the difference between what Americans pay and what everyone else pays) is completely wasted. (Or worse, given the many bad effects of drugs, surgery, and other high-tech medicine.) The American excess isn’t trivial, so median income, adjusted for it, has been going down for a long time, over the same period of time that median income in almost every other country has gone up. Quite a comment on the quality of our government.

As Brill says, the health care debate has been about who will pay? The question are prices too high? has been ignored.  Jon Stewart said, “This should be a Silent Spring moment.”

Celiac Experts Make Less Than Zero Sense

In the 1960s, Edmund Wilson reviewed Vladimir Nabokov’s translation of Eugene Onegin. Wilson barely knew Russian and his review was a travesty. Everything was wrong. Nabokov wondered if it had been written that way to make sense when reflected in a mirror.

I thought of this when I read recent remarks by “celiac experts” in the New York Times. The article, about gluten sensitivity, includes an example of a woman who tried a gluten-free diet:

Kristen Golden Testa could be one of the gluten-sensitive. Although she does not have celiac, she adopted a gluten-free diet last year. She says she has lost weight and her allergies have gone away. “It’s just so marked,” said Ms. Golden Testa, who is health program director in California for the Children’s Partnership, a national nonprofit advocacy group. She did not consult a doctor before making the change, and she also does not know [= is unsure] whether avoiding gluten has helped at all. “This is my speculation,” she said. She also gave up sugar at the same time and made an effort to eat more vegetables and nuts.

Fine. The article goes on to quote several “celiac experts” (all medical doctors) who say deeply bizarre things.

“[A gluten-free diet] is not a healthier diet for those who don’t need it,” Dr. Guandalini [medical director of the University of Chicago’s Celiac Disease Center] said. These people “are following a fad, essentially.” He added, “And that’s my biased opinion.”

Where Testa provides a concrete example of health improvement and refrains from making too much of it, Dr. Guandalini does the opposite (provides no examples, makes extreme claims).

Later, the article says this:

Celiac experts urge people to not do what Ms. Golden Testa did — self-diagnose. Should they actually have celiac, tests to diagnose it become unreliable if one is not eating gluten. They also recommend visiting a doctor before starting on a gluten-free diet.

As someone put it in an email to me, “Don’t follow the example of the person who improved her health without expensive, invasive, inconclusive testing. If you think gluten may be a problem in your diet, you should keep eating it and pay someone to test your blood for unreliable markers and scope your gut for evidence of damage. It’s a much better idea than tracking your symptoms and trying a month without gluten, a month back on, then another month without to see if your health improves.”

Are the celiac experts trying to send a message to Edmund Wilson, who died many years ago?

Assorted Links

Thanks to Vic Sarjoo.

A Little-Known Problem With Being a Doctor

When she was a little girl, a Korean friend of mine, when asked, said she wanted to be a doctor. She got the idea from her mother — it is what her mother wanted. When she was older, she had a friend whose father was a doctor. The friend told her that when her father was sick, he had to pretend that he wasn’t sick, and that this made her sad. After my friend heard that, she decided she no longer wanted to be a doctor.

End-of-Life Medicine: Enormous Lack of Informed Consent

A few weeks ago I blogged about undisclosed risks of medical treatments. Undisclosed risks are common. They might be the norm. The situation would be even worse — in some sense, much worse — if doctors knew of these risks and failed to tell their patients. It was unclear if doctors knew of the undisclosed risks I wrote about.

Recently Tyler Cowen quoted a newspaper story about Israeli doctors giving birth control injections to Ethiopian women immigrants “without their knowledge or consent.” Every commenter thought this was repugnant.

The latest RadioLab podcast (“The Bitter End”) is about the dramatic difference between how doctors want to be treated when they are near death (they want no CPR, no ventilator, no dialysis, no surgery, no chemotherapy, no feeding tube, no antibiotics, nothing except pain medicine) and how the general public wants to be treated (most people want CPR, ventilator, dialysis, surgery, chemotherapy, feeding tube, antibiotics, and so on).

The RadioLab guys were puzzled by the difference.   Continue reading “End-of-Life Medicine: Enormous Lack of Informed Consent”