Monday, April 25, 2016

Influenza Week
I've seen a number of cases of the flu--or at least what appears to be the flu--this month. Clinically, the flu is marked by sore throat (usually), high fever (or high-ish, low 100s F), muscle aches, fatigue, and often a cough. However, like any bug, you need a lab test to be sure, and we hardly ever get those, unless lab facilities are close by and insurance is really good. There are innumerable respiratory viruses and many potential bacterial infections. The former must be treated with antivirals within about 2 days, and the latter often do but don't always respond to antibiotics (for example, whooping cough).

Anyway, I had no opportunity to culture anyone anyway. Helpful remedies have been Bryonia and Nux moschata--in the latter case especially sleepy flu cases! (And it is just a few cases.)

"Did you have your flu shot?" People might ask.

In general, I avoid vaccination for non-fatal diseases, and despite what some TV doctors say about it, the flu isn't usually fatal. You just feel like you want to die.

Why? Hmm, I have a sense that we need some sicknesses to maintain some ecological balance to our world. Sickle cell trait confers some protection against malaria. Cancers have been known to recede during periods of fever from infection. My sense is not entirely a random hunch.

A physician assistant writes in The Clinical Advisor, an online, sponsored medical magazine, that there are undisclosed financial relationships between flu committee members at the CDC and vaccine manufacturers. Further, he notes that dangers may be overstated (especially in terms of fatalities, which are low).

One might ask: is any fatality acceptable? A philosophical question, and unanswerable in a practical sense because people value different things. Much of what passes for the "vaccine controversey" is really a discussion about the value of the public good versus the value of the individual's good. This is a discussion--or just a cussin' out sometimes--between those who have set their needle for public good to a point which they believe is good and just, and those who set it a bit farther back. This becomes a very complex equation when you consider all the forces at work in someone. Multiply those "someones" and society's decisions become vexing indeed.

By "forces" I mean those motives of concern, whatever they are: financial, personal, religious, and so forth. Those experts who hammer people about immunization, they forget that people operate as much from the heart and the gut as they do the head. No one's a brainiac 100% of the time either. Fully rational decisionmaking has never been a marked human trait! So I find all the "preachifying" by experts to be a bit tiresome, and I think unproductive.

Immunization makes a certain keen sense when one considers it in the context of industrial medicine: moving lots of people into higher states of health, at least as health happens to be defined at the time. That too is a moving target. However, I can't say I entirely disagree with the premise of today's industrialized, mass medicine. It has a certain achievable efficiency.

Yet at the same time in political reality, that efficiency will reach some natural equilibrium with the crazy, mixed-up human spirit (and by this I mean mind, or consciousness, or perhaps something like a soul). Whatever it is, it's not predictable, and therefore no theory of human phenomena is entirely predictive. In short, no matter what a good idea some people think a thing is, not everyone will, and that will create a conflict.

So back to that PA's comment. I dug out the original journal article. Peter Doshi, of Johns Hopkins, wrote in British Medical Journal in 2013 that low vaccine effectiveness (it's been reported from 25-75% and varies year to year), overstatement of health risks, and poor study methodologies lead him to the conclusion that the annual influenza vaccination cycle is a marketing strategy without any clear benefit and uncertain costs. Doshi accomplishes this simply analyzing the CDC's own publications.

It's not that I didn't think that people weren't making money. It's not that I imagine that every nurse and every doctor that recommends a flu shot has mercenary motives, either. But it is those folks who mean well who I would urge to stop overstating the value of flu shots and the risks of the flu. If I had dollar for every person who I diagnosed with the flu who had their flu shot, I could buy a nice flight to Florida for the worst of the season.

Saturday, April 16, 2016

The Week in Infectious Diseases

This past week the Centers for Disease Control confirmed that Zika virus can cause microcephaly in those born to mothers infected with Zika. We don't know why it does so, but for now it causes us to consider several things:

  1. Those areas where the Aedes mosquito carries Zika--a lot of good vacation spots and the site of this summer's Olympics--are probably riskier places to go if you are a woman currently or planning to become pregnant. If your plans will take you to the American topics this year the CDC has a Travel Medicine section to assist with specific advice.
  2. It is too early to tell, but the warming Earth may lead to advance of the Aedes mosquito's range northward. Don't panic, but stay tuned. Expect that public health authorities will be monitoring for this in 2016. It reminds us of the importance of funding for public health and the importance of getting state budgets ready on time.
  3. Birth control and access to pregnancy termination vary a lot by country and politics. It will be interesting to see what happens in Latin American and Caribbean countries, many of which have strict laws against either or both practices. It is easy to think of these things in the abstract. When disease threatens, I wonder if it will cause women to become more politically active--especially in those countries. I wonder if the reality of Zika may cause some to think differently about medical technology and family planning.
  4. Nature is always at work, busy birds and bees...and viruses. Evolution can inspire fear, but it can also inspire change. It may be that the common good could require a lot more cooperation, both abroad and at home. Nurse researchers Meaona Kramer and Peggy Chinn observed that one way we know our world (and our world is the health business) is socio-politically. In short: one can't effectively divorce our health from our politics. In a society, we share diseases together, or we learn to stay healthy together. 
...Including, the "Society" Inside Us

Late in 2015 Egija Zaura and her colleagues in Amsterdam reported that the human microbiome--the league of bacteria that live inside our guts--can be affected for up to a year after a single course of antibiotics. Ciprofloxacin ("Cipro") had the longest-lasting effect in this study. Ira Flatow of NPR's Science Friday frequently has stories about this microbiome, and what we are learning about it, how it affects everything from digestion to mood, immunity, and general health. Even short courses of antibiotics can lead to development of bacterial resistance. 

Recently I was updating material for a course I teach and had to update my array of "superbugs" that have emerged in the last year. Mostly, these won't immediately affect the average person. Hospitalized persons are most at risk (which doesn't make us feel great about being in the hospital!), although I've been seeing more methicillin-resistant Staph infections in the office in the last few years. 

I will use antibiotics if necessary, but many times antibiotics aren't needed. Now we have even better reasons to use caution with these drugs that seem so harmless otherwise. Fortunately, herbalism, homeopathy, and nutrition can be used to help the body back to health and also relieve some symptoms. So far these things have not shown any negative interactions with the gut, but it's an area where a lot more research could be done.

Full citation: from McGraw, M. citing Zaura E, Brandt B, et al. Same Exposure but Two Radically Different Responses to Antibiotics: Resilience of the Salivary Microbiome versus Long-Term Microbial Shifts in Feces. mBio. 2015. 

Saturday, April 9, 2016

Social Response to Lyme...and things like it

Do new diseases emerge?

Fibromyalgia, chronic Candida, variations on Lyme disease, chronic fatigue syndrome, etc. These are all examples of modern disease about which there is controversy. Doctors don't agree on the existence of these conditions, much less on their treatment. The scientific literature hasn't categorized these things very well. The accepted diseases all fit into a category of "known" because they fit the existing model of disease.

In fact, even these labels themselves reflect that way of thinking, that is, that "diseases" fit into a way of thinking about diseases (regardless of what patients think or feel).

We are all very indoctrinated into thinking of disease as discreet things that can be neatly categorized with a label. In regular medicine, those labels all fit into a few categories.

  1. A pathology. This means that there are tissues changes that always fit a certain pattern. Cancer is a good example. A pathologist examines the tissue changes found in the tumor, and voilá you have an actual disease!
  2. A change in physiology. This means the chemical processes are changed. A good example is adult-onset diabetes. Ultimately, a tissue pathology will probably be found. The chemical features of such a disease are usually well-described (in diabetes? an inability to properly process sugars).
  3. A germ-caused disease. This is when a germ--a virus or bacteria or whatever--causes changes (sickness, really) that follows a set of known patterns. Good examples today include influenza, Ebola virus infection, and so on. ("Chronic Candida infection doesn't fit this category. Neither does late-stage Lyme).
  4. A gene disease. This is when there's a known gene defect that leads to physiological changes or changes in tissues. An example would be Down syndrome,and other well-known genetic conditions.
Pretty much everything in the International Classification of Diseases, 10th Edition, fits into one of those categories. The causes vary. Trauma can cause tissue damage, for example. Category 1. Get the idea?

Interestingly, mental health diseases aren't really known to fit any such category. Even today, most mental health problems like depression or anxiety are mysteries. 

What about these diseases about which doctors don't agree?

Sufferers of such "dis-eases" often also suffer the disbelief of doctors in mainstream medicine. To be fair, most physicians are materialists. This is the model they know. It is a good model for many things. It has its limits.

So in step the specialists--mainstream and alternative--to try to sort things out and bring relief. There's a belief by many that these are "first world problems". That is, they are only problems because we have the appropriate conditions for them to emerge (wealth, ease, too much food, etc.). But that's a short-sighted way of looking at things. There's also a belief that these problems can respond to regular medicine, imaginatively-reinvented. In some cases I have observed that to be true. These things are being researched, in some cases, and may become part of the canon of medicine.

Probiotics during antibiotic treatment. Well researched, and consensus-approved, it nevertheless remains an underutilized preventative. So, even when something's accepted, it may take years to become a real part of every doctor's world view.

Then, there are the skeptics. I'm not sure what skeptics stand to gain from treating these maladies like some sort of aberration, or psychiatric cases, or malingering. If people feel sick they feel sick. The question is why.

Society also tends to take cues from the doctors and the skeptics. As such, some with "chronic Lyme" may be viewed as crazy or just lazy.

This is why so many people who claim to suffer from such diseases seek alternatives. And because of the we are all taught to characterize "disease" these folks label themselves! For the classical homeopath, these labels aren't very important, except maybe to gauge what the expected trajectory will be, and perhaps to give the patient a bill with an acceptable label so that insurance might reimburse the person. For the homeopath, it's more important to know the pattern of symptoms, regardless of the cause.

So in summary, society's response to chronic Lyme (or any of these other emergent diseases) isn't to wonder if nature is evolving (it is), rather it's to fall back to commonplace, materialistic explanations, and when those don't fit, to label the person as "anxious" or "crazy" or "attention-seeking." It is logical to imagine that as our world, evolves, so does disease. In that sense it seems rather arrogant for doctors to not be at least curious about what their patients present with.

But, if you don't have a way to view the problem, then won't have the tools to fix it. That leaves doctors stuck, and being stuck really makes doctors uncomfortable.