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Healthcare is a big business in the US, and getting bigger all the time. The internet and social media have entered the action in response to consumer demand for information as part of a healthy desire for, well, more health. For the venture capitalist this means opportunity with a capital O.
This consumer demand is as old as mankind. Through the ages, communities around the globe have depended on their shamans, clerics, or medicine men. Science and evidence base led to startling new developments beginning in the nineteenth century. As the science of medicine has evolved, the now infamous snake oil salesmen emerged with it. Travelling across the country, they pawned off Aunt Elmira’s secret miracle health tonic as the cure from everything from hangnail to heart disease. Read the rest of this entry »
A couple of the research blogs I follow lately have had some insight that really struck me as they fought off dualism in regards to the thorny issue of psychological vs. physical addiction and the brain, arguing that the elimination of mind and body distinctions is a good thing, as addictive pathways are real, physical represented by neuronal circuits.
This is an interesting argument, that collapsing psychology to the brain mechanisms brain can erase stigma by medicalizing it and making it a matter of physical function. In addiction it makes quite a bit of sense. We know what part of the brain is being stimulated, that dopamine reward pathways are building and feeding the habit. The derogatory statement, “It’s all in your head,” remains technically true, but loses its bite when you can explain it in such a real and tangible way. Read the rest of this entry »
And now, the moment you have been waiting for all week. No– not that moment. It is the moment when yours truly presents the best, the brightest, the most informative, interesting, and entertaining of my sojourn on the internet. Today I have gratitude, no worries, losing recognition of our own face, the God of the future, marrying biblical sisters, Scrubs and the end of life, and a football team without a home field, and eloping six year olds, amongst a lot of other really, really good stuff. So dig in and enjoy the best of the internet (I could find)- Read the rest of this entry »
First Published May23,2008
We hear a lot on-line about everything that is wrong is medicine. Improvement should always be our aim and this is healthy. I think it does us all a little good to take a step back and realize just what we have. There are some things medicine has done for us I don’t think you could put any price tag on. While most are intensely aware of shortcomings, here is a reminder of just what how powerful modern medicine has been.
1. Antiseptics– In the mid 18th century, around the same time, Oliver Wendell Holmes and a Hungarian physician, Ignaz Semmelweiss, both noticed that when obstetricians washed their hands, it drastically cut the number of mothers who died of fever afterward. Semmelwies reported this observation and was roundly chastised, discredited, and ridiculed. Holmes had actually published this same finding in a medical journal a few years earlier, even advocating disinfectants, where it was uniformly ignored.
Holmes turned prophet when the germ theory of disease emerged two decades later. Joseph Lister learned about the discovery of microbes as the cause of fermentation from Pasteur, theorized they could be the cause of wound infections and developed sterile operating technique with phenol. Infections rates plummeted, Lister’s fame soared, and the mouthwash named after him remains in use to this day.
2. Smallpox eradication– This disease killed an estimated 400,000 people in Europe every year in the 18th century, including 4 sitting monarchs. The mortality rate was 30% and it left survivors scarred for life wherever the sores developed. Sores on the eyes made it the #1 cause of blindness. Edward Jenner discovered the principle of vaccination in 1796, some efforts to organize campaigns to vaccinate were made as early as 1803 by the Spanish, however it took time to accept this wacky idea of injecting disease to get rid of disease.
Inoculation was banned in England in 1842. Over the next ten years the course reversed completely and vaccination was mandated in 1853. By 1900, Smallpox was virtually eradicated in the US and Britain, by 1978, it was eradicated from planet earth except in the freezer at the CDC for some suspect reason.
3. The polio vaccine– In the 1920’s Poliomyelitis was a scourge and a plague that everyone lived in fear of. The initial infection was as common and pretty identical to the common cold or influenza. Most people got, spread it and recovered. However, 10% of those infected had weakness, 1 in 10 of these developed permanent paralysis as the motor neurons in the spinal cord were destroyed.
Vaccination was first developed in the 18th century, and scientists fought to develop the vaccine for over fifty years. It took time to realize there were three different polioviruses, each pretty stable over time. In 1949, Dr. Jonas Salk made a breakthrough when he developed a technique to grow poliovirus in culture, rather than in live monkey brains. He then found a way to weaken the virus and the one of the most massive clinical trials in history was begun. People rushed their children to the doctor and proudly displayed buttons they were polio pioneers.
Today, polio has been eradicated in the Americas and tragically, only exists in very poor nations with poor vaccination rates. The WHO has long held a goal for complete eradication, which is theoretically possible and humans are the only host for the virus.
4. Anesthesia– Humphry Davy reported anesthetic properties of nitrous oxide in a paper in 1800. However, chemists decided it was much more fun as a recreational drug, until it was used in the first painless tooth extraction in 1846. Four years earlier, a surgeon by the name of Crawford Long had discovered diethyl ether had similar effects on the body as nitrous oxide and used it to anesthetize a patient before removing a neck tumor. Ether had this problem of flammability and tendency to explode leading to the development of several other inhaled anesthetics and now many IV anesthetics, which are much easier to administer reliably. This development, more than any other, is what allowed the advent of modern surgery.
5. Antibiotics- Though bread mold had been used to treat wounds by the Egyptians, and several other scientists had documented the penicillium molds ability to kill off bacteria in 1897-1914, the discovery of Penicillin is credited to Sir Alexander Fleming, who discovered the bacteria killer in 1928, just because he had the strange habit of playing around with fungus to see how it beat the bacteria off. He did not believe it would last long enough in the human body to kill bacteria and dropped the study in 1931. It remained for others to develop it for use as a drug and the US government went into large scale production during World War II. As sulfa, streptomycin and many others have been added to the arsenal, bacterial disease has never been the same since, pretty much uniformly sinking like a rock on the list of the top causes of mortality in the developed world.
6. Cracking the human genome– In 1950, A mysterious molecule called deoxyribonucleic acid had long been known to sit in the center of cells innocuously, not doing much. This changed in 1952 when Alfred Hershey and Martha Chase proved that DNA was the genetic material for the T2 bacteriophage virus. James Watson and Frances Crick then discovered the structure of deoxyribonucleic acid (DNA) and the way it could vary with 4 base pairs. This allowed Crick in 1957 to hypothesize the relationship of DNA, RNA , and protein in 1957. He would be vindicated as other scientists cracked the genetic code a few years later. Fast forward forty some odd years and the entire genome of mankind has been sequenced. Our understanding of inherited diseases has skyrocketed, with new information gained every day, multiplying exponentially both new ethical dilemmas and the possibility to treat the untreatable.
7. Medical imaging– In 1895, Wilhelm Conrad Roentgen was playing around with a myterious new “x-ray” he had discovered when he stopped in front of his ray detector and caught a glimpse of the shadow of his own skeleton. Two weeks later he took a picture of his wife’s hand and started us down the road to the entire field of Radiology. X-rays are vital to diagnose and treat bone problems and pneumonias, to name a few. Real time x-ray movies, or fluoroscopy is used routinely in surgery, CT scans gave us the first view of soft tissues, vastly improving the ability to visualize tumors, abscesses. This was followed by MRI, which my specialty is particularly fond of, giving us a chance for the first time to see detailed brain anatomy without radiating or cracking open the skulls of patients. Procedures such and functional MRI and PET are unlocking function and physiology secrets in living patients without laying a finger on them.
8. Acute lymphocytic leukemia– There are 4000 cases of ALL in the US annually, 3000 of these occur in children at a peak age of 2 to 5 years old, making it the most common childhood cancer. 30 years ago it had 100%mortality and was a death sentence. Since then, the development of Bone Marrow transplantation, umbilical cord blood stem cell transplantation and a National registry allowing clinical trials on a massive scale, have lowered that mortality to 20% in five years, for the most common type, 90% go into complete remission with about 60% cured.
9. HIV/AIDS antiretrovirals– Just when you thought we were done with all the major advances these days, along comes a new and deadly plague with knocking out the bodies defenses causing 100% mortality. Intensive study into the human immunodefieciency virus has led to antiretroviral medications that can knock HIV to undetectable levels. While we are still looking for a permanent cure, the current state of the art is bright. Unfortunately, Africa and Asia are in the throes of crisis and the developed/undeveloped gap has reared it’s ugly head, just as it did in the past with vaccines and antibiotics. Here’s hoping for another smallpox type resolution, rather than measles or polio.
10. Insulin- In 1889, Oscar Minkowski and Joseph von Mering decided to remove a dog’s pancreas to test the organ’s role in digestion. The animals keeper noticed afterward that swarms of flies were attracted to the dog’s urine. Thus they demonstrated the first link between the pancreas and diabetes, leading to the discovery of the insulin as the hormone all higher lifeforms use to metabolize sugar from the blood.
Type I diabetes was 100% fatal whenever it hit prior to this discovery, and became treatable for the first time. First the hormone was derived from animals, now gene splicing has enabled the production of genetically engineered human insulin, delivery systems are advancing all the time with the ultimate dream envisioned of the artificial pancreas, or perhaps pancreas insulin producing cell transplantation. Many, many years of life have now been added to both type I and II diabetics around the world.
So the next time you read about diminishing returns of medicine in improving our health, take a good look at just where medicine has taken us. I don’t think many people would want to go back. While learning to control costs and improve efficiency, and wise use of technology will be critical to sustaining healthcare in the future, it is hard to overestimate the benefits of modern medicine. What do you think? Did I leave anything out?
First Published April 25, 2008.
Becoming the parent of a child with a genetic disease is a harrowing experience. This is likely more true today than it has ever been. We are hardwired to want the best for our children. Discovering they have a life altering condition pulls the rug right out from under parents. Discovering that the very genetic blueprint they passed on to the child is the problem makes this “act of God” personal. Suddenly, it is your fault.
Child birth is an exciting time full of anticipation. What parents often don’t anticipate is the possibility that anything could ever go seriously wrong. I took a first year medical school genetics elective right at the time my wife was expecting our first child. Note to all medical students. DO NOT EVER do this. It is a bad idea. It brought me right down to Earth real quick. It also caused me lost sleep, racing thoughts, and all around needless worry.
I also witnessed firsthand some real parental anguish. My heart ached for them. They became very caught up in questions like what the diagnosis actually was, what the chances of having another child with the same problem were, and do they need to have family members tested. The more understanding we have, the more directed the questions and more uncertain the future.
This has created or at least accentuated a new phenomenon, gene guilt. In college I had a cell biology professor who referred to himself as a “genetic cess pool.” on account of a daughter with spinal muscular atrophy, type I, a fatal recessive genetic disorder. The irony is that his genes were likely no worse than anyone else’s. It just happened that he married someone with a matching bad gene. We likely all walk around with at least a few faulty genes, usually more, among our thousands. Any one of these could result in disease if we concieve children with someone with the same exact hit. The odds of that are low, like winning the lottery, only the prize is heartbreaking.
Some genes are bad enough that disease shows up with just one copy, but for unknown reasons is super mild in some people, who may go undiagnosed until half their children get it. Other gene mutations, called nucleotide repeats actually worsen through generations until the unlucky one gets disease, and then their children get worse disease. With X chromosome disorders, the Mother passes a gene to her sons that caused her no problem because she had both a good and a bad copy. Problem is her son gets the bad gene, and has no second copy because he is male. Other diseases of the mitochondria are given strictly from the mother. All of these situations can worsen the guilt and crush the self esteem of the parent.
Science compounds the problem with evolution. We learn that nature’s way is survival of the fittest. Bad genes are selected out of populations naturally. With medicine, we have sort of beat evolution over the head by outsmarting nature, at least temporarily. People with chronic conditions are living longer and better than ever before. It is a natural step therefore, once we know about a bad gene and see its effect, to wonder if we should not select it out of the population by not having any more children. This is unnatural selection, if you will. We reason that we must do something nature has been doing anyway without our input. Some reason that if they have children they are threatening the gene pool of the race. I think it is a very flawed mindset.
Certainly many disagree with me. During the above mentioned genetic rotation, I met a teenager who was diagnosed with Li-Fraumeni syndrome, a disorder that increases susceptibility to cancer. Her parents died at a young age, and she was being raised by an aunt. The conversation between them was profound. This patient felt emphatically that her life was not a mistake. To suggest this was perhaps even offensive to her. Who would want to think their life was a mistake? For this reason, she insisted that she intended to have kids if the opportunity arose. The Aunt was mortified.
Granted, this patient had not yet experience the ravages of cancer, perhaps her point of view was flawed, but I think she had a point. This is a tough issue and certainly there are no easy answers. But I believe we often overestimate the suffering of others. I can’t help but admire her for realizing she is more than her genes. Her life was more than her disease. Individuals have much more contribution to make to society than just their genome.
I think this is a point too many people miss, especially us doctors. We are consumed with patient’s conditions. The disease too easily become the only reason we relate to them at all. We start to refer to patient’s who happen to have Cystic Fibrosis as CF’ers, Sickle cell disease as sicklers, with Asthma as wheezers, etc. al etc. It obscures the fact that we a dealing with living, thinking, feeling human beings. We physicians wan’t to prevent disease, not enable it. We grow weary of those who do not take care of themselves and present us with disease. Too many doctors fall into the snare of exasperation and contempt for the reproductive habits of those we care for.
We are too obsessed with perfection in this country. We airbrush pictures of models, causing young women to starve themselves to meet a nonexistent ideal. We celebrate beauty, strength, speed, endurance. We reject difference. It is a natural social response with ugly consequences. Just as the sick, albino or deformed chick will be relentlessly assaulted by the rest of the brood, we can have a visceral revulsion witnessing malformation, scarring, or amputation. For me, this is the human flaw we really need to work on, not the diseases. As we gain the power to manipulate our genome, how will we decide what is appropriate to treat and what is not. Short height is now an indication for human growth hormone therapy. I find that disturbing.
We need to learn to see the beauty in our flaws. Only then will we really see the beauty in humanity. I believe our imperfections are a centrally important part of our being here in the first place. Forty years ago, a French philosopher named Jean Vanier founded a religious community devoted entirely to living and worshipping among developmentally impaired adults. Speaking of Faith featured L’arche in a podcast with some profound, moving, and amazing descriptions of what we can learn from them. I encourage everyone to take a listen.
The dystopian movie Gattaca takes a look at just where a culture of perfection can lead. It isn’t pretty. In the 1930s a madman rose to power with a dream of a blonde haired, blue eyed master race setting off the most massive conflict in world history. Will we as a people fall prey to the same ideas as we develop the power to actually make it happen?
There is a dirty little euphemism we all learn about in medical school called health care disparities. It seems the health care system is better at treating heart disease in men compared to women, hypertension in whites compared to blacks, and in keeping rich people healthier across the board in every category compared to the poor. The problem runs deep enough and fundamental enough that it appears no one is immune. It is the problem of poverty that I find particularly perplexing. Read the rest of this entry »