“Medicalization”

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I have just carefully read through several editorials in the January 16, 2018 issue of JAMA, the Journal of the American Medical Association. This issue reflects a growing enthusiasm among medical editors for what’s generally called a “focus issue.”

Since I’m not an editor, I have only a vague idea of how this works. In my mind’s eye, I see the editor sitting at a very large, cluttered desk with accepted but unpublished manuscripts piled by subject. As a pile grows to a threshold size, say seven and three-quarters inches, the editor says, “Aha! A focus issue.” Then he or she gathers up the pile and says to the staff, “Print all these together in 6 or 8 weeks, and we’ll be done with them.”

Readers know that I have no intention of writing about the focus of the issue, which happened to be obesity. What I do want to reflect upon are the social changes that have moved obesity from a straightforward statement about body composition to a medical problem worthy of a focus issue of JAMA, arguably one of the most prestigious medical journals in the world.

When I was a kid, turning to a dictionary definition of the assigned subject provided an easy “out” for starting an essay. I hope I’ve become a bit more sophisticated; now, I’ll turn to Harvard Magazine instead. I quote from the issue of April 23, 2009: “There are perhaps few academic topics of equal interest to scholars of history, law, anthropology, neuroscience, and literature. But this was part of the point when scholars of these disciplines gathered on April 22 for a symposium on medicalization—a phenomenon, they argued, that has infiltrated nearly every facet of modern life.” Not exactly stirring prose, but I’m sure you see the point. Or do you?

Beginning roughly in the mid-1970s, when faced with really tough social-behavioral problems, particularly those that have serious health consequences like alcohol abuse, drug addiction, and obesity, Western society has declared them medical problems.

This process, “medicalization,” relieves broad swaths of professionals from dealing with insoluble problems. Physicians, however, seem to willingly accept the process. We seem to say, “Give us your obese, your addicted, your anxiety-ridden… Send these to my clinic, to my hospital, I lift my stethoscope beside the golden door.” Not only do we engage in this altruism, we campaign to make their diagnoses “official” and billable, and then try to find treatments.

Lest this sound a bit negative, the Harvard conference attendees catalogued the forces that help to drive the trend toward medicalization:

  • “the very existence of health insurance (costs are only reimbursable when associated with a definable medical condition
  • death certificates (the need to give a name to what caused a person’s death)
  • research funding (funding is more likely for problems defined as diseases)
  • drug trials and approval
  • and even a desire to wash one’s hands of blame for one’s condition (for instance, by considering obesity a disease that assails people rather than the result, at least in part, of one’s own actions and lifestyle).”

As I become more senior in the medical community, my awareness of the importance of communication, both among doctors and between doctors and patients, continues to grow. How long will the medical community continue to accept the process of medicalization before we say, “Look, we can help to manage the physical consequences of behavioral problems. If you are too heavy, we can replace your worn-out joints, get your cholesterol and blood sugar down, and help with your blood pressure. But we can’t modify your behavior; you have to decide to do that.”

Cold nights are coming. Curl up with a good book

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The Amherst gymnasium, the site of JFK’s last speech.

 

Although Paul Dimond’s novel, The Belle of Two Arbors, appeared in April of this year, the epic story begins in the early twentieth century. Based on the temporal setting, the Weekly Packet can bring it to your attention without violating the underlying principle of reporting well-seasoned news.

I’ve just finished reading the 800-plus page story. I will admit that I am a “story” reader, not an “ear reader.” I skimmed lightly over many of the poems that Martha Buhr Grimes contributed to the novel in the guise of Belle, the central character.

Set primarily in what is now northwestern Michigan’s Sleeping Bear Dunes National Lakeshore, and in Ann Arbor, Dimond has constructed a rich story line with a dynamic female protagonist, a complex and powerful family, three world-famous poets – Frost, Roethke, and Auden – and the academic politics of two great American institutions, the University of Michigan and Amherst College.

The 200 to 250-page novel has become fashionable in recent fiction. Dimond’s 800-page story reminded me of Annie Proulx’s Barkskins. Both authors have created complex and fascinating families and followed them through generations. In both books, the author’s passionate commitment to the environment infuses the story, and each writer addresses the injustices done to native Americans.

The story of Belle and her family makes for the old-fashioned reading experience than I enjoy most: curling up in a big leather chair with a lap-blanket and escaping to another world for an hour or two in the evening as the story unfolds. Immerse yourself in it, and reap the rich rewards.

The author, Paul Dimond, is an Ann Arbor lawyer and writer, and an Amherst alumnus, Class of 1966. He, too, was in the audience in October, 1963 when President Kennedy spoke about poetry and power at the dedication of Amherst’s Robert Frost Library. Like many who heard that speech, Paul credits it with a long-lasting impact on his life and his career.

A fifty-four-year retrospective assessment of the impact of a single speech on a single day is fraught with hazard. The possibility of overweighting JFK’s words in the balance of long-ago decisions certainly exists. Nonetheless, I urge you to read The Belle of Two Arbors. As you enjoy the story, you’ll be amazed by the depth of Paul’s research and the clarity of his values. Surely with this sustained creative work, he has honored Kennedy’s proposition that, “art establishes the basic human truths which must serve as the touchstone of our judgement.”

One Fall Day

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Last week at this time, I was at the American Heart Association 2017 Scientific Sessions meeting in Anaheim, CA. I’m not going to risk a libel suit for telling you what I think about Anaheim.

I’m sure that anyone who has read my previous posts knows that events of only a week ago have not aged sufficiently to write about anyway. But being at the AHA brings back memories. I attended the 1977 AHA meeting that was held in Dallas, and I have never entirely gotten past it.

If you remember, President John F. Kennedy was assassinated in Dallas in November, 1963. The 1977 meeting was my first visit to Dallas, and the United States had just traded Gerald Ford for Jimmy Carter in the Oval Office. The loss of JFK was still fresh.

On a sunny but chilly day in early November, I walked the several blocks from my downtown hotel to the Texas School Book Depository building. At the time, the building was in a sort of renovation limbo, and it looked haunted. It was impossible to keep from looking at the sixth floor and wondering which window Lee Harvey Oswald shot from.

I’ve never felt good about Dallas, or the American Heart meeting since.

President Kennedy gave his last public address at Amherst on October 26th, 1963. I was lucky enough to be in audience. I have joined a group of classmates (some of whom are shown here) working on a documentary that looks at the content and impact of that speech, and offers some commentary on its relevance today. As part of the effort, our group met at Amherst College on October 28th   for a Saturday event called “Poetry and Politics, A Celebration of the Life and Legacy of JFK.”

The day was not unlike the October day in 1963 when the President spoke: a crisp, sunny fall day in New England, enough leaves on the ground to rustle as you walk, and enough still on the trees to stand out in color against the blue sky and high, thin clouds. After three outstanding presentations by current students and a panel discussion, the 150 or so of us who were “celebrating” gathered on the grassy quadrangle in front of the Frost Library, the building JFK had come to dedicate.

The keynote speaker looked familiar as he stepped vigorously up to the podium. Congressman Joseph P. Kennedy III is unquestionably one of “the” Kennedys. He looks more like his grandfather, Attorney General Robert F. Kennedy, than his great-uncle the President, but the resemblance is strong.

After the speech, I took a little private walk around the campus. I looked at the second floor of James dorm where I lived, at the Chapel where I had listened to Robert Frost say his poems, and the playing field at the foot of Memorial Hill where I had watched JFK’s helicopter land.

The young Congressman gave a good speech. Not perfect, but perfectly adequate. He’s just 37; there’s time, and there’s hope.

Yankee Ingenuity

In previous posts on The Weekly Packet, I have offered the idea that fifty years is a good amount of time to gain perspective on issues.  As often happens, a recent trip has changed my thinking somewhat. Travel, of course, is a good thing.  That sounds straight out of Martha Stewart, so let’s turn to Mark Twain, who said, ““Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.”

So we (Katherine and I) took a short trip to get together with some of my Amherst fraternity brothers. The whole story of the Amherst fraternity experience (very benign in our era) will prompt another story.

Our travel took us to Old Saybrook, CT. where the 406 mile-long Connecticut River flows into Long Island Sound. Our host has a lovely old home on Ayers Point, and this is how we stumbled onto a bit of 246 year-old news to share with you. In Revolutionary War days, Ayers Point was the site for the fabrication of the Turtle, the first military submarine to attempt an attack on an enemy vessel. The standard information says only that Sgt. Ezra Lee, of the Continental Army was the operator of the one-man vessel, and that he unsuccessfully attempted to drill a hole in the hull of a British ship.

Actually, the story is considerably more interesting. David Bushnell, who had attended Yale, designed the Turtle and, enlisting a number of skilled craftsmen in the area, he solved a myriad of technical problems, not only constructing the boat, but also designing a timing mechanism to allow the boat to escape after attaching an explosive mine to the enemy vessel. But he needed someone with brawn to operate the boat. The operator had to move the boat forward and backward with a front propeller driven by a treadle and a hand crank and also supply the muscle required for a vertical propeller on the top of the boat that assisted with ascent.

Enter David’s brother, Ezra Bushnell. Younger and considerably stronger, Ezra must also have been either somewhat less bright or much more courageous. Perhaps he combined both attributes. Nonetheless, Ezra provided the crew and the power for the Turtle’s initial trials that took place just off Ayer’s Point. By all reports, Ezra became quite proficient at maneuvering the vessel.

The intrepid submariners loaded the Turtle onto a boat, and headed for New York Harbor, where the British fleet with its flagship, HMS Eagle, were anchored. Before they could mount an attack, Ezra Bushnell became seriously ill. This brought Sgt. Lee into the picture, as a volunteer to step into Ezra Bushnell’s spot. The Connecticut History website details Lee’s courageous but unsuccessful efforts against the Eagle.

The “news” from almost 250 years ago?

Invention, ingenuity, creativity, and craftsmanship combined to make the impossible happen; a submerged vessel with a single man aboard attacked the flagship of the British fleet.

The success of the venture depended on the skills of one man, who was laid low by illness, and a second, who made a gallant effort on short notice.

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Today, we may have more powerful technology, but we would be hard-pressed to match the mind and spirit of the Connecticut Yankees.

 

Note: see also Manston R.R., Frese F.J.,  Turtle: David Bushnell’s Revolutionary Vessel. Westholme Publishing

Goldilocks.

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The Coast Range, British Columbia

 

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The Bulkley River, British Columbia

 

This has been a busy summer! I spent a week in Brooklyn with my son as he underwent and initially recuperated from a total hip replacement. During my stay, I had the opportunity to read Goldilocks and the Three Bears not just once, but several times. Probably about 11 times.

My grandson, Walker, (think Walker Percy, the writer or Walker Evans, the photographer) obviously thinks highly of the story and so do I.

Actually, my interest in Goldilocks began some years ago when I was managing immunosuppressive medications. The trick with immunosuppression is, of course, not too little and not too much! Abstracted a bit more, the story tells us that in many of our activities, the relationship between a given parameter (temperature of soup) and a desired outcome (good taste of soup) is not linear. These relationships often take a U-shape or a J-shape, depending on how one draws the graph.

Walker lost interest when I tried to explain how to graph his story (increasing soup temperature on the X-axis, increasing tastes good on the Y-axis = upside down U.) You shouldn’t. This is how a lot of things work in life. Now we’re going to talk about one of them.

The August 22 issue of JACC (the Journal of the American College of Cardiology) has now completed preliminary seasoning. It has rested quietly in a stack of printed material on the breakfast counter, slowly making its way to the surface.

In it are some interesting data, along with a thoughtful editorial. (data, Xi et al, J Am Col Cardiol 2017; 70:913-922 and editorial Gaetano and Costanzo, pgs 923-925.)  The data are a re-confirmation of the J-shaped relationship between alcohol consumption (gm/day) and the relative risk of total mortality.

If one sets the baseline relative risk of dying at 1.0 for “never consumed alcohol” abstainers (this excludes problem drinkers who are abstaining for health reasons), the relative risk of dying from any cause actually decreases to about 0.85 for those who take a drink or two a day. Then it heads right on up, so that when you get to a half-dozen or more pops a day, your risk is well above 1.0.

What does this mean? However the Goldilocks story began, it means that the concept of getting something “just right,” whether it’s the dose of cyclosporine or the temperature of the soup, is something that humans have been working on for a long, long time. Probably almost as long as they have been fermenting stuff…

Note: 20170827-DSC02182.JPGThe two landscape photos are panoramas of multiple shots with my Nikon D7100, put together in Adobe Lightroom. Enjoy!

August at the Lake

It’s August at the Lake.

I should be writing about our recent houseguests, a family that includes two delightful teenagers. Yes, there are really nice teenagers. I know this from direct observation.

And, I would like to describe the clear cool water, the loons diving for their dinners, the four-pound smallmouth that took a surface popper on the first cast a couple of nights ago, and the eagle that has nested across the way. All these things are beautiful, lyrical, like the sky in the few minutes after sunset, still glowing with the memories of pleasant days.

But…I just had lunch. I fixed it and ate it by myself. It was a pretty mundane lunch: extra-crunchy peanut butter and mixed berry jelly on whole wheat with a small bottle of fizzy water. So, while I crunched, I entertained myself by reading the July issue of Nature Biotechnology.  This is not as technical as your average Car and Driver, but still, it’s pretty technical. The news items included a piece on chimeric antigen receptor T-cell therapy and another one on protein scaffold drugs, relatively small polypeptide chains that maintain the binding specificity of antibodies. Then I turned to another item describing the conjunction of artificial intelligence and drug discovery.

Then I stopped, and tried to think for a minute. What do these bits of news mean and, more importantly, what do they imply for the future? Of course, the future is an assumption highly dependent on the statesmanship of leaders like Kim Jong-un and Trump the Donald. As Nat King Cole wrote, “Tomorrow may never come/ For all we know,” and old Blue Eyes answered, “The fundamental things apply/As time goes by.”

I digress. First, these news bits show us the incredible pace of change in biotechnology. Remember, kids, it has less than 75 years since Pauling’s work on protein structure and just 64 years since Watson and Crick described the structure of DNA! What a ride!

But what does this news imply for the future? I don’t mean, what will the next rabbit to come out of the hat look like? Much more important than that, I mean what happens to our society when having a good job means that you have to understand some physical and organic chemistry, a smattering of X-ray crystallography, and have a nodding acquaintance with deep-learning algorithms?

I just spent a week with my younger son, Drew. While he recovered from a total hip replacement (so much for eugenics!), we had plenty of time to talk. He teaches young adults in New York City who want to attempt the TASC (Test Assessing Secondary Completion) exam that leads to a High School Equivalency Diploma. These students, and millions more like them across the country, are totally unprepared to deal with the STEM (science-technology-engineering, math) material that’s required today for employment in the modern world. They don’t have the academic skills, the basic reading and math knowledge, to learn STEM material.

Economic inequality is real, and it’s easy to measure and show on a graph  . But for tomorrow, the critical issue will be educational inequality. Yes, they are highly correlated, but they don’t have to stay correlated. We could try to make sure that the next generation has a chance to acquire better academic skills, that they don’t go to school hungry and come home to violence.

Oh, but that might take some government interventions. Whoops.

Are scientists innately boring and out of touch?

 

The popular viewpoint seems to characterize scientists as dull. The popular media often give the impression that scientists, a.k.a. “nerds,” or “geeks,” insulated from the real world of apps, ride-hailing, and rap by their glasses and pocket-protectors, aren’t much fun.

I’m working on editing a memoir that my friend, Bernie Witholt, left unfinished, and wildly unstructured, when he died two-plus years ago from pancreatic cancer. Bernie was a full-fledged scientist. He spent much of his life in the lab, studying the biochemistry of bacteria. PubMed lists 179 separate publications for him; he held many patents, and his colleagues remembered him as a remarkable salesman for his ideas.  “With visionary lectures, he convinced policymakers and companies to invest. He was a fantastic advisor for, and initiator of, numerous successful biotech start-ups, and was the founding father of the Zernike Science Park in Groningen. In 1992, he established [a laboratory] in the Institute of Biotechnology of Swiss Federal Institute of Technology in Zürich (IBT, ETH Zurich) and worked on alkane-degrading bacteria, biocatalysis and bioplastics until 2005 when he retired.”

In addition to his science, Bernie was an avid oarsman. We rowed together at Amherst, and for the summer of 1963 we rowed a double scull for Vesper Boat Club in Philadelphia. He continued rowing in Zurich with gusto and considerable competitive success.

He and his second wife, journalist Renske Heddema, were an elegant couple with an active social life.

My task in editing his memoir is to communicate the joy of living the scientific life and of asking questions and finding one answer that leads to a dozen new questions. But beyond that, the real scientist also finds joy and excitement in seeing how the world fits together, in knowing about history and the arts as well as science.

Christine Rosen, writing in The New Atlantis in 2006, said, “It is not, alas, the stuff of great memoir, so severed has the actual practice of science become from the broader concerns that animated many early scientists — the wonder at life in its fullness, the observable mysteries of the natural world.”

She nailed the issue! Today’s science involves questions that require detailed technical knowledge that the general public does not have. Yet many of the scientists I know do, indeed, “wonder at life in its fullness.”

I would be delighted to hear from readers who have ideas or suggestions about successfully writing about scientists.

Aargh! By AARP

 

 

 

 

 

 

I have several medical journals open on my desk with interesting topics that I thought I might mention in “The Weekly Packet.” By and large, the open journals are now properly aged, like pieces of meat at a fine steakhouse.

Nonetheless, they will have to wait. The most comment-worthy item to come along this week was in the AARP weekly flimsy.  Painful truth: my wife and I joined AARP to get the substantial discount offered by our local optometrist’s shop on new glasses. Even more painful truth: I was pulled in by the headlines about “why do drugs cost so much?”

I did not have high hope for a rigorous exegesis in the AARP journal, but the presentation was actually quite balanced. The writers covered the long timelines from drug discovery through clinical trials and the FDA approval process, and even covered phase 4 studies. They also touched on the vast amount that “big pharma” spends on marketing. In all fairness, they at least mentioned that Medicare cannot, by law, negotiate drug prices and touched on the strange role that “pharmacy benefit managers” play in the US system.

What’s my point? An AARP member who actually spent some time carefully reading the article would have a basic vocabulary, would become familiar with some of the players in the market, and would have been introduced to two key facts: pharmaceutical costs are only about 10% of overall health care costs, and big pharma spends as much on marketing as on basic research. Not bad. Although the authors did not point out to their readers that without this industry, their diabetes, high blood pressure, high cholesterol, and cancers could not be treated.

More importantly, what the AARP reader would NOT know, struck me last week when I attended the Clinical Leader Forum in Philadelphia. The pharmaceutical industry, particularly the clinical research organizations that have proliferated in the past couple of decades, exemplifies the new economy.

Let me try to explain. In one lifetime, mine, pharmacology has gone from a collection of empiric facts about medicinally useful herbs like digitalis or compounds, like sulfa, to an integrative science and technology focused on identifying “drug targets” in pathophysiologic processes.

From this point of view, the new drugs that pharma generates are the physical tokens, the representation of knowledge and of enormous amounts of data. The patients are not really paying for the drugs, they’re paying for the data. I think eventually, we will work out something more functional for drug pricing. But take a step back, and look again.

Kids who under-achieve academically will not find jobs in this industry. What I saw during last week’s meeting was a relentlessly driven technological and sociological wedge splitting the workforce into those who could deal with complexity and those who could not.

And I’m sure that other industries are similar.

There is no going back. No matter how much we would like to idealize the post-WWII economy, it’s gone.

Here’s the really scary thing; there’s good evidence most AARP members don’t understand what this kind of industry means for our society.

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Time Travel is REAL!

This time last week, I was in Havana.

This is not a report from last week. It is a report from the late 1950s or early 1960s. If you don’t want to take my word for it, read Carlos Manuel Alvarez in the New York Times. 

Packet-style breaking news from Cuba: we Americans have been involved in armed conflicts twice there, in the Spanish-American War in 1898 and in the 1961 Bay of Pigs invasion. The count so far looks like one and one. After 1898, Cuba shook off Spanish rule to become a unique and vibrant society, and most Cubans seem to view that intervention positively. Plus, San Juan Hill gave Theodore Roosevelt an enormous boost.

By the mid-1930s, Fulgencio Batista, strongman, dictator, and certainly a friend of the mob, consolidated his hold on Cuba. He eventually brought rampant gambling and widespread corruption to Cuba. Although the US government supported Batista, revolution was in the air by the mid-1950s. A young lawyer, Fidel Castro, and his brother Raoul, along with Che Guevara, led the successful overthrow of the Batista government in 1959.

In April of 1961, a Nicaragua-based, CIA-sponsored, 1400-man anti-Castro “brigade” invaded Cuba at the Bay of Pigs. The invasion was a disaster. Over 1100 of the brigade were captured. “14 were put on trial for crimes allegedly committed before the revolution, while the others were returned to the U.S. in exchange for medicine and food valued at U.S. $25 million. Castro’s victory was a powerful symbol across Latin America, but it also increased internal opposition primarily among the middle-class Cubans who had been detained in the run-up to the invasion. Although most were freed within a few days, many fled to the U.S., establishing themselves in Florida.” https://en.wikipedia.org/wiki/Fidel_Castro

Having seen the terrain around the Bay of Pigs, including the dense Cienaga de Zapata, it’s not hard to understand why the invasion stalled. Most Cubans seem to view the Bay of Pigs for what it was, a fiasco.

After the events of 1961, time stopped. In fact, with the fall of the Soviet Union, from 1990 to about 2000, time went backward. This was Cuba’s “Special Period,” when support from the Soviets ended and the entire country fell into dire straits, short of everything.

Today, what we saw was how Castro’s unrestrained idealism, with the best of intentions, nearly destroyed a country. Cubans have universal education, universal healthcare, and no homelessness. But in this society, the infrastructure has crumbled; housing stock has steadily deteriorated, and the highly educated are vastly under-employed and underpaid.

The current government has reduced restrictions on free enterprise. Independent restaurants, “paladars,” flourish in Havana (see the photos). Some restoration and refurbishing is happening. But the work to be done is daunting!

High points of the trip: the Hemingway museum at Finca Vigia  and the National Museum of Fine Arts in Havana.

If you click on any of the photos in this post, you should get a slide-show view that will have nice size and detail. I have almost 900 photos sitting in Lightroom; more to come.