Vol. 153 September 1, 2016 Is Nothing Sacred? No, Not in Medicine.

September 1, 2016

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It can be frustrating and unsettling when after years of telling us that something is good…or bad for you, doctors then tell us that the opposite is true! “Redefining the truth” is the essence of science, particularly the science of medicine. The medical mantra is: Keep studying, keep collecting data, keep analyzing, and if the “truth” changes, report it!
Here are some more revisions of the truth as examples.

Baby Dolls and Teen Pregnancies
Giving high school students a baby doll to take of care for several weeks is touted as a deterrent to teen-age pregnancies. The sophisticated doll is programmed to cry, make demands, go to sleep (or not), etc. just like a real baby. Students are instructed to care for it 24/7 as if it were a real baby. The expectation is that such a “reality-check” would make teen agers more aware of the burdens of caring for an infant and that would convince them to use effective birth control.

A recent report in the British Medical Journal documented that the average teen age pregnancy rate in those who cared for a doll stayed the same or even INCREASED in some schools. The article speculates that the positive, loving experience that some teens had and the extra attention they received while caring for the doll caused this. The company that makes the dolls quickly switched its marketing pitch from “reducing teen pregnancy” to “teaching quality infant care”.

Get the Lead Out”
The high level of lead in the water in Flint, Michigan in 2015 immediately raised an alarming concern about “poisoned children”.  A blood lead level of 5 micrograms per deciliter is considered “a threshold for official action as a “precautionary principle” according to public health experts.   5% of the kids in Flint had blood lead levels of 5-10 micrograms per deciliter.  The increase from 2.4% having a level over 5 in 2013 to 4.9% of kids tested in 2015 raised the public health alarm.

It is well known that the body can excrete lead. If the input of lead (ingested in food, water, or dirt or breathed in from car exhausts) exceeds the excretion rate and the blood lead level reaches 40-69 micrograms per deciliter then outpatient treatment is recommended, even though the person is asymptomatic. Blood levels above 70 can cause symptoms and are treated by hospitalization. None of the Flint children had lead levels over 40.

Lead performs no essential function in our bodies and chronically high levels can cause neurological damage, so it is incumbent of public health officials (and politicians) to prevent prolonged exposure, but these children have NOT been damaged. They will, I am sure, be monitored and studied for years to come to see if there is any subtle effect of these low lead levels. Because that’s what medical science does.

Lowering Blood Pressure in Intermediate-Risk Persons Without Heart Disease with Two Drugs Did Not Decrease the Rates of Major Cardio-vascular Events

NEJM 374:21 May 26, 2016,pg. 2009-2019

Lowering Cholesterol in Intermediate-Risk Persons Without Heart Disease and Normal Lipid Levels With One Drug Decreased the Risk of a Major Cardio-Vascular Event from 4.7% to 3.6% (a 25% reduction)

same NEJM issue pg. 2012-2031

Lowering Blood Pressure AND Cholesterol in the same study as above with Three Drugs Decreased the Risk of Some Major Cardio-vascular Events from 5.0% to 3.6% (a 30% reduction)

same NEJM issue pg. 2032-2043

Like Fox Radio, “We report the news. You decide.”

“Get the Fat Out…But Which Fat?”
The British Medical Journal published an article in April written by a team of scientists at NIH headed by Christopher Ramsden, called the “Indiana Jones of biology” because he specializes in excavating old studies, particularly those that go against our “mainstream government-sanctioned health advice”. He unearthed a 1968 five-year, tightly controlled study of over nine thousand participants randomly assigned to either a vegetable oil based diet or a standard animal fat diet.

The study documents that eating vegetable fats instead of animal fats did NOT, repeat did NOT, reduce the risk of heart disease or death. Substituting a vegetable oil diet ( about half of the saturated fat of the standard diet) did lower the average blood cholesterol by 14%, BUT the risk of death INcreased 22% for every 30 points the cholesterol fell! 

Dr. Robert Franz of the Mayo Clinic, the son of the organizer of the 1968 study, speculates that his father’s team was disappointed that they could find no benefit of the vegetable oil diet, and so didn’t publish it widely. An accompanying editorial in the BMJ concluded that “ the benefits of choosing polyunsaturated fat over saturated fat seem a little less certain than we thought.”

Again like Fox Radio:  “We report the news. You decide.”

“Worried About Peanut Allergy in Your Family?
Avoid Peanuts! No, NO, Eat Them as Early as You Can!”
The experts use to say “no solid foods to infants before age 4 to 6 months.”
Experts now say “do not delay solid foods beyond 4 to 6 months.”

In the past 10 years childhood peanut allergy has doubled from 1.4% to 3% (still small).
The experts use to say that “if you’re worried about peanut allergy in your child do not give peanut food until age 3 years”.
Experts now say “give the infant peanut food as early as 4 months of age.”

A 2015 study in the New England Journal of Medicine showed that consumption of peanut food at 4 months of age reduced the development of a peanut allergy (documented by skin-prick tests) by 70% – 86%!!

“We should no longer recommend avoidance of allergenic foods in infants.”

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Vol. 140 January 15, 2016 A Review of 2015 Hubslist Blogs

January 15, 2016

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Click on the date to see the full blog

 

January 1 – 5 out of 10 of my resolutions were “kept”. You guess which ones.

January 15 – 6 reasons why patients are non-compliant , excuse me, “non-adherent”- the new PC term, with their medications.

February 1 – incidence of sudden death while watching the Super Bowl (Patriot fans probably don’t have to worry about that THIS year.)

February 15 – some myths revealed about cholesterol in your diet, global warming, measles vaccination rates, herbal supplements, and Dr. Oz, vendor of snake oil(s).

March 1 – 8 new causes of death caused by cigarette smoking added to the previously identified 12; a total of 20.

April 1 – Athena Health purchases MySpace which raises more concerns about privacy of health care data (April Fools edition).

April 15 – what does a “board certified physician” mean, and what does it have to do with Presidential candidates (Rand Paul)?

May 1 – physicians’ prognoses are often too optimistic for the same reasons patients’ are.

May 15 – E-cigarettes open new avenues for adolescent use of marijuana and synthetic cannabinoids (“bath salts”).

June 1 – annual review of sunscreens and bug repellents plus less universities providing student access to tanning booths.

June 15 – new forensic techniques of identifying individuals by bacterial, viral, and DNA “fingerprints”.

July 1 – 6 positive access outcomes and 4 positive health care delivery outcomes of Obamacare at 5 years of age.

July 15 – dangers of synthetic cannabinoids (attn: Chandler Jones?) and the minimal (“pending”) review of sunscreens by FDA.

August 1 – two websites with the best “symptom diagnosis” track record for helpfulness, and the one that is the worst.

August 15 – [ family vacation in a lighthouse without electricity or running water]
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September 1 – why new drugs cost so much, no “gay gene” identified yet, and the myths of low testosterone, chronic Lyme, and  8 glasses of water a day.

September 15 – The health benefits of our “microbiome” and the “microbiome” of the New York City subway.

October 1 – the misleading, untruthful attacks on Planned Parenthood.

October 15 – the scope and magnitude of adverse effects of dietary supplements.

November 1 – transgender, transsexual, transvestite, and hermaphrodite, oh my!

November 15 – toddlers shooting people and other “norms” of gun deaths – “By Degrees“.

December 1 – changing advice about what NOT to eat during the holidays.

December 15 – the benefits of research using fetal tissue, short history of political attacks on Planned Parenthood, and why if you are NOT fat and live a long life you should thank your parents.

HAPPY NEW YEAR


Vol. 137 December 1, 2015 Holiday Season Eating Advice

December 2, 2015

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“WHY LISTEN TO SO-CALLED HEALTH ‘EXPERTS’
WHEN THEY ARE ALWAYS CHANGING THEIR MINDS
ABOUT WHAT’S GOOD OR BAD TO EAT?”

With the passing of the Thanksgiving turkey we are officially in the “holiday season”. Weight gain during the 6 week holiday season represents 51% of our annual weight gain which is actually only about a pound or two on average. Much less than the average weight gain during a 7-day ship’s cruise of a pound a day. So, what foods should be avoided in the next 6 weeks?

JUNK FOOD?
Junk Food has been the traditional scapegoat for our increasing obesity. But, what is junk food? Decades ago I remember a very savvy pediatric endocrinologist, Dr. Gilbert Forbes, challenging a forum of physicians at a national pediatric meeting to define junk foods.
“Food high in sugar and carbohydrates”, was our immediate response.
“Like grandma’s apple pie?” was Dr. Forbes’ equally quick reply.
“Oh… high starch foods” was our second try.
“Like potatoes? How come all Germans aren’t fat?”
Our working definition after an hour or more of back and forth boiled down to “anything wrapped in cellophane or delivered by a vending machine.” Dr. Forbes’ point was that it is the total number of calories ingested and not any particular food that contributes to obesity.
Today that definition still holds true

In its inexorable march towards the truth medical science has just thrown a stone at the junk food glass house. A Cornell study (1) based on nearly 5,000 surveys done by the CDC in 2007-2008 surprisingly showed that for 95% of the people their BMI  (a measure of obesity) was NOT linked to soda, fast food, or even candy. The researchers expected to find that the more junk food people ate the more apt they were to be obese. Instead they found no correlation between eating junk food and a higher BMI; no link between junk food and obesity. The researchers concluded that it was our increased intake of grains and added fats that was driving up the number of calories consumed by the average American.  “Junk foods may not be the central difference between fat and thin. Limiting those foods is a part of a healthy diet, but it might not be the whole thing.” (2)

 SUGAR?
Sugar continues to get a bad rap, and we consume more and more sugar substitutes. But, as we say in medical science, “there ain’t no free lunch”. Studies showing that Canadian lab mice were more prone to develop bladder cancer if fed saccharine (Sweet and Low) certainly caused a bit of a flap until someone calculated the comparative human doses to be several shovelfuls a day. Sucralose (Splenda) is now under investigation because its effect on our gut bacteria may make us more prone to gain weight and develop diabetes. Like Fox radio news says, “We report, You decide.”

SALT?
Excess (added) salt does seem to correlate with higher blood pressure.  I don’t have the space here to summarize again the whiplash swings of research on salt and disease, but I can tell another story from the past that makes the point more succinctly.
A bunch of physicians (all male – I told you this was a story from the past) who were having lunch at the same table in a hospital cafeteria started remarking about the prodigious amount of salt a cardiologist was pouring on his food. As the discussion heated up, the cardiologist looked up from his plate and stopped it with a question, “How many of you have talked to your father in the past year.” Half of us raised our hands. “You guys can eat what you want. The others better watch their diets. You just have to pick your parents right.”

EGGS?
After decades of branding eggs as “bad” because of its cholesterol the federal government’s Dietary Guidelines Advisory Committee reported in 2015 that “eggs are OK.” A 1999 Harvard study showed that there was no correlation between an egg a day and the risk of heart disease in healthy people (3). 90% of our cholesterol is manufactured by our own liver as directed by our genes. Restricting our intake of certain fats can normally decrease our cholesterol level by about 10% at most.

WINE or BEER?
Previous studies have shown that wine drinkers seemed to experience less heart disease and certain cancers. Efforts to analyze why wine seemed so healthy resulted in tagging resveratrol, a chemical in grape skin, as the “active ingredient”. Dozens of nutritional supplements containing resveratrol ($12 – $25 for a month’s supply) immediately hit the market. Four Danish scientists thought that answer might be too simple and launched a study of what else those wine drinkers were buying at the food store. After examining 3.5 million store receipt transactions from 98 supermarkets they found that wine drinkers were more apt to buy olives, low-fat cheese, fruits and vegetables, low-fat meat, spices, and tea. Beer drinkers were more likely to buy chips, ketchup, margarine, sugar, ready-cooked meals, soft drinks, and, of course, beer. (4)

BOTTOM LINE for this holiday season?
“PICK YOUR PARENTS RIGHT, AND EAT AND DRINK IN MODERATION.”

References:
1. Boston Globe, B12, November 23, 2015, Megan Scudellari
2. David Just, Cornell University Professor of Applied Economics and Management
3. Boston Globe, March 15, 2015, Walter Willett, MD, Professor of Nutrition and Epidemiology, Harvard School of Public Health
4. The Dorito Effect: The Surprising New Truth About Food and Flavor, Mark Schatzker, May 2015 as reported in The Atlantic, June 2015


Vol. 121 March 1, 2015 Friends Don’t Let Friends … Smoke

February 28, 2015

hub20 established causes of deaths caused by cigarettes:
(Surgeon General Report 2014)
11 cancers – Lip and oral, esophageal, stomach, colorectal, liver, pancreatic, laryngeal, lung, urinary bladder, kidney, and
acute myeloid leukemia
6 vascular – ischemic heart disease, other heart disease, stroke, atherosclerosis, aortic aneurysm, other arterial diseases
2 pulmonary – Pneumonia and influenza, COPD
Diabetes

These diseases account for about 83% of the total excess mortality (higher mortality rates than non-smokers) observed among current smokers.

Several causes of death newly associated with cigarette smoking have recently been added as a result of a study of 1 million men and women over a 10 year period. (NEJM 372;7, Feb 12, 2015)
About 9% of both men and women were current smokers.
42% (women) and 58% (men) were former smokers. (56-70% quit over 20 years ago)
49% (women) and 32% (men) never smoked.

Causes of deaths newly associated with smoking (with relative risk compared to non-smokers)
(1.0 is the mortality risk of a non-smoker)
ischemic disorder of intestines – 5.6 (nearly 6 times that of a nonsmoker)
liver cirrhosis – 3.6
cancers of unknown sites – 3.2   ( 2-6% of all cancers)
hypertensive heart disease – 2.9
all other digestive disorders – 2.6
renal failure – 2.1
all infections –  2.2
prostate cancer – 1.2

Most of the remaining 15-17% of excess mortality of smokers over nonsmokers is accounted for by these newly designated diseases.

The relative risks of death for smokers went up as the number of daily cigarettes smoked went up.
The relative risks went down among former smokers as the number of years since quitting went up.

How do people stop smoking?

YES
Conscious decision “cold turkey” (after being scared to death by statistics like this) – 4-7% success rate
nicotine replacement therapy (NRT) –  gum,patch, aerosol, lozenges
prescription medication – Wellbutrin, Chantix (always needs to be combined with support or cognitive therapy – even just telephone
counseling) 25% success rate at 6 months
support groups – NA, quitnet.com, Great American Smokeout

 MAYBE
hypnosis, acupuncture, mind-body practices, herbals
E-cigarettes – the jury is still out; no consistency of ingredients among brands is one problem in evaluating health risks.

NO
filter cigarettes – do not reduce nicotine inhaling; actually can increase craving
magnet therapy – “a small magnet on each ear”
chewing or other oral tobacco

The addiction to nicotine and to marijuana can be mapped using functional MRIs to the same part of the brain – the part of the brain that “lights up” with cocaine ingestion.  Some treatment programs and several research projects are honing in on this “dual addiction” of cigarettes and joints.

Interestingly, ingestion of the most common food “addictions”, ice cream, pizza and french fries, also maps to this same part of the brain.  Maybe as we get fatter and happier as a nation by using these substances other than tobacco, we will smoke less cigarettes, and live longer!


Vol.120 February 15, 2015 Disillusioned …Again and Again

February 14, 2015

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 “Scratch any cynic and you will find a disappointed idealist.”
― George Carlin

Maybe it is just that time of year, the record snowfall, the frigid temperatures, the lack of sun, but I feel like the world as I have known it is crashing down around my ears. Brian Williams has fallen off his pedestal, Bill Cosby is canceling shows all over the place, Tiger Woods is not coming back, Jon Stewart is leaving The Daily Show, Steven Colbert has already left, the towns are running out of sand and salt, and the trial of Dominique Strauss-Kahn, former head of the International Monetary Fund, has come up with the unique defense of his “aggravated pimping” “at a sex parties with “you can’t tell the difference between a prostitute and a naked socialite”.

So many of the truths we have held dear in medicine, science, politics, and society are being revealed as mere illusions. To wit:

  • Cholesterol need no longer be a nutrient of concern”. So sayeth the “nation’s top nutrition advisory panel” after 40 years of telling us just the opposite! High cholesterol levels in your blood do increase your risk for heart disease, BUT dietary cholesterol contributes only about 10% of that level. Of course, the panel couldn’t just leave it at that. According to them the REAL danger lies in foods heavy with trans fats and saturated fats. However, if you follow recent arguments in the literature closely enough you will see that there is some debate about which are the “good fats’ and which are the “bad fats.” Maybe we’ll have  to wait another 40 years for consensus.
  • Mississippi and West Virginia, among the poorest states in our country, have the best rates of measles immunization, and it is because they are the ONLY states that refuse to accept a waiver from immunizations on the basis of parental beliefs when children enter school. Mississippi’s measles vaccination rate is 99.7% for entering kindergarten students. West Virginia is at 96%. Epidemiologists have established a 94% immunized rate for measles as necessary to sustain “herd immunity”. In California and Arizona ( where thousands of Super Bowl visitors came and went back to their own states) the rates are 90.7% and 91.4% respectively.
  • Spewing sulphur gas into our high atmosphere could help block sun radiation and help cool off a warming earth. Isn’t sulphur one of those toxic pollutants given off by burning coal and other fossil fuels? Well, yes, says the National Academy of Science, but the computer models of blocking the sunlight with released sulphur have such a positive logic about them that “we should test it in some small pilot studies”.
  • Four out of five bottles of supplements taken off the shelves of GNC, Walmart, Walgreens, and Target in New York did NOT contain ANY of the herbs listed on their label. Ginseng pills “for physical endurance and vitality” contained only powdered garlic and rice. Ginkgo biloba for “memory enhancement” contained powdered radish, houseplants, and wheat. That label even claimed that it was wheat- and gluten-free! The FDA can only target products that have dangerous ingredients. It took the NY State Attorney General’s office to reveal this harmless ingredient sham, aka “profit by placebo” (NY Times, Feb. 3, 2015, pg.1)
  • Half of the health information and recommendations given on The Doctor Oz Show and The Doctors is false. Not only did 80 recommendations from each TV show picked at random from the 900 recommendations identified have NO evidence to support them, but many were even contradicted by evidence. In typical academic, “English speak” the authors suggest that “consumers and clinicians should be skeptical about these TV show recommendations”. (BMJ 2014 Dec. 17, 2014, 34)

Is there any hope for us optimists?   Well …

  • Crime rates in Boston have plummeted during this cold snowy weather. Homicide is down by 70%, rape by 50%, and vehicle theft by 46%. I guess everyone is staying inside, wearing lots of clothes,  and skipping the shoveling needed to steal a car. Rates for violent crimes in New York City, which had less snow and higher temperatures, all increased during the same period.

Vol. 119 February 1, 2015 Watching The Super Bowl Could Be Harmful To Your Health

January 31, 2015

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Sudden cardiac arrest among fans is a well-documented occurrence at exciting sports events.

 

 

  • Two fans dropped dead this summer as the Argentina soccer team beat Netherlands in a 4-2 shoot out to break their 0-0 tie. The 16 year old boy collapsed in front of a giant TV screen the mayor had set up in the village square as the winning goal was scored. The 49 year old died during the post-game celebration.
  • A 2010 European study of 190 major soccer arenas revealed that there was 1 sudden cardiac arrest in the stadium every 5-10 matches.
  • An American study of heart attacks after the 1980 and 1984 Super Bowls showed that, on the day of the game and for several weeks after, men had 3 times the number of heart attacks then expected; a jump from 1 to 3 in 100,000. Further analysis showed that the rate was higher in the fans whose favorite team lost and was lower in fans whose team won!

The presumed mechanism is the outpouring of adrenaline during peaks of excitement which causes heart muscle to go into contractile spasm or ventricular fibrillation. Either one is lethal if not stopped. The European study felt the problem was significant enough to make 6 recommendations for soccer stadiums to ensure that stricken fans could get immediate access to life-saving medical care.

Is there anything that you can do to reduce your risk? Unless you are already taking daily aspirin to reduce your risk of a heart attack DON”T start now. Aspirin has real risks of causing intestinal bleeding AND, truth be told, there is NO evidence that daily aspirin prevents your first heart attack (“primary prevention”). Its beneficial effect is well proven only in reducing the chances of you having another one (“secondary prevention”).

Alcohol is a well-known contributor to high blood pressure (not the best thing for a heart), so if you are truly worried you could take that rather drastic step.

Us coach potatoes can take some solace in the fact that we are not the only ones with increased risk for sudden cardiac arrest.

  • Endurance athletes (“continued exercise for 3 hours or more”) have about the same risk, 1 in 50,000, of acute heart attack or sudden cardiac arrest within 24 hours of completion. (1)
  • A 1999 study of 38 Austrian athletes in a 143 mile bicycle race with 18,000 feet of altitude change revealed that 34% of them had elevated heart enzymes in their blood at completion; an absolute sign of heart muscle damage. The winner had the highest level! (2)
  • A subsequent study of participants in the Hawaiian Ironman Triathlon found that 11% had signs of heart damage at the end. Of course, this is not new. Remember that Pheidippides, the first marathon runner, dropped dead just after delivering his message.

It is interesting that these studies involved only men. Because heart attacks are still the number one killer of women and that 46% of the last Super Bowl audience were women, perhaps it is time to broaden the study population.

I used to collect articles about the dangers of running in order to support my resistance to popular peer pressure at the time, so I am personally heartened to know that the risk for sudden cardiac arrest during a sporting event is about the same for both couch potatoes and players.

References:
1.  Jour Am Coll Card 28:428, 1996
2.  Am Jour of Card 87:369, 2000


Vol. 118 January 15, 2015 It Ain’t Just Vaccines That People Decline

January 15, 2015

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Half of U.S. patients don’t take their medicines as prescribed by their physicians.(1,2)

We use to call such patients “non-compliant.” As “patient-centered care” became the mantra for contemporary medicine that “passive, judgmental” term of “non-compliant” was banished and replaced by “non-adherent”, a presumably less derogatory term implying a partnership of patient and physician. (3)

A cardiologist, struck by the number of her patients that did not comply with adhere to their heart medicine prescriptions, asked 20 of them who had survived a heart attack why they didn’t adhere to medications that had proven benefits of secondary prevention of a next event, an event that could cause death. (4) Their comments (listed first below)  were surprisingly similar to feelings expressed to me by parents who decline immunizations for their children (typed in bold italics ).

1. Risk Aversion
“Why take medicine that could wreak havoc on your body.”
In people with negative emotional reactions even a small risk of side-effects seemed to overpower any positive feeling about the proven benefits of a drug. Their perception of risk is greater than their perception of benefit. They are “far more sensitive to possibility than to probability”.(5)
Despite numerous studies showing that there is no probability of an association between measles vaccination and childhood autism some parents still feel that there is always the possibility. Arguing relative probabilities of vaccine side effects versus disease effects with them is not productive.

2.Naturalism
“Medications are chemicals and should not be in your body on a regular basis”.
Vitamins, herbs, and other health supplements of all kinds are often turned to because they are not “chemicals”.
“I don’t want to have any foreign proteins injected into my child”. Natural immunity, of course, depends on our body recognizing and reacting to foreign proteins so that symptoms resolve and our next exposure to the same foreign protein doesn’t make us sick again. “It is the additive proteins that we don’t want” is often the next statement from the parents. Pointing out that there are 315 “foreign proteins” in today’s vaccines  rather than the thousand’s in the vaccines before the 90’s does not reassure them.

3.Denial
“Men don’t like taking medicine because to do so they are admitting that they are not strong. Most people like to think that they are strong and mighty. …Their very sense of well-being after surviving a heart attack and quickly resuming healthy lives may convince them that medications are not necessary.”
Some parents feel that their unimmunized children are safe from disease because the rest of the children are immunized, the “herd immunity protection” argument. Pointing out that herd immunity is effective only when the community reaches the currently unachievable high percentage of immunity (a 94% threshold in measles and whopping cough) has no effect. You would think that the possibility of measles in their unimmunized child in a partially immunized community would override the small probability of side effects from the vaccine. It doesn’t with some parents.

4. Avoidance of Sick Identity
“Has having a heart attack become too easy?” People can spend more time being sick from flu than having a therapeutic cardiac cath within 90 minutes of arriving at the ER and walking out of the hospital 24 hours later.
Has the absence of children dying or being crippled by measles, polio, diphtheria, or croup dulled our ability to imagine our children in such a sick state? Sporadic epidemics of whooping-cough and croup in certain states have been successful in raising immunization rates a bit. If there were an Ebola vaccine, I wonder how the vaccination  non- adherent parents would have juggled that possibility/probability calculation for their children.

5. Difficulty Visualizing Benefits
“The benefits of cardiac medications may be imperceptible and the absence of perceived benefit is a well-documented reason for non-adherence”. Adherence to anti-platelet medications (“blood thinners”) is higher than other cardiac meds perhaps because the patient can easily visualize the “thinned” blood flowing smoothly through an unclogged pipe. That the medication is actually “doing something” is reaffirmed by the prolonged bleeding from a razor nick.
Maybe we pediatricians should develop an app and FitBit that could non-invasively measure antibody levels and send an alert to the child (via his/her own smart phone, of course): “Your antibodies against [insert tetanus, diphtheria, or whatever disease name here] have been declining for years and are now at a level that no longer protects you. Go immediately to your nearest [insert sponsoring drug/ convenience/department store name here] and get vaccinated.”

6. Avoiding Dependency
“Relying on cardiac medications is another form of addiction. I brought on this heart attack by my life style and it is my responsibility to avoid another by changing my life style.” Taking medications may be viewed as a loss of control, as “following orders” , as “being told what to do”.
This rejection of authority rings true in my experience with some parents who decline immunization for their children. It also may explain why pockets of unimmunized children who are not in poor families are sometimes clustered within tree-hugging, organic food eating, aging-hippy communities. Frustrating as this rejection of authority is to the physician, repeatedly battering the head and shoulders of these parents with all the scientific facts proving that vaccinating their child is safer than having them contract the disease is counter-productive.

The discussion with parents who decline immunizations for their children is hardly ever a rational one. Some beliefs and feelings seem impervious to facts. Certainly a parent’s personal knowledge of some child, usually a cousin or a nephew/niece, who had a vaccination and then had a seizure or who “has never been the same since” is a real conversation stopper. That personal experience can generate such deep feelings that I no longer even try to talk them out of that hole. We don’t experience that same depth of feelings if an older adult we know survives a heart attack only to die of a second one months or years later. We often feel, not knowing all the details, that “C’est la vie”.

References:
1. NEJM 2005;353:487-97 Adherence to Medication
2. J Gen Intern Med 2008;23:115-21 Secondary Prevention After MI
3. Ann Pharmacotherapy 2004;38:161-2 Adherence or Compliance?
4. NEJM 2014;372;2:184-7 Beyond Belief
5. Psych Bull 2001;127:267-86 Risk as Feelings


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