Sex, Drugs, and Public Health

February 1, 2022

WHAT  COVID  HAS  TAUGHT  US

Filed under: Uncategorized — cbmosher @ 8:10 am

            Sometimes, whether writing on paper or two-fingering on the ‘puter, an issue reduces me to a hopeless tangle of glitching neurons. Shaking the Magic 8 Ball for the hundredth time, hoping for different answers, I asked people what the Covid pandemic had taught us about ourselves. Our list includes many lessons – some painful, some hopeful. You may have your own list. 

            Americans thought that our Health Care system was resilient – the best in the world. To be more accurate, most of those who believed this did not work in health care. To hold this belief, you’d need to ignore the two most basic facts about U S “Health Care.” First, that it’s been the most expensive system in the world for decades. Currently costing $10,500 per person each year. Second, that the Health RESULTS from our system have been among the worst in the industrialized world. And I’ve seen “Third World” countries with better health outcomes than we get for our massive investment.

            (Stops typing to face-palm himself about this yet again).

            OK. I’m back.

            How could so many people ignore these realities for so long?

            Answer: the “Sunk Cost Fallacy,” a Cognitive Bias which states that we invest more in things that have already cost us something, even if that results in a negative outcome. “Investment” can be money or emotional commitment.

            What Covid did was rip the bandage of denial from this Sunk Cost fallacy with wave after wave of variants overwhelming every aspect from ambulances to ICU’s. Nurses and physicians have been stressed, exhausted, heart broken and have been attacked by hostile families. Patients in need of non-Covid care (planned surgeries, heart attacks, cancer treatment) have been triaged to the back of the line, to their detriment.

            One of the most eloquent synopses of this situation was written by an E R doctor and dean of the School of Public Health at Brown University (Rhode Island). Some out-takes:

  • many beds are closed in the emergency department and across the rest of the hospital (including ICU) because of a lack of staffing.
  • patients have been waiting on emergency department stretchers for hours, until an intensive care unit, medical or surgical bed becomes available.
  • Health Care Workers suffer emotional exhaustion from caring for horribly sick Covid patients — especially now that the disease is so preventable. Said one, “I feel like we’re rats on a sinking ship. Do I jump off now or hope that someone saves us?”

            Added to this, a friend who is a cancer specialist in SoCal reports that blood donations have fallen off so drastically that there is no longer enuf for leukemia patients who need blood regularly to survive. 

            An E.R. nurse recently wrote about why she (like many others) is quitting. “A patient in critical condition who was waiting outside, coded in the ambulance bay, I learned that the patient had an active bleed and was given two units of blood at the previous facility where he was being treated. They ran out of blood there. ‘Would you like me to run and get STAT blood, doctor?’ I asked as I looked down at the pale, motionless body in front of me. ‘No,’ he replied. ‘We only have two units left, and we are saving it for any emergency pregnancy complications.’ I am watching my country’s health care system crumble in front of me.” 

            “I feel like we’re rats on a sinking ship.” (E R physician)

            So it took getting to this point, where our Health Care system is being held together with fraying twine and chewing gum to realize that it’s been run like a profit-making business, and is so lean that anything more than the short-term crush of several trauma victims at once or of sick folks during Flu season is too much for it. What we need, what you deserve for all that $10,500 per person, is a system that stresses Prevention. Keep as many people healthy and out of the E R and hospital as possible. Take the stress off Health Care Workers. And put together a system that serves the Public (not just those with good insurance), eliminating the profit motive which thrives on admitting as many “heads-in-beds” as possible. Meanwhile – – –

         Topless Urgent Care Centers !

            This satirical line from, “Don’t Look Up” is not as far from reality as I’d like. As politicians early on in the pandemic undermined Public Health professionals and the virus ran thru us as gleefully as an 8 year-old in Disneyland, Quacks and Scammers moved in for the kill. These are the descendants of the Old West’s Dr. Feelgood, who, from his covered wagon hawked magical elixirs (chief ingredient in “elixir” is alcohol) and snake oil.

            Exhibit 1: in Florida and Texas, they set up Covid testing sites which take your money and Social Security number, give you a swab, then disappear. 

            Exhibits 2 thru 5:  bleach, U-V light, Ivermectin, drinking pee.

            Exhibit 6: people that demand hospitals perform malpractice on critically ill family members by administering some of these fake cures.

            How can people BELIEVE this stuff?

            This question keeps popping up when people get together outdoors to drink and eat. Comes from both sides of the political chasm and is, apparently, applicable to most any human behavior these days.

            Answer is found in two more Biases – the “Dunning-Kruger Effect” wherein the less knowledge one has, the more confident he / she is. And the “Bandwagon Effect” where beliefs grow as more people adopt them.

            Ask not what your Society can do for you – – –

            Thought we’d learned that (paraphrased) lesson back when our skin was smooth and our hair wasn’t gray. But :

            Exhibit 7– flight # AAL38, one hour into its journey to London, had to turn around and return to L A because of one person acting out her distorted concept of “freedom” by repeatedly refusing to wear a mask. 

            Exhibit 8 – recently, another person in Virginia threatened to shoot local school board members who were discussing following State law about masks to protect the children.

            Exhibit 9 – people who study the genes of viruses and others who study the virus’ behavior (“epidemiology”) have found that the un-vaccinated population has become the breeding grounds for Covid variants. So we’re not waking up anytime soon from this nightmare. There are places in the world where people are begging for the vaccine but there’s not enuf available. Here, it’s the opposite. We are begging folks to take the (free) vaccine to protect, not only themselves, but everyone around them. But – – – nope.

            My Flabber is exceedingly Gasted at what Covid has revealed – the depth to which America’s concept of Rugged Individualism seems to have degenerated into flat-out self-centeredness. What Public Health does to protect people in a situation of a highly contagious virus  can only be successful if everyone (or some large majority) of Society co-operates. Society is people who do things for you (road repair crews, flight attendants, Health Care Workers, waiters, store clerks, teachers) AND you doing things for them (not running them over with your car, paying a living wage, getting vaccinated, wearing a mask or – failing that – staying away from them).

            A sizable segment of people has basically abandoned Society, endangering others with their behavior and justifying it with words. “Personal Choice.” “Pure Blood.” “Freedom.” There’s a Bias working here, too, “Reactance,” wherein we do the opposite of what we’re told. (Kind of thing we were supposed to out-grow around age 16).  

            We’re seeing the damage this is causing as the unchecked spread of Covid, but an even more profound damage to our Society comes from what underlies that: the subversion and rejection of our Public expertise and government service, which is dragging our Society off a cliff.

O.T.O.H. – – –

            Got a friend here in Mariposa and another off in Texas who had simultaneous epiphanies, not too long into the closure of schools in an effort to protect the kids and to control the outbreak.

            “Have a renewed appreciation of teachers,” they wiped their sweaty brows.

            Teachers’ jobs got even harder with Covid, what with re-working their curricula to fit the Zoom app. But family members had to keep the kids at the computer, urge them thru lessons, drill-sergeant their assignments. Teachers (along with the citizen-volunteers who make up School Boards,     nurses, restaurant servers, flight attendants, store clerks) are the previously underappreciated heroes, revealed to us by this pandemic. 

            We saw restaurants and other businesses struggling, failing. And we responded by supporting them with take-out orders, outdoor dining (in the snow, some places) and ordering for curb-side pick-up.

            Neighbors helped those who were afraid to go shopping because of their age or medical conditions.

            We reconnected more intensely with family and friends.

            Flip side of that coin: we came to see ourselves as Citizens of the World. Now a virus from an animal half the world away can hitchhike in someone’s pharynx and de-plane into a virgin population in mere hours. We’re all in this together. 

            We learned what Public Health does to keep all of us safe.

            Covid revealed how valuable Public Education is. With a constant whirlwind of mis-information and outright lies bombarding us and confusing us (not only about Covid), it reminded us that teaching young people to know how to find accurate facts and how to detect flawed information is crucial to a Free Society.

Punchline: as a physician friend said: “Life is short, sweet, precious and highly fragile.”

October 20, 2021

What We’re Made Of

Filed under: Uncategorized — cbmosher @ 5:47 am

            The same stuff that makes up the world around us – rocks, soil, grass, trees, air – makes up our bodies. The same water that covers 71 % of the Earth makes up 60 % of your body. The Calcium which makes rocks hard is in your bones and teeth. The Iron which turns red with rust makes your blood red. The Nitrogen that grows plants and trees is in your DNA.

            You shrug. So did I when a Native American said this, but then it made me look at a picture larger than what I’d learned in Med School. And it forced me to see the even larger picture that looms for all of us on a fast-approaching horizon.

            Goes like this: the Sun is a gigantic Hydrogen bomb in the midst of its explosion. It, and many other suns (which we call “stars”) are fusing atoms of the smallest element – Hydrogen – into larger, heavier building blocks. These include Carbon, Oxygen, Silicon, Iron and Nitrogen. These elements make up our atmosphere (Nitrogen, Oxygen, Carbon) and our Earth (rocks, water, sand, various minerals).

            These building blocks become molecules, like di-hydrogen oxide (AKA “water”), and build plants and trees. Carbon, Nitrogen and Oxygen unite to form proteins, fats, carbohydrates and nucleic acids. These molecules keep living things (from viruses to plants to us animals) functional. Silicon provides elasticity to our cartilage, skin and connective tissue.

            And we get our energy from the same engine that powers everything from grass to hurricanes. Radiation from our Sun stores its energy in our food. And the bio-chemical reactions I learned about in Med School do the rest.

                        “Existence is a free gift from the Sun.”

The LOOMING

            One of the great gifts of Mariposa is just beyond my back deck. On occasions when I ignore the i-phone and ‘puter  and go out there, I drink in the sound of breezes thru the pine needles, the smell of late Summer grass or Springtime flowers, the almost-too-high-to-hear voices of the hummingbirds, the definitely audible “thwack” of the hummers when they fly into each other, the soft undulations and subtle colors of the mountains, the dances of the leaves on trees, the daily cavorting of turkeys, rabbits, deer, snakes and quail like some circus parade across my yard.

            I’d like to believe it’ll go on forever.

            But the drought has the deer abandoning their natural wariness. They approach us, looking for water and something to eat. Of California’s twenty largest fires since 1932, the increasing heat has birthed nine of these over just the past two fire seasons. Abnormal heating of the ocean’s water has spawned increasingly powerful, increasingly wet hurricanes in the last few years. The Carbon Dioxide level in our planet’s very thin atmosphere is higher than it’s been in the last 800,000 years. And it continues to climb.

            If you too, go out on your back porch to take in the Beauty, do yourself a favor and take an apple. Wrap it in a single layer of Saran Wrap. If the Earth were the size of that fruit, the part of our atmosphere we call “the air” – the part in which we can survive – would be as thin as the plastic wrap. This layer supports life with oxygen and is where we find “weather.” It’s both very thin and very vulnerable.

            As can happen to our bodies, our planet has a fever. You can feel it in the air. You can measure it in the ocean’s water which then swirls up into the vortex of growing hurricanes.

            As can happen to our bodies, our planet has a chemical imbalance. You can measure it as Carbon Dioxide levels. You can measure the smoke contaminating our atmosphere. It’s like a worsening case of emphysema.

            As can happen to our bodies, our planet is starving. It is becoming depleted of the minerals we mine and the chemicals we suck out thru our oil and gas wells. Seems counter-intuitive, but our supply of sand, composed mostly of the element Silicon which suns have created, is  becoming scarce. This high-demand commodity (second only to water) is used to make concrete for roads, buildings, cities. Desert sand won’t work – has to be beach or river sand, created by water, not wind. Additionally, crop yields are down about 5% since 1981 due to increasing heat.

            As can happen to our bodies, our planet has a fluid imbalance. The engines that produce weather (air pressure systems, ocean currents, warming seas) are causing two opposing extremes: expanding deserts and more powerful, wetter cyclonic storms. California’s getting drier and the Sahara desert is enlarging. While hurricane frequency has not changed much in 150 years, their intensity is worsening. Can you imagine living thru a storm that dumps 60 inches of rain? That happened in the U.S. in 2017, breaking a record set in 1950. Meteorologists project a pattern of tropical storms bringing even more precipitation in coming years. And those massive storms are moving progressively poleward, away from the equator which has been their historic stomping grounds. Storm surges are greater, causing worse flooding, due to rising sea levels (2.6 inches higher since 2014).

            And we humans?

            We creatures made of the elements the stars created and which makes up our planet? How we doing?

            On September 16, The New England Journal of Medicine, America’s most prestigious Medical journal, and multiple other Medical publications world-wide sounded an alarm. They documented that deaths from excessive heat events among those over age 65 have increased by 50% over the past 20 years. More specific human illness related to the changing environment includes pregnancy complications, increasing and emerging new infections, Mental Health issues, kidney insufficiency and increasing death from heart and lung illness.

                        “We can not wait for the Pandemic to pass

                   to rapidly reduce emissions.”

                                                                        (Medical Scientists in N.E.J.M.)

            As anyone who can fog up a mirror with their nose could figure out, disruption of the planet’s health doesn’t only affect humans. 23 species were recently removed from the Endangered Species list. Not because they’re no longer endangered. They are no longer found, and believed to have gone extinct. Including the “Lord God bird,” a spectacular woodpecker of southern U S forests whose beauty has triggered people to exclaim that reference to God in awe at seeing it. At the current rate, its is projected that half the animal and plant species alive today may be extinct within 80 years. 

What we’re running out of:

            Let’s do this as a Quiz.  Ask Mr. Google or go old-fashioned – read a book.

            1. Clean Water –  

                        What percent of Central Valley wells are contaminated?

                        What % of California’s water is used by the Ag Industry?

                 In return, what % of California’s Gross Domestic Product comes from Ag?

            2. Clean Air – 

                        How many weeks in the year does smoke contaminate the

                                    atmosphere we breathe?

            3. Clean Food – 

                        What chemicals end up in the meat we eat?  In the veggies?

            4. Sand –

                        How many tons of sand are taken from beaches and riverbeds each

                                     year to make concrete?

            5. Beauty – 

                        How much Natural Beauty has been lost to cities, industrial activities, 

                                    freeways and suburbs?

                         How much Natural Beauty has been lost to wildfires?  To droughts?

            6. Shelter – 

                        What percent of humans can’t shelter from excessive heat waves?

                        What percent of humans can’t shelter from hurricanes / typhoons /

                                     cyclones?

            7. Happiness – 

                        What’s the goal of your life’s work?

                        Does pursuit of money stress you out?

                        Is Wealth fairly distributed ?

                        Has Capitalism degenerated into Greed?

            8. Love –  

                        What do you do to make the lives of others at least tolerable, 

                                    and, perhaps, enjoyable?

                        Who is it that Jesus called our “neighbors” when He said 

                                    “Love – – – your neighbor as yourself” ?

                        Has pursuit of money gotten in the way of Giving love? 

                                    Receiving Love?

                        “The world is violent and mercurial – we are saved

                  only by love – – – love for each other and the love

                  we pour into the art we feel compelled to share.” 

                                                                                                            (Tennessee Williams)

            There’s more to HEALTH than the simple absence of disease.

            This free gift from the Sun, this – – – Existence we experience for a while – is doomed if we continue our destruction of the health of the planet, whose atoms and molecules we share.

            Want a healthier planet and atmosphere to live in?  For your grandkids to live in?

         DO SOMETHING.

August 15, 2021

“Does Your Mother Love You?”

Filed under: Uncategorized — cbmosher @ 5:12 pm

            A friend who has had a flamboyant career as a print and T V journalist over the past six decades – – – (Oh, no! Am I THAT old? Yes. Finish your thought) – – – tells the story of a well known CBS reporter’s first day on the job.

            Boss (Editor): “Does your mother love you?”
            New (Cub) Reporter: “Of course.”
            Boss: “How do you know?”
            Cub: “[?]”
            Boss: “Ask her.”
            So Cub calls his mother at home and asks her. She confirms that she does, and Cub reports back to his new boss.

            Boss: “Now you KNOW.”

            The Cub now had a FACT.

            Also decades ago, in Med School, I was trained on how to “present a case.” When asking for advice or referring a patient to another physician, we must start with the Chief Complaint. What it was that brought the patient to us initially. It should always be phrased: “the patient STATES that – – – .” Because, until the investigation is done, we don’t know the FACTS of the case. We can’t report the patient’s complaint as a medical Fact.   

            A case illustrating this “Does your mother love you?” and “patient states” search for Facts was the middle-aged man who came into the ER where I worked. He was accompanied by his wife.

            “He just has indigestion,” the wife shrilled before the guy could say anything. “He has it a lot. I told him not to bother you, Doctor. Give him some antacid and we’ll leave. He has work to do at our store.” She glared at me with eyes both icy and burning with fury. She had given me the diagnosis and an order of what to do. Her priorities, where her husband was concerned, were obvious. And terrifying.

            There followed an uncomfortable and bizarre discussion wherein it was impossible to get much info from the patient – his wife answered for him every time – and wherein the wife refused to wait outside while we cared for him.

            He was, of course, having a heart attack.

            Point is – you can’t report accurately nor make an accurate diagnosis without getting accurate Facts.  Accepting what you believe, or what someone else believes, may lead to being wrong. In some situations, that can be catastrophic.

            Public Health tools :

            In the clinical situation, my stethoscope, otoscope, EKG machine, lab tests and X-rays are crucial tools. These help me gather Facts and avoid the pitfall of accepting a diagnosis which was wrong. In Public Health, one of our best tools is statistics. I know that’s off-putting to many. After all, statistics are math. And, for many, boring. But it’s a crucial tool for quantifying Facts as Data. With Data, we can arrive at an accurate Public Health diagnosis of a population – a community. Might as well use Covid as the example.

            We are currently at a fascinating and critical turning point in the Covid pandemic. And it’s a perfect example of the long and winding road Science must travel to pursue Facts. Unfortunately, it’s also an example of flawed Public Messaging.

            On May 13, the CDC Director said that Americans who were fully vaccinated could go without masks or physical distancing in many cases, even when they are indoors or in large groups. This caused a whiplash in behavior and confusion with the Public. Many mis-interpreted the message as meaning that all restrictions were lifted. That the pandemic was over.

            While that CDC message – if correctly interpreted – was relatively accurate based on data at that moment, the virus wasn’t standing still. And now the Delta variant has shown us how wrong the Public’s mis-interpretation of the CDC’s massage has been.

            What went wrong?

            Mostly, it was our powerful desire to get back to “the way things used to be.” Not unlike our heart attack victim’s wife who wanted things to be unchanged. Or our Cub reporter who wanted to believe his mother’s love without checking the Facts.

            The Scientific Method:

            Humans have wrestled with this problem since forever. In the face of a society-upsetting disease, we want simple answers and want them quickly. Since Nature doesn’t work that way, the door is open to Quacks and Liars, as depicted in paintings of the Black Plague epidemic. You’re seeing the same thing going on right now. Not knowing how to differentiate between what’s true and what’s not can cause fear, insecurity and a tendency to follow someone who promises simple answers quickly.

            That almost never works out.

            Thus, during the Renaissance, humans developed the Scientific Method to uncover the Facts about how Nature works. You know, gravity, the sun’s daily rising, DaVinci’s vision of flying. Applies to the science of Medicine and Public Health, too. Goes like this:

  1. Observation
  2. Hypothesis (of how a specific thing works)
  3. Test hypothesis with Studies
  4. Obtain Data
  5. Revise hypothesis if new observations or data crop up.

            We act on currently available Data as the best Facts we have until new information challenges the hypothesis.

            COVID’S Curveball :

            The Observation was that Covid is caused by a virus. The Hypothesis is that this virus, like almost all viruses, can be combatted by antibodies which vaccines can stimulate. Tested with studies, first during vaccine development, and now with data from millions of vaccinated people out there. Here’s some of that Data:

            Vermont is the most vaccinated population in the U S at 67.4%.  That State’s Case Rate is just 3979 per 100,000 people so far.

            Mississippi is the least vax’ed at only 34.3%. Case Rate is a whopping 11,541 per 100,000.

            Of all recently hospitalized Covid cases, 97% are un-vaccinated.

            The hypothesis has been tested in the real world. The best Facts are that vaccination works. Thus the CDC’s May 13 announcement that the Vaccinated won’t need masks.

            Oops. Along comes the Delta variant (a mutation of the original Coronavirus). Science brings new Data:

  • 75% of new Coronavirus infections in Singapore are among the Vaccinated
  • Massachusetts testing reported on July 4 shows that the Vaccinated shed viruses as do the Un-vaccinated.
  • A study posted July 12 from China reveals that Delta has a shorter incubation time and faster replication in the body, producing up to 1200 times as many virus particles as the original virus. Explains its increased transmissibility.
  • A study of the Pfizer vaccine showed effectiveness falls after six months from 96% to 84% (reported July 28).

            So, while it’s true that Un-vaccinated folks are primarily driving the pandemic, there’s more infection – and possible transmission – occurring among the Vaccinated than we previously knew. You can almost think of it as a new disease.

            The Good News is – – – vaccination is still effective against severe disease and death. Most of the cases of infection in the Vaccinated referred to in the Singapore and Massachusetts studies were found on testing in people who had no symptoms or just mild cases.

            So Science did not fail us. It did exactly what it’s designed to do – modify the hypothesis based on new Data. Now we have more Facts to drive our decisions. Thus the CDC changes its recommendations to reflect the new Facts.

            We’ve been learning about this virus at the same time as we’ve been fighting it. We’ll continue to learn new Facts as we go. The Coronavirus looks like it’s not going away anytime soon. Just because we may not like the Facts that Coronavirus hurls at us doesn’t mean we should believe the Quacks and Liars.

            Just like the Cub reporter, we have to check our beliefs against the Facts from time to time. Science will do that for us.

            And, hey. Call your mother.

May 9, 2021

Miracle Molecules

Filed under: Uncategorized — cbmosher @ 6:51 am

         In 1890, an American cancer surgeon discovered the case of Fred Stein, a German immigrant with a rock-hard lump in his neck. It was an inoperable, malignant tumor – a sarcoma. In addition, the poor patient developed a skin infection caused by the bacterium Streptococcus. Doctors were flabbergasted when Stein’s deadly tumor disappeared after the infection. Dis-satisfied with standard treatment of malignant sarcomas at the time, the surgeon experimented on hundreds of patients with terminal, inoperable tumors, injecting bacteria or bacterial products. A large percentage of the patients showed complete tumor regression. 

         In 2017, while walking on a warm and sunny beach in Country X, I wandered away from the scattering of bikini-clad European tourists, into a cluster of palm trees. There I ran into two natives of the country who were at work with rakes and plastic bags, keeping the beach clean. After hellos, they burst into an enthusiastic expression of national pride. “Do you know about the vaccine we created? It cures cancer!”

         On a level not immediately obvious, these two events are connected. As are the Coronavirus vaccine and modern cancer treatments. Let’s dive in.

         When I entered Med School, Medical Science had progressed from Gross Anatomy (what your eyes can see in the dissection lab), down into increasingly smaller components of our bodies only visible in a microscope. And we were teetering on the verge of an exciting new, much deeper world with the electron microscope. With it, we could observe the interior of our cells in much greater detail.

         Also at that time, most cancers were considered very difficult to treat. As an example, the most common childhood cancer, Acute Lymphoblastic Leukemia (ALL), was considered incurable.

         The progress bequeathed to us by Medical Science since those days has been stunning. ALL is now curable in 90 to 95% of kids. We treat most cancers with surgery, radiation and chemotherapy. I think of these therapies as blasts from a shotgun, sometimes hitting the target of cancer, but often causing a lot of collateral damage to normal tissues. As someone once described chemo to me, “we hope to kill more cancer cells than normal cells.”

          But now, we are again teetering on the verge of an exciting revolution in both prevention of infectious diseases and in cancer treatment. This progress is due to our having gone deeper into the human body than even the electron microscope could take us. Down to the level of molecules.

         Molecules, you may recall, are the chemicals that are composed of atoms. Like water (composed of hydrogen and oxygen) or table salt (sodium and chlorine). The molecules which are the building blocks of Life are larger and mostly carbon-based. And with all the dizzying activity required to keep living organisms like us going (turning food into energy, turning an egg and sperm into a person, repairing our bodies when we damage them) there are two molecules that keep it all from descending into chaos. You know them: DNA is the keeper of all the codes that govern how the body functions; RNA is the workhorse that turns the codes into action.

         Think of DNA as a string of pearls. Each one of the pearls along the string is responsible for giving one very specific message to your body, with it’s own set of instructions. Each pearl is called a gene. This priceless string of pearls remains deep inside our cells, protected within the nucleus in the center of the cell, like a princess behind the fortress wall. RNA takes orders from the DNA by making the proteins, allowing the DNA code to be implemented for our bodies.

         Scientists can now find the exact make-up of the DNA code in our cells, and of RNA which carries out the orders. Taking that information, they have created maps of the genes. Going further, scientists can cut out certain unwanted genes or insert needed genes. We are now even able to build a piece of RNA to use to our benefit. This is “genetic engineering.” 

         You’ve already experienced it.

         Vaccines: 

         When you got a Covid test, the lab searched your nasal swab for the exact RNA in Coronavirus. And when you got the m-RNA vaccine, it consisted of a small piece of engineered RNA, made to look just like the gene which the virus uses to make the “Spike” protein on its surface. The vaccine RNA never got into the nucleus where your DNA is. Beating the virus to the punch, this RNA directed your cells to manufacture a protein identical to the “Spike” which the virus uses to infect you. The vaccine RNA was then destroyed, and your immune system began creating antibodies against this Spike protein, ready to repel the virus.

         Cancer:

         Recall that, back in Med School days, we perceived cancer as an attack of a hoard of abnormal cells that couldn’t stop multiplying. Our current concept of cancer is that it starts with a single error in the DNA of a cell. As that cell reproduces, the offspring may accumulate more errors in its genes. At some point, your immune system should recognize abnormal cells and destroy them.

         However a few abnormal cells may survive because changes in their structure helps them evade immune attack, even though the immune system has many different ways to kill cancer cells. 

         Think of this like what happened with bedbugs. The same species of this pest can be found in Florida and New York. But studies reveal that the New York bugs have quickly evolved mutations to protect them from pesticides. They are many times more resistant than their Florida cousins.

         Cancer, too, evolves, but on a microscopic scale.

         Sometimes, the immune system needs help in this fight. What we want is some sniper rifles instead of more shotguns. Well-aimed bullets instead of chemotherapy and radiation with all the collateral damage. We might be able to specifically target cancer cells by strengthening the immune system.

         Cancer Immunotherapy:

         This is the rapidly expanding field of harnessing the body’s own immune system to successfully attack a tumor. Lucky for us, tumor cells have targets on them. We start by finding the genes and molecules that cancer uses. Let’s focus on three: first, many tumors have genes that produce Tumor Antigens (molecules) which are displayed on their surfaces. A lot like Coronavirus Spike proteins on the surface of the virus. Second, scientists have found genes in tumors that control multiplication of the cells, spread of the tumor, and resistance to the Immune system. Third, tumors use various external molecules as Growth Factors. Examples include hormones that stimulate growth of prostate cancer or breast cancer.

         Knowing this, we can now help the Immune system target a tumor specifically, and reduce damage to normal cells. Here’s how:

  1. One unique treatment – some have called it “a living drug” – involves incubating cancer cells with normal immune system cells (B cells) in the lab. The immune system cells make antibodies against the cancer cells. Then the gene for making these antibodies is snipped out and inserted into the patient’s own immune system T-cells (Killer cells). These T-cells are multiplied in the lab, then are injected into the patient. When they encounter cancer cells, the antibodies they carry from the lab help them recognize the target. Like well-aimed bullets, they attack and kill the cancer cells.
  2. In cancers that depends on external Growth Factors, one method of reducing these is to develop a vaccine which will direct the Immune system to destroy these molecules. That’s what Country X did with its CIMA-Vax . Another approach is to use antibodies against the Growth Factor as a treatment.
  3. Using bacteria in a lab, scientists are working to create RNA vaccines that can force production of Tumor Antigen. The body’s Immune system would then learn to build antibodies against that antigen to lead the attack. Pretty much like the m-RNA vaccines for Coronavirus stimulated antibody production. See how that works? 
  4. Emerging information shows that some bacteria can enhance or diminish tumor growth, most likely by producing specific molecules activating the Immune system. One example currently in use is the administration of modified Tuberculosis germs into the bladder to treat bladder cancer. Immune system cells stream to the bladder to kill the TB, and then also attack the cancer. So our sarcoma doctor in the 1890’s was doing cancer Immunotherapy, even though he didn’t realize it.

         As with any scientific efforts, there will sometimes be setbacks with vaccines or cancer therapies. But the goal is always to do much more good than unintended harm.

         Science, including Medical Science, advances both by serendipitous  discoveries like the 1890 observations of our sarcoma doctor, and by building upon the foundations established by preceding scientific work. As did Country X. We are now exploring the detailed complexity of the human Immune system at the molecular and genetic level, and already reaping benefits for protection against pandemics and against many kinds of cancers.

April 2, 2021

EPIDEMIOLOGY

Filed under: Uncategorized — cbmosher @ 2:28 am

Retired !

Now what ?

Luckily, many of my patients over the years were in the same predicament cat-bird seat. So I have seen the models.

Model # one involves a couch, a TV, and lots of beer. Initially. Later, it’s lots of vodka. I’ve seen the blood tests on these folks, so – – – no.

Model # two involves cruise ships, tour guides and sunscreen. Also, vodka. But instead of taking pictures of people in foreign lands, I prefer to live with and talk to them. So, again, thanks anyway.

Model # three involves making other people’s lives better. A proven way to feel useful. But – – – Covid. What can you do for others when stuck here?  Well, step one could be De-bulking. Stop acquiring  crap  stuff  things and begin getting rid. Helps the kids with the clean-up after – – – you know.

Step two is get the mail. Chances are fair that, mask on and hand sanitizer in pocket, I’ll be stopped at the Post Office. “Hey, Doc. Can you look at this thing on my forearm?” or “Oh, Doctor. I hate to bother you, but they just diagnosed cancer and I don’t know if I should do Chemo. What do you think?” Actually, after empathizing, the correct answer to most of these situations is “get an appointment with your doctor (or a second opinion).”

Step three uses the miracle of electronic communication. Via e-mail, Zoom and What’sApp phone calls, we’ve been able to continue work with two Foundations. The Mariposa Community Foundation has helped some non-profit agencies weather the Covid –related financial impact. And another Foundation called FAKS (Functionally Active Kids) has kept some children in Guatemala and Honduras walking. Here’s a picture of Mario. 

He was born without a foot. One additional strike for a kid living in a country wracked by chronic poverty, political upheaval and violent crime. FAKS Foundation helped his family obtain a modern prosthetic at a fraction of the cost in the U.S. The result: Mario’s in school, and he’ll be able to support himself without begging. He’s even playing soccer. We’ve been able to stay in contact with Guatemala during Covid, communicating with the local Rotary club.

Step four – turns out, retirement doesn’t erase your career from your dreams or occasional, unsolicited thoughts. If I thought retirement would be Epidemiology – free, well, like some wild animal virus, it tracked me down. Those Post Office consultations have become increasingly centered on the Coronavirus. Both in individuals and in the population. Figuring out answers for a new disease involves knowledge of Medicine, of Physics and of Statistics.

Medicine – are we observing the effects of infection by a virus or of the body’s immune response?

Physics – is the virus transmitted thru the air by droplets or by aerosol?

Statistics – are the deaths we’re seeing “excess” deaths over and above the normal population death rate? Are the control measures decreasing transmission and subsequent infection?

All these aspects – and more – go into the Epidemiology of a disease. Which, by definition, is the study of the behavior of a disease within a population and its control. So, if you were asked to define the epidemiology of the new disease called Covid, how would you approach it?

  1. Count it.  Find out its frequency. For the disease of Covid, the U.S. has the highest case count in the world at over 30 million. You can also by calculate the disease’s Incidence. That is, how many people become new cases over a time period? Or how many become ill? Or die?
  2. Find the pattern. Which groups in the population are most affected by the disease? Most diseases are not distributed uniformly thru a population. Some don’t get infected. Some get infected but not ill. Some get ill and recover completely. Some get ill and remain crippled. Some die from it.
  3. Find the Determinants (AKA Risk). What causes the disease? What influences in the environment or society facilitate it? Protect a group from it? With Covid, the cause is the virus and we quickly learned that close contact, especially indoors, was a major determinant. However, medical conditions and age were also powerful determinants.
  4. Studies. With this unknown disease, we needed information. Fast. Hundreds of studies looked at virus behavior, immune response, clinical syndromes, treatments, prevention measures, vaccines, and the effectiveness of environmental / social preventive measures.
  5. Prevention. All the information generated thru Epi investigations is worth very little if it can’t point to preventive measures. Very quickly with Covid, we implemented what we learned. Face coverings. Distancing. Screening (AKA testing). Vaccination.

The other Public Health epidemic in the news has been with us longer than Covid, but flares into the headlines periodically. So let’s see how Public Health applies epidemiology to Firearm-Related (FAR) deaths.

         1. Frequency: in the U.S., the death rate from this disease is 12.2 per 100,000 per year. That’s more than any other high-income country in the world. The number of FAR deaths in 2020 was the highest in 20 years at 44,000 deaths.

         2. Pattern: the data available (there isn’t as much as we need – see “Studies” below) shows that U.S. FAR deaths include suicides, homicides and accidents. The death rates vary greatly among the states.

3. Determinants: Many people believe that having a gun close by makes you safer. A few studies (too darn few) have been done on this topic. But the clue of differences among states helps. The Rand Corporation spent two years looking at available data and found that (A) a lot more studies are needed on FAR deaths and (B) states with the most permissive policies on gun ownership had higher FAR death rates than states with more restrictive policies. Some studies have shown that households with guns suffered more FAR deaths than those without. There are more guns than people in the U.S. (120 per 100 people). No other country has such a determinant.

         D. Studies: in 1996, congress passed the Dickey Amendment which ordered the CDC to NOT spend any money on studying FAR deaths. This shut down most investigation on the issue, relying on private funding (with the potential of biased studies).

         E. Prevention: a hot topic. In spite of polls from 1990 to now showing a higher percentage of Americans favoring “gun control” than those opposing, very little action on prevention has occurred. Moreover, an Association which represents gun manufacturers is a perennial voice in legislator’s ears.

What does “gun control” mean? Should we outlaw assault weapons except for police and the official U.S. military? Should we apply testing and licensing as we do with the privilege of driving a car or truck (the cause of 38,800 deaths a year)? Should we screen for high risk individuals (those at risk for suicide, for violence, for poor anger control, for situations ripe for accidents)? Like we screen for Heart Disease, Cancer, Covid?

         As with most diseases, more studies will produce more knowledge  which leads to better decisions. If we don’t study a disease, if we don’t apply the proven principles of Public Health, if we don’t act to prevent death-causing diseases, the problem will never go away.

         Next time, it may not be someone else’s child.

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