Sex, Drugs, and Public Health

My father (who did not specialize in Public Health) relates that, while in Med School in the 1930’s, his professor of Clinical Biochemistry pontificated thus:

“As physicians, you must use all your powers of observation to reach the correct diagnosis. Your patients’ lives will depend on it. For example – – – ”

He reached under the counter and placed before him a chemistry flask containing yellow liquid.

“This is urine from a patient on the wards. Of course, you can look at it to see how dilute it is, but there is more you can do. You have other tools available to you, also. For instance – – – ”

He dipped his finger into the liquid. Then, dramatically, he put his finger into his mouth, rolled his eyes ceiling-ward in thought, and said:

“ – – – it’s sweet. There’s sugar in this urine. The patient has diabetes.”

He picked up the flask.

“This is an important lesson. You will all taste as I did.”

So he handed the flask to the student at the end of the first row, and the urine began its slow odyssey among the fledgling Med Students. Presumably, the professor moved on to another subject while the flask made its way among the cringing faces.

When it finished its rounds among the grimacing students, the professor placed it on his counter again and stared at his class.

“This was an important lesson,” he emphasized, “about the power of observation. Had you observed me closely, you would have seen that I inserted my index finger into the urine – – – ”

He held up his index finger – – –

“ – – – and inserted my ring finger into my mouth. Class dismissed.”

Guest editorial by World – famous  psychiatrist to physicians,  Dr. Pannikatakus

I hear from physicians what, to no one else, they tell. Their secrets. Their fantasies. Their failures. Their sick little ideas.

Case # 286

I tell you now about the case of Dr. R. He comes to me, Dr. R., lies down on my leather couch and I put a box of Kleenex on his chest.

“I’m conflicted,” he says to me. “I always do what’s best for my patients, but sometimes they don’t appreciate my efforts. Like Mrs. La Barge.”

“Tell me,” I say in comforting voice. “Tell me about this patient, La Barge.”

“She asked her husband to take her, for their anniversary, to the French restaurant in town. Nice place. They serve the old style haute cuisine. She wore a new dress. It was loose fitting in the style of – what do they call them? ‘Mumu’s,’ I believe. Like a colorful tent.

“The waiter seated them, but Mrs. La Barge complained about the chair. It was uncomfortable, she said. One glance at the seat, completely swallowed up beneath Mrs. La Barge, was all the waiter needed, to know what to do. He brought her a wider chair with heavier legs.

“She ordered the Boeuf Wellington with extra Bordelaise sauce and foie gras. Her husband requested a bottle of Pinot Noir. She arranged her pills in front of her, next to her glass of water, like soldiers defending a fortress.

“The waiter returned. ‘I’m sorry, Ma’am,’ he told her, ‘but you’ll have to change your order. Your doctor called and you can’t have the pastry wrapped beef. May I suggest the Chef salad?’ ”

“And this,” I ask Dr. R., “she did not like?”

“She  just doesn’t understand Full Service Medicine. What should I do? Let her kill herself?”

“That would be against the Oath of that other great Greek physician,” I warn him. “Come back next week. We talk again.”

They have three goals.

They want to get you hooked. So they give you free samples. Once you’re dependent on it, it gets real expensive real fast.

They need to get you to listen to them for their initial pitch, so they can dangle their bait. That’s why they exude the personality of “nice guy” or “nice girl.” If you don’t analyze them any deeper, that’s all they need.

They want to keep you coming to them for your drugs, so they purchase your loyalty to their Brand, using gifts, free samples, and advertising.

All three goals remain constant. What’s changed, over the course of my career in Medicine and Public Health, is their tactics. When I was new to this business, a trim, healthy young guy in a suit and shiny shoes stuck out his hand:

“Nice to meet you, Doctor. I’m Tim. How’s your day going?”

He had an easy smile, and knowledge of football. After a minute and a half, he slipped into his spiel:

“For your patients with hypertension, a recent study in JAMA – I have a copy of it right here for you – shows that this product performed better than all the beta blockers. I’m going to leave you a supply so you can try it on your patients. No charge, Doctor.”

Soon the cartel assigned a new Pusher to my office – an attractive redheaded girl who wore a dress perfectly tailored to her curves, and high heels. Perhaps the young guy was re-assigned to an office with woman physicians.

Then, in addition to the free samples she gave me in hopes that my patients (and I) would get hooked, she invited me to dinner. Dinner with a medical lecture. These were always held at the priciest restaurant in town. I never went, but several of my colleagues did.

The most recent shift in tactics bypasses the guy with the prescription pad entirely. Now, like Pushers at a High School, they market their drugs directly to the kids – i.e. our patients:

“Ask your doctor if our drug is right for you” is pretty much like saying “ask your Mommy and Daddy if they’ll let you have a little sip of wine before dinner.”

It puts the physician (like Mommy and Daddy) in a no-win position. Which is exactly how the Pushers like it. After the T.V. ad with promises of butterflies fluttering around the patients, and smiling people with happy lives, the physician has only two options: write for the requested drug, or say “I don’t think this is the right drug for you,”  and live with the consequences. In the first case, you take on the responsibility for the cost of the drug, and for its failure to work and/or for its side effects. In the second case, you get into a fifteen-minute argument with your own patient. As with users of illegal drugs, the physician turns into a whore.

A neglected whore. With the success of the direct pushing (advertising) of their drugs to patients, the cartels can cut out the expense of pushing to the docs. So, these days, neither the young guy in the suit nor the redhead in her high heels are anywhere to be found.

Public Health authorities have been bombarded with questions about radiation. Like many things in our lives, radiation can be both good and bad for us. Depends on how much and what type.

Last Week, many people in the United States became concerned – some became panicky – about a new kind of air pollution: radiation from Japan’s nuclear reactor accidents. At the Health Department, we received several phone calls asking about the threat. The press, we noticed, focused on the topic to an extraordinary degree.

Most of the radiation in our daily lives comes from the sun (which is, after all, a gigantic nuclear explosion in the sky). It warms us when we are cold, it helps our food grow, and it creates Vitamin D in our bodies. But it can also burn us or, if we are foolish, it can blind us. You could think of these ill effects as overdoses of radiation.

Another source of radiation in our lives is medical radiation. Chest x-rays, various types of scans, and cancer treatment radiation are all thought of as beneficial. Radiation affects different tissues in the body in different ways. Generally, tissue which multiplies quickly is more susceptible (e.g. skin and intestines). One specific use in medicine involves the thyroid gland.

Sometimes we give a patient radioactive iodine in low doses to get a better look at the thyroid – to find cancer hidden within it, for instance. The thyroid gobbles up iodine readily and a scan with radioactive iodine can give us a picture of the gland we otherwise can not get.

In those patients with overactive thyroid glands, a way to “remove” the gland without surgery is to give a high dose of radioactive iodine, which will destroy (“ablate” in medical terms) the gland. All these uses are beneficial.

But the ingestion of radioactive iodine which is a by-product of a nuclear reactor leak can be dangerous to a certain group: young people who live close to the reactor. Studies after the Chernobyl accident showed that people who were children at the time of the accident had an increased likelihood of cancer from exposure to radioactive iodine (a certain number of cases of thyroid cancer would occur even without exposure to a nuclear accident, so we measure “excess incidence” of the cancer.)

The reason nuclear regulatory agencies provide potassium iodide to residents close to a reactor in case of a leak, is to make their thyroid glands get “saturated” with iodine, thus rejecting radioactive iodine. It’s a little like you, after a big Thanksgiving Day meal, might reject an ice cream sundae. Thus the potassium iodide can protect against excess cancer of the thyroid caused by “radioactive iodine” among people young enough and close enough to be at risk.

Is there a danger in taking potassium iodine? Sure, it is a drug. Thus some of the concerned Americans who, 6000 miles away (about 5950 miles beyond the “danger zone” where potassium iodide might be used) who took it on their own, ended up in the emergency room with allergic reactions or a potassium overdose, which could be lethal.

So the best approach is to allow the Air Pollution and Public Health folks to continue their monitoring to determine whether any excess radiation has appeared from Japan, over and above our “natural background” levels of radiation.

So far, that is not been the case.

Retired Air Pollution Control Officer Dean Wolbach contributes this:

An eighth grade graduate should know the following facts of nature; the warmer the water the faster it will evaporate, and the warmer the air the more moisture it can hold.  When a warm moister containing packet of air is cooled below its ‘dew point’ the moisture will precipitate out, sometimes as dew, sometimes as fog, sometimes as rain, and sometimes as sleet and snow.  Two further facts that a high school graduate might know (but a college graduate surely should know) is that heat is thermal energy and that temperature is a measure of the thermal energy in a system.

There are a couple of harder facts of nature to understand.  Each molecule of gas can absorb a certain amount of thermal energy.  The more gas molecules present the more energy that can be stored by that gas.  The more energy that is stored the hotter the gas.  Carbon dioxide is particularly good at absorbing energy in the temperature range of the atmosphere. Also, when moisture in the atmosphere condenses it releases that original energy required to turn it into vapor.  Thus the air tends to warm a little when it begins to snow!  These facts and the facts stated in the previous paragraph are laws of nature.

Now let us speak of a different type of fact.  This will be an observed or measured fact.

First, the oceans are warming.  They are approximately 1 degree Fahrenheit warmer now than they were 35 years ago.  This temperature increase results in 4% more water vapor being put into the atmosphere.  This additional water vapor leads to 8% more rainfall precipitating now than in 1975.  Therefore more energy is released when the moisture is precipitated from the atmosphere.  Storms are more violent.  This is an observed and measured fact.

Second, the annual average amount of heat coming from the sun to the earth has not changed since direct measurements began to be taken in the 1960s.^[[1]] Indirect measurements show no change in this flux over the last 2000 years!  This is an observed and measured fact.

Third, the concentration of carbon dioxide has been rapidly increasing since the beginning of the industrial revolution (about 1800).The most dramatic increase has been since the end of WWII.  From the period 1000 AD to 1800 AD CO₂ levels averaged about 280 parts per million (ppm) ±4 ppm.  By 1950 it had jumped to 300 ppm, and now it is at 330 ppm.  And the average number of volcanic eruptions per year has not changed over that 2000 year period.  This is an observed and measured fact.

So let us put together those laws of nature with those observed facts and see what precipitates.

Climate change (more violent storms and more rain and snow) is linked to ocean warming.  Ocean warming is linked to more thermal energy in the atmosphere.  Carbon dioxide is a sink for solar thermal energy.  More carbon dioxide in the atmosphere means more solar thermal energy is held in the atmosphere, thus raising the atmospheric temperature.  The only source of increased historic carbon dioxide output is human activity.

Climate change (e.g. global warming) is here, it is real, and it is most likely man-made.  For those of you who do not accept observed facts there is no hope.  For those of you who do not believe in the laws of nature, well….