Sex, Drugs, and Public Health

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….

He was assigned by an out-of-town agency to work with us just one day a week, but the big, balding Teddy Bear who came to the office every Tuesday had quickly charmed the ladies. He didn’t try to disguise his half bald head with a comb-over. He took time to chat and laugh with the secretaries, nurses, and managers of other Public Health programs.

And on the summer day they replaced the carpeting in our office, I returned from a meeting to find all the staff, evicted temporarily from their desks, sitting outside on folding chairs. Naomi and Cindy worked on papers they held in their laps; Francine and Mickie helped callers with their usual efficient cheerfulness. Their phone lines cascaded from an open window and coiled on the sidewalk beneath their chairs. Electric fans, connected to extension cords, swept the group.

“It’s so hot out here,” Cindy said to me, “that my papers are sticking to my forearm.”

“Sorry,” I offered, feeling a little guilty about the weather, “I’ll check on them and see if we can get back in within the hour.”

“Oh, we’re O K,” chirped Naomi. “He’s brought us a pan of brownies he baked all by himself.”

They turned to smile at the Teddy Bear, some of them still munching. He sat with the rest of them, on a folding chair too, his knees almost up to his chest, scribbling on a notepad. He looked like a parent squeezed onto a  kid’s chair at the pre-school.

“I had to do something to help us get thru this day,” he shrugged at me.

It was only a couple of weeks later that I stumbled upon a small article in the nearby big city’s newspaper:

“Paramedic accused of trying to poison wife with heart drug.”

Why did I take time to read that page thirteen filler? Was I temporarily bored? Or was it the ironic headline juxtaposing “wife” and “heart drug?”

A nurse had accused her paramedic husband of slipping doses of digoxin into her food or coffee or something. This Agatha Christie-esque plot line would have been a mere curiosity except that the husband – whose marital relationship was clearly in the I C U – had a name identical to our Teddy Bear’s. Our Paramedic Teddy Bear’s.

I called the agency for which the Teddy Bear worked. They promised to talk with the local Sheriff and get back to me.

“Marital problems,” they reported back. “Messy divorce. Apparently no evidence to confirm her complaint.”

So the next Tuesday that he came to work, I spoke with him.

“Aw, it’s embarrassing,” he hung his head a little. “We’re going thru an ugly divorce. She’s jealous of my girlfriend. She’d say anything.”

Then, a couple of weeks later, the newspaper disclosed that her family had reported her missing.

I asked the agency to remove him from my office, temporarily, until issues were resolved.

“We’re in touch with the Sheriff’s office,” they told me. “He’s under surveillance. Innocent until proven guilty.”

“But I have an office full of people to protect,” I lobbied.

“Can’t. Unfair labor practice,” they retorted. “We’d be sued. Have your lawyer discuss it with our lawyer.”

So, while the lawyers talked and the Wheels of Justice (whatever those are) ground away at their usual pace, I planned to be at the office an hour early on Tuesdays, stay there all day, and remain until everyone was gone.

Then, one Tuesday, he didn’t show up for work.

“They took him in for questioning,” the agency head replied to my call. “He told me, when I asked him, that she was hiding out in Mexico with a friend, trying to frame him.”

So I gathered my staff together and went thru the information I had. None of it condemning, all of it circumstantial.

I think I saw Naomi shiver for a second.

“But, he’s SUCH a NICE guy,” Cindy wondered aloud.

“Must be a mistake, “ Francine shook her head.

Naomi remained uncharacteristically quiet. Until, as if mumbling to herself:  “I ate the brownies.”

She shivered again.

I anticipated that everyone’s mood would change for a while after I spoke to them. People gathered in clumps in each other’s offices several times each day. The usual office bustle was replaced with slowly shuffling feet and murmured voices. But I hadn’t thought that they’d remain spooked for as long as they did. For over two months, no one would go into his office space. People continued to bring baked goodies to the office to share, but it was over six months before I saw brownies again.

After he was convicted, Naomi’s eyes peeked into my office.

“You have a minute?”

“Sure. Come in.”

“But he was so nice. Not like what we expect a murderer to be like.”

“What did you expect a murderer to be like?”

“Oh, we don’t know, but – – -”

“ ‘But” what?” I encouraged her.

“I mean, how could he have done it? He’s, basically, just like us.”

Jim, a healthy, muscular thirty year old, took antibiotics for – – – well, something. Something relatively minor, as I recall: bronchitis or an ear ache.

Unfortunately for him, the antibiotics wiped out, among other bacteria in his body, the normal bacteria that lived in his gut, where they helped him digest his food. I saw him in the Emergency Room with cramping, miserable diarrhea, including blood. That almost always gets the patient’s attention.

Jim had Pseudomembranous Colitis – an inflammation of his gut caused by a new bacteria moving in where his “normal flora” used to reside. It’s actually, a relatively common complication of antibiotic use. And a fairly serious complication.

So, how do we fix this problem? It may not surprise you to hear that, in this society of ours, the treatment for this problem caused by antibiotics is – – – to give more antibiotics. Different antibiotics. Expensive antibiotics. And cross your fingers.

Now, some people, thinking in the right direction, try to replace the “good bacteria” by eating yogurt, kefir, and other potential sources of bacteria. This approach has not been an overwhelming success for several reasons.

But now, taking the same thinking a little further, we have a new therapy that I learned about at a medical conference in San Francisco. It’s called “Fecal Transplant,” or, for those either squeamish about the words or into New Age cures, “Human Probiotic Infusion.”

The vision you’re imagining right now is probably exactly correct.

“You need two things,” the professor of Medicine elaborated: “a donor, – – – and a blender.”

How creative. How logical. How frustrating to the pharmaceutical companies.

For those of us who specialize in Prevention, the problem of Pseudomembranous Colitis from antibiotics is just another warning (along with increasing bacterial resistance) that we’re WAY overusing antibiotics.

And that form of drug abuse is coming back to bite us.

Question your doctor whenever (s)he prescribes antibiotics, to be sure it makes sense to you, before you put that drug into your body. Jim will be doing that, probably for the rest of his life.