Tuesday, June 29, 2010

Collateral Damage In The War On Cancer

Since the war on cancer was declared by then president Nixon in 1971 much effort has been devoted to the war. So how are we doing? In 2007 there were 12 million new cases of cancer reported world wide and 7.5 million deaths.These numbers are projected to rise to 27 million new cases and 17.5 million deaths by 2050.

These figures do not suggest that what we are doing is working a s well as it might be. The other figure which, does not get quoted much is the collateral damage which is done in the war. Hang on a minute, what is collateral damage? Surely screening for and treating cancer is all good even if it doe not always work.

There is a view which is promoted in the media and by doctors(particularly those involved in cancer screening) that screening is all good and that early detection is important. There is no argument that early detection is better than late detection. There is also no doubt that some people have had their lives “saved” by early detection.

Do we know how many people are in this particular boat? Do we know how many people had unnecessary procedures including biopsies and surgery not to mention needless stress because screening tests picked up cancers that were not actually there? Do we know how many people have early cancers which f not found would not actually develop and lead to a reduction in life expectancy?

Figures are starting to emerge. The British Medical Journal published figures on mammography. The difference in deaths in women aged 40 to 55 that can be attributable to mammography screening is 0.06%. Looked at another way for every woman who would otherwise not have found the cancer and died, 1610 women need to have tests. In addition to this ten women will undergo surgery, which will provide no benefit to them, only potential complications.

With prostate screening the situation is even worse. For every cancer successfully detected and treated early, 48 men will have unnecessary surgery, which can lead to urinary incontinence and impotence in one third of cases. Another review suggested that screening led to no decrease in death rates. The inventor of the PSA test, which is used for screening(but was not developed for that use) described prostate testing as like flipping a coin.

The positioning of cancer screening as saintly leads to criticism of anyone who questions the current orthodoxy. Keep in mind that there are considerable vested interests invested in screening programs and those advocating screening may have a conflict of interest, which would not be acceptable in any other field.

Every person who has surgery or other unnecessary procedures is collateral damage in the war on cancer. Some will say this is a reasonable price to pay. Others may not see it this way. The key point is that you can only make a decision on how you want to proceed if you know all the facts.

Friday, June 25, 2010

A Week Used To Be A Long Time

It is an old adage that a week is a long time in politics. With the world speeding up it seems like a day is now a long time. It is highly unlikely that Wednesday morning that many Australians would have thought there would be a new prime minister within 24 hours.

The fall of Kevin Rudd is quite remarkable. Twelve months ago he was riding high in the polls and at one point enjoyed record high approval. This is a first term government, which came to power after over 11 years in opposition.

Certainly the popularity of politicians goes up and down. Polls, which seem to dominate all thinking these days are necessarily done on small numbers of people and the results extrapolated. Often they are close to the mark but as all the politicians know there is only one poll that really counts.

Clearly the labour party formed the view that they were likely to lose those years election with Rudd in charge and replaced him with his …deputy.

This raises the real question of style versus substance. Were people turning “against” the prime minister because of the policies of his government or him personally? It is worth remembering that as his deputy, new Prime Minister Julia Gillard was involved in policy making. So it is not likely that a new face will bring about huge change in policy. One of the key issues has been the mining profits tax and I wrote about the connections between wealth and health previously.

So is the issue the message or the delivery of the message. Are the governments’ approval ratings falling because people do not like what they are doing or is it simply that what they are doing has not been “sold” in the right way.

Julia Gillard will, like all new leaders, have a honeymoon period. Many will like to see her succeed because she is the first woman to be Australian Prime Minister and this will in itself provide a boost in the polls and an air of goodwill, which will color people’s opinions and also media coverage.

Ultimately the problem though facing many countries is that there is a focus on personality rather than policy and a fixation on polls and the 24-hour news cycle. To grow an apple tree you need to pant the seed and tend it over many years before it grows and provides fruit. Expecting fruit after three months and declaring the tree a failure (and ripping it out) if that doesn’t happen would be ridiculous.

Equally with government policies, which have, long-term effects, judging policy success in a short time frame and then acting on that may make as much sense as ripping out the tree. Of course bad policies should be dropped as would trees, which are not growing be removed from the orchard.

With an election due within nine months it will be interesting to see whether we see changes in policy (particularly the unpopular mining tax) or simply a change in selling the message or perhaps a bit of both.

Most interesting will be the response of the people.

Tuesday, June 22, 2010

Relationships Do Not Have To Be Complicated

Relationships form one of the pillars of DIY Health. There are many different relationships that we have and over the last week we have seen examples of how the way we conduct these this impacts on people, for better or worse.

There are two separate events, which caught my eye; resignation of the CEO of David Jones department store after allegations of sexual harassment, and the furor over allegedly racist comments by a former footballer. Both say something about our relationships.

Firstly were the comments made at a private function by a former footballer Mal Brown who allegedly made references to Aboriginals and cannibals in jest. Not surprisingly this made the news for a few days and led to the usual screaming from those with a vested interest in doing so.

Now I was not at the function, so do not know the context of the comments. However following media reports millions of people became aware of the comments of one person instead of the small number in the room. More interesting are the claims that one person’s remarks are widened out to suggest it represents “systemic racism” either in football or society in general.

Of greater significance is that the man who made the comments has a long track record of playing and coaching Aboriginal footballers and has probably done much more to help their advancement than many of those now screaming out in “horror”. A sign of maturity in race relations will be when jokes whether bad or good are seen as jokes rather than put into a political context. Laughter is one thing we all have in common as humans.

The resignation of David Jones CEO Mark McInnes again highlights how traits, which serve people well, can lead to their downfall. There is a long long history of leaders be it in business or government having multiple affairs, relationships, mistresses or whatever term was popular at the time. This goes back to the days of Caesar and continued through to Bill Clinton. “Leaders” in other fields have a similar track record.

In this particular case the man has resigned and is forgoing something in the order of $16 million in lost entitlements compared to seeing out his contract. There is no way a fine of that magnitude would be imposed by a court. Furthermore nobody is disputing he was extremely good at his job.

None of this excuses behavior, which is unacceptable and he has paid a high price. Equally one can also wonder if the behavior is shaped by the fact that other women may well have warmly received or even sought his attention. It is likely that some did. It is also likely others did not but were not prepared to speak out. There will undoubtedly be more stories emerge over the next week or two

The problem is that often the exact same drive and personality traits which led to success and rising up the power ladder can send you right back down again. A football coach who calls a spade a spade may go far on the playing field but come unstuck at after dinner functions. A CEO who charms women does well in running a retailer but comes unstuck from his private dealings with people if he does not learn where to draw the line.

Relationships are often made more complicated then they need to be. They are never helped when people who are in no way affected jump in with opinions or interpret behaviors through their own biases or worldview.

The old golden rule of do onto others as you would have them do onto you does not even quite work in the politically correct age. You need to do onto others, as they would have you do onto them. For that to occur we need to be honest and open in our dealings with people. We can not expect others to be mind readers. We need to tell them what we do and do not accept and we need to act on that accordingly.

Maybe relationships are not that difficult after all.

Tuesday, June 15, 2010

Be Questioning

A survey of Australians shows that church attendance has fallen about one third over the last 16 years. A number of other “religion” parameters such as belief in heaven and god have also fallen although running in parallel with this is an increasing interest in spirituality, separate from religion.

This trend is part of a broader trend in society away from “authority” figures and institutions in general and to a greater desire to find ones own way rather than be told which way to go. We see this in declining church attendance but also declining regard for judges, police politicians (of course) and dare I say even doctors.

Ultimately the problem we have is that people have used authority badly and come to feel that it is the position they have which confers importance upon them rather than position being recognition of what they bring to it. In other words putting a robe on me does not give me moral authority if I do not have it without a robe. If a person is corrupt, putting them in a police uniform does not change who they are. Yet we see time and again the excuse of position being offered when people are caught out.

There is no doubt in my mind that the response to child sexual abuse by the church has contributed to its loss of credibility. There has been more energy expended trying to defend people and position than trying to resolve the issues.

In other fields similar problems emerge. Reports of two undercover policemen arresting and charging a skimpy barmaid for showing too much buttock will leave many wondering why the police are not spending their time investigating murders and robbery. A similar thought goes through my mind every time I cruise by two policemen under a shady tree holding a speed radar.

The medical profession is not immune to this trend and is also guilty of undermining public trust by its own actions. Reports of researchers and doctors being paid by pharmaceutical companies for research which invariably is favorable to the sponsors does not help credibility. Neither does beat ups like swine flu.

Despite overwhelming evidence that this is not a major threat, health authorities are at it again with claims of chaos and horror to come. This is after a vaccine, which was not needed, was rushed to market and then withdrawn from use in children under five following an unexplained death. Official pronouncements of safety do not sound good in these circumstances. Little wonder that peoples confidence is shaken.

Meanwhile we are constantly told that the whole reason for vaccination is that people are protected against the illness they are vaccinated against. This flies in the face of the actions of the WA health department after a case of measles was found. A frantic search was done to find all possible contacts. If the herd immunity principle works, then why the panic? Interestingly one of the three cases was a paramedic who you would assume was vaccinated.

A two page circular to doctors gives “useful “advice like conducting an examination in a room which can be left vacant for two hours and avoid “suspects” using the waiting room. And who are these suspects? People with a fever ,cough and sore throat. The average doctor would of course not see many of them in winter would they? Apparently people born before 1966 are automatically immune!

Now measles is not a pleasant illness and vaccination has contributed to its decline. However generations survived it in much lesser circumstances than we enjoy today. If the whole purpose of mass vaccinations is called into question when one case is found is it any wonder that people become questioning.

Friday, June 11, 2010

Wealth and Health are Connected

Whilst being rich does not of itself guarantee a long or happy life and many people with little by way of monetary wealth live a long and happy life wealth and health are linked.

As nations become wealthier the overall standard of health rises. We have seen over the course of the twentieth century that as nations industrialize, standards of living improve and so does health. This is not due particularly to medical science and owes very little to high technology medicine.

It comes about through people having clean water, better overall hygiene and sanitation, better protection from the elements and of course access to enough healthy food. The last one can go the other way as we see with problems of too much of the wrong sorts of food being consumed leading to a whole different set of health problems.

The other aspect that is important in health and is pillar eight of DIY Health is fun and purpose. As humans we need to be doing something that we feel matters and that we enjoy. As nations become richer the diversity of opportunities increases exponentially. Once we are free from having to spend much of our time looking for food or defending our territory we can focus on other things.

This may be a job, running a business, creating works of art travelling or a myriad of other things. The key things from a health perspective is that we enjoy what we are doing, that it has some challenge and that we feel there is a purpose. These three components are what the University of Pennsylvania has described as constituting authentic happiness.

Equally, we all need a certain amount of money to live. I am not talking about living in a palace or flying first class but enough to be comfortable and do most of the things we would like to do. People who are successful usually become wealthy because other people are attracted to the value they create. This can be in business or in the arts or any field of human endeavor.

When people have made an effort and created value it is fair and proper that they be rewarded for it. Furthermore, often these people create wealth for other people too either in the form of paid jobs or investment opportunities. Once again this is right across the board with regards human activity. Many who are successful increasingly put back into their community in a variety of ways.

The current debate about the mining tax in Australia highlights the passions aroused when those who create wealth and opportunity for themselves an others find themselves subject to arbitrary government rule changes. Governments by their nature can never create wealth or add value. This can only be achieved by individuals, acting alone or with others, in some form of business.

Different countries have prospered because of different industries. All countries, which have prospered, have done so because individuals and businesses were prepared to take risks in the hope of reward. To attack the reward after the risk has been taken will naturally arouse anger. I am not aware of any other country, which deliberately set out to weaken the business sector, which had been its most successful. Australia’s most successful industry is mining.

Governments argue that the taxation money can be spent in the community. Sadly governments of all persuasions have a bad record of efficient use of funds. Suffice to say the current one is true to this pattern. Excessive taxes and government interference in the economy leads to increased unemployment.

The best way to strengthen the community and for people to prosper is for people to have purpose, like a job or business, and the opportunity to invest their monies. Diminish this and you diminish the community and the nation.

When the wealth of the nation is collectively affected, the health of the nation will also be affected. It is little wonder passions are running so high and across so many levels of Australian society.

Tuesday, June 8, 2010

Human Emotion Is Not A Disease

One of the things one tends to do when in another city is use public transport. And so it was that I was waiting for a train at Sydney Town Hall Station when the billboard caught my eye.”7 out of 10 Australians will suffer a mental health illness” was the headline. Below the headline was a diverse looking group of people with thought bubbles above their heads.

Amongst the thought bubbles were things like, I am stressed at work, I am grieving for my mother who died, I have mortgage stress and I feel anxious at times. The billboard was promoting a charity, which amongst other things provides support for people with “mental health problems”.

There is an increasing tendency for a variety of medical groups, patient support groups and charities to make problems look bigger than they are so that they can get attention or raise money. To do so however, they reclassify normal parts of human emotion as an illness to boos the numbers and create a sense of crisis. In turn those who create the crisis stand ready to solve it with donations from the public.

If it is not a mental health illness to feel happy when you win a lottery why is it an illness to feel sad when a loved one dies. If it is not an illness to feel nervous before performing on a stage, why is it an illness to feel anxious sometimes? Stress in relation to work or finance is a normal response depending on the circumstances and is not an illness.

In a similar vein eating disorder “experts” are warning that anorexia nervosa is more prevalent than being reported. Part of the basis for this is that ninety per cent of teenage girls have allegedly been on a diet. The experts warned of an “alarming” number of young people developing eating disorders as they battle obesity.

Being on a diet is not the same as anorexia and people “battling” obesity are unlikely candidates for anorexia which in fact has nothing to do with food and is all about control issues. However “alarming numbers” and “experts” makes for great headlines, as did the claim that one in 10 women will develop an eating disorder.

One question though. How did they define eating disorder? Depending on the definition you could widen it to nine or even ten out of ten women.

Meanwhile it has been shown that Australians are being prescribed antidepressant medication for reasons other than those for which the drugs have marketing approval. This is particularly the case in the elderly. In the USA increasing prescribing rates for antidepressants over the last decade has not improved the overall mental health of the populace.

So here is the problem. Feeling stressed or down or a bit anxious is not the same as a mental illness. Conditions like anxiety and depression represent one end of a spectrum of human emotion and behavior. Labeling every emotion as a disease is good for sales of medications, for groups seeking to raise funds and for academics pushing research agendas.

It is not good for people. Reclassifying normal human emotion and experience as a disease portrays people as victims in need of the support offered by those raising the monies or selling the medication. As soon as you are not a victim you are in control of your own destiny and may not need the “support”.

None of this is to deny that some people have genuine mental health illness and need support and in some instances medication. It is to say that it is easy to reclassify human emotion and behavior as an illness and that doing so can be very profitable.

Friday, June 4, 2010

With Tests And Treatments Less Is More

In the previous blog I wrote about problems with long term use of medications particularly those used for lifestyle related conditions. It looks like The American Medical association agrees with me. The association’s Archives of Internal Medicine Journal has highlighted the often unpublicized downside of tests and treatments in a recent edition.

In an editorial titled “Less is more: How Less Health Care Can Result In Better Health” the spotlight has been turned on how extra tests and un necessary treatments not only do not help but can cause significant harm. The fractures and diarrheal illnesses associated with long-term proton pump inhibitors (used for heartburn) were one of the cases highlighted. According to Dr Deborah Grady of the University of California, San Francisco “There just seems to be this assumption that the more health care you get, the better”.

This is an incredibly important issue. The Archives Journal will have a regular “Less is More” feature looking at where treatments have expanded to the point where harm outweighs benefit. Doctors and patients have become conditioned to the notion that if tests are good, more are better and that pills are the answer for just about everything. Yet there is never such a thing as a free lunch. All pills have side effects. These can be justified when the benefits outweigh the risks and when no other treatment is available. When simple changes in lifestyle will have the same effect though they cannot be justified. The issue of cost is a whole other component of this.

Tests are also seen as wonderful because of their capacity to find “unexpected” serious illness such as cancer. Tests are fallible though and many people go through further tests and even surgery because of a finding in a test which may in fact be meaningless but “once found must be acted on”. Mass screenings add to this problem. Issues with PSA testing led the tests inventor to describe PSA testing for cancer as being like flipping a coin. The benefits of mammography screening have been significantly overstated.

So what drives the test and pop agenda? There are two main drivers. One is litigation and the use of defensive medicine. Ordering unnecessary tests on 1000 people will not get a doctor sued, regardless the cost and inconvenience but the one person where a diagnosis is missed may well sue. The other is commercial and vested interest.

Obviously the pharmaceutical industry has a legitimate interest in selling its products and is clever at marketing. It also drives a lot of research. If a study is done looking for a use for a drug there is a fair chance it will be found. Extending the number of people classified as needing treatment (for example by lowering cholesterol target levels) boosts sales.

Whole industries have sprung up behind screening too. Those involved in the mammography business dismiss any criticism of mammography, as an attack on women, usually. Unnecessary surgery on breasts is not seen in the same light.

There is no point saying that there is an across the board clear cut answer. And herein lies the real issue. One size fits all models do not fit all. Attempts to screen or treat everyone the same has led to this problem. Over emphasis on guidelines and protocols stop doctors (and patients) considering the individual circumstances of each case. Well meaning scare campaigns convert everyday bodily functions into danger signs of cancer leading to a race to exclude what was never there.

The answer then is in fact simple. Focus on being healthy rather than enter the obstacle course of avoiding disease. Have faith in your own body and what it is telling you. It knows more than most tests. Ask your doctor about the downside of tests and side effects of medications. Take the non-pharmaceutical option first. Do not buy into scare campaigns or disease mongering.

Tuesday, June 1, 2010

Long Term Drug Use Can Have Unexpected Side Effects

Much is made of the fact that pharmaceuticals are tested before being released. Trials are done to assess whether the drugs work and to assess the side effect profile. Many drugs never make it to market because in the trial process either they are not found to so much or there are significant other problems, which outweigh their benefit.

This process is a useful one. However it also has limitations. Over the last few weeks we have seen data emerge about long term unexpected problems with widely used drugs. Statins and proton pump inhibitors are in the top five for widely used drugs in many western countries. They are also amongst the most costly to the health system. Statins are used to “treat” cholesterol and proton pump inhibitors are used for ulcers reflux and other stomach acidity problems.

When trials are done they are conducted on relatively small numbers of patients for a relatively short period of time. At tops it may be a few thousand people and often for less than two years. Indeed it may be so many hundred people for so many months. It should not come a s a surprise then that less common problems or those which may take many years to show up will not be picked up in these trials.

When the drugs are used by millions of people for many years new problems may emerge. For example an effect, which occurs one in every 100,000 people, may not be seen in a trial of 5000 but there may be 20 by the time 2 million people have used it. Of course effects, which take ten years to show up, will not be seen for at least that time.

So after nearly 20 years of statin use we are seeing that there are increased rates of liver dysfunction kidney failure, cataracts and myopathy (muscle damage) in those taking long-term statins. The increase may be as high as eight fold. These figures come from studying 2 million people over a six year period. The findings were published in the British Medical Journal.

Meanwhile the FDA has called for labeling changes on proton pump inhibitors after finding an increased rate of fractures in people using them long term. It has also been found that long-term users have much higher rates of clostridium difficile infection causing diarrhea.

It is not surprising to me that when you interfere with the gut there will be consequences. The stomach has acid for a reason. Block it and you will affect absorption of food and other gut functions. The higher rates of diarrhea suggest that the bacteria are better able to survive in a less acidic stomach. Bone fractures suggest the absorption of minerals is being affected. There may be other direct effects on bones too, which have not been determined.

Does this make these drugs dangerous? No it does not. What it shows is that long term use of medications have unexpected consequences. In also shows we do not always know the long term safety of drugs when they are released.

Most importantly it tells us that reliance on drugs for lifestyle related conditions is not a free lunch. The notion that it is easier to take a pill than to change our eating patterns (for example) may seem fine in the early days. After the unexpected long term problems arise it may not seem like as good an idea.

The bottom line is that lifestyle related conditions require lifestyle solutions. Some people may need medication but this should be used for as few people as possible and for the shortest possible time.