I was just reading an article on the NYT which described a new method that doctors can use to decide whether to put patients on statins or not.
Statins work to prevent cardiac events by reducing cholesterol levels. While widely used, they are controversial as a means to prevent heart attacks in people without cardio-vascular disease.
As a public health guy, I’m interested in health diagnostics. So when I noticed that this hi-tech “calculator” was available for download from the NYT article, I immediately opened it up. I expected some sweet Java-based interface, with boxes to check a number of things like age, weight, ethnicity, dietary and exercise habits and family health history.
To my dismay, I found that it’s an Excel spreadsheet with space to enter ten items:
As you can see, I filled in my own information (as best I could, based on recall).
I was happy to see that my lifetime risk of CVD is a mere 5% and, as I resist taking medications of any kind, even more happy to see that a doctor would likely not prescribe me statins.
However, I’m not sure what this really tell me. Does this say that I don’t have to exercise anymore? Can I eat tons of fried crap and finally ignore my family’s host of health problems now?
Mostly, I’m struck by how arbitrary this is. Smoking, high blood pressure, advanced age, being male and being African American are all known predictors of CVD. The absence of potentially modifying factors such as diet and exercise just make the picture even more arbitrary. I may be old, black and male, but I may have made lifestyle changes to counter those factors, thus reducing my risk for disease.
More frightening to me is how ad hoc medical care is. Doctors are praised for “shooting from the hip,” or making diagnoses based on gut feeling. In most cases, this is satisfactory. Sometimes health problems resolve themselves, or are too serious to effectively treat in the first place. Other times, this can lead to over prescription of medications or uninformed (praise god for the internet!) “patient directed medical care.” Though this calculator attempts to counter that behavior, I fear that its cheap simplicity makes a mockery of quantitative diagnoses of health risks, undermining the project’s goals.
The truth is, of course, that we really don’t know enough about complex diseases such as CVD. Though medicine is able to spot obvious candidates for serious disease (particularly after one develops it), the truth is that no one can say for certain whether, absent the obvious, one person is more likely to become ill than another. This calculator doesn’t change that.
It was a great epiphany for me when I realized that, though I am at low risk for CVD, given my expected long life expectancy, I am more likely to die due to, you guessed it, heart disease.
For those keeping up, you may remember that I spent the summer in Kenya, working with a team extracting blood samples from camels, cows, goats and sheep. We were in contact with all of these animals on almost a daily basis. We weren’t wearing any protection at all, but it’s inconceivable to wear a full hazmat suit while taking blood from goats in a Maasai community. You’d get laughed out of town.
My days right now are running in a fairly predictable pattern. I wake up, feel pretty good, eat breakfast and drink some coffee. At about 10-11 a.m. I begin to feel dizzy, sweat somewhat, a low grade fever kicks in and a horrible taste develops in my mouth. My peripheral vision is limited and I have trouble focusing on distant objects. It gets progressively worse throughout the day, but improves before dinner. After dinner, I feel worse than before. I’m positive that the brunt of the physical symptoms are associated with anemia. It’s like a low grade malaria.
The psychological effects are fascinating. Again, in the morning, I feel fine. As the day progresses, I am less and less able to string coherent sentences together (not that I’m good at it in the best of times), lose thoughts in mid sentence and can’t remember important vocabulary words. I’m stuck in an existential funk where the thought of tomorrow is dark, I’ve forgotten the past and the present isn’t all that meaningful. I often find myself staring into space and time passes quickly.
Though I have no other negative physical effects and am able to leave the house and move around, I’m finding this incredibly debilitating. Even writing this blog post is a challenge.
From the pathogen’s standpoint, this situation is ideal. It doesn’t immediately kill the host, and the bacteria tends to incubate in cells so that it can avoid the body’s immune response. If I were a herd animal, eating and defecating in the same space, I would be able to transmit for, conceivably, the rest of my life. The low grade anemia keeps the animal mobile, yet impedes its ability to evade predators, allowing transmission to occur from herbivorous ungulates to carnivorous animals.
Again, because the bacteria hides out in cells, it’s a bear to kill. I have two months of two types of antibiotics to look forward to, both with different schedules and dietary requirements. One causes awful nightmares (doxycycline).
If left untreated brucellosis can include abscesses in the joints, spinal problems, blindness and inflammation of the testicles. It is anecdotally associated with elevated rates of suicide in veterinarians. I’m wondering how much chronic brucellosis there is in pastoralist communities in Sub-Saharan Africa. The burden must be quite severe.
This is going to be rough, but it’s better than a lifetime of these symptoms. I’m certainly finding this scientifically interesting, though I will be happy to have it gone for good.
Several drugs to treat Tuberculosis have made it to the FDA’s drug shortage list. (I recommend a quick glance at the list. Big government (thankfully) at work!)
A friend/acquaintance of mine posted that the following medications are presently in short supply, or unavailable: Isoniazid, Rifampin, Ethambutol, Amikacin, Streptomycin, Tubersol and Aplisol.
Now, I’m not going to pretend to be an expert on TB, though I do know enough about the condition to know that TB is most common among the poorest and most marginalized members of society. In Malawi, I’ve seen active and advanced cases of TB. It’s an awful sight.
People who live in substandard housing in urban areas, prisoners, alcoholics and homeless people are at particular risk for infection. It’s particularly common in Africa, and a problem that seem to be getting worse, rather than better. Coinfections with HIV are common.
Japan, specifically the Airin area of Osaka, where homeless men and day laborers congregate in substandard and densely occupied housing units, is well known to have one of the highest incidence rates of TB in the developed world. Russian prisons are also famous for TB transmission, as the work of Paul Farmer has shown.
According to the FDA list, many of the drugs are in short supply due to “Demand increase for the drug.” I find the claim to be somewhat dubious. Drug companies have long been known to be sleeping at the wheel when it comes to development of new drugs for TB. Most of the drugs that are currently used were developed in the early the mid 20th century, with one very recent exception (Bedaquiline).
I find it highly unlikely that demand for the drugs went by unnoticed to drug companies. I suspect that there simply isn’t enough profit in the drugs to warrant ramping up manufacturing.
The implications are, of course, immense. If drugs to treat TB are unavailable, opportunities to transmit TB will persist. Given the nature of the populations which are at risk for the disease, we can expect a resurgence in cases. Worse yet, the longer a patient has the disease, the more likely it is that the infection will become resistant to all medications, making treatment nearly impossible.
as one would expect. The Institute of Medicine within the National Academies of Sciences recently produced a 230 page report addressing the concerns of parents that the current recommended vaccine schedule is too “crowded” and thus puts children at excessive risk.
Upon reviewing stakeholder concerns and scientific literature regarding the entire childhood immunization schedule, the IOM committee finds no evidence that the schedule is unsafe. The committee’s review did not reveal an evidence base suggesting that the U.S. childhood immunization schedule is linked to autoimmune diseases, asthma, hypersensitivity, seizures, child developmental disorders, learning or developmental disorders, or attention deficit or disruptive disorders.
Existing mechanisms to detect safety signals — including three major surveillance systems of FDA-approved products maintained by the CDC and a supplemental vaccine safety monitoring initiative by the FDA—provide further confidence that the current childhood immunization schedule is safe.
It’s quite a tempting narrative. Small defenseless children are jabbed multiple times, allowing harmful foreign substances to enter the body, all with the nefarious intent of making profits for large pharma giants. However, children are assaulted by pathogens from the second they exit the birth canal, and continue to be throughout the course of their lives.
The inactivated versions of the pathogens they might otherwise come into contact with should present no extra burden to an immune system that already anticipates invasion. Of course, coming into contact with a dead version of a pathogen is far preferable to coming into contact with the live version. The assertion that the schedule is “crowded”, given daily attacks on the immune system, is completely absurd.
Moreover, the report found that States with loose vaccine policy, have higher incidence of disease, in this case Pertussis:
While parents generally worry about children’s health and well-being, and their concerns about immunization safety can be viewed in that context, delaying or declining vaccination has led to outbreaks of such vaccine-preventable diseases as measles and whooping cough that may jeopardize public health, particularly for people who are under-immunized or who were never immunized. States with policies that make it easy to exempt children from immunizations were associated with a 90 percent higher incidence of whooping cough in 2011.
Of course, we are experiencing record numbers of Pertussis cases. It must be noted, that like influenza, most cases of Pertussis are asymptomatic. In fact, it is estimated that 5 out of 6 cases of Pertussis come without symptoms, yet transmission occurs. (2 out of every 3 influenza cases are asymptomatic. Next time someone tells you they never get the flu, don’t believe them.) Unvaccinated people may still contract the disease, not experience symptoms, and still pass it one to an unvaccinated person, who, of course, could very well die.
Many of the diseases on the vaccine schedule are very much still in circulation. One excellent example is tetanus, a bacteria which lives happily in soil (not rust, as commonly believed). Tetanus passes through our digestive tract regularly through food, but when the bacteria enter the other parts of the body, particularly the low-oxygen environment of the muscles, the usual outcome is to suffer for months and often die a truly horrible death. Nearly all cases of tetanus in the US occur in unvaccinated individuals.
Given tetanus’ ubiquity in the environment, I often scratch my head when parents tell me they don’t vaccinate their children as the risks of the disease far outweigh the risks of the vaccine. Here, of course, it isn’t the vaccine that’s killing kids, but politics and self-serving conspiracy hacks.
“Malaria transmission is particularly difficult to interrupt in areas with efficient mosquito vectors, a long or year-round transmission season, poor state of overall development, marginalized populations and weak health systems with inadequate coverage of health services, as well as in areas with civil unrest, illegal cross-border movement, or areas that border high-burden neighboring countries and experience intense cross-border population movement. Each of these factors will reduce the feasibility of malaria elimination”
Shouldn’t this be completely obvious? They are describing every place where malaria is, outside a few exceptional cases at this point. The WHO is stating clearly that malaria elimination in Sub-Saharan Africa is absolutely impossible.
A search for all articles with “malaria” in the text yields an amazing 33,800 results. Browsing through the headlines is like reading a brief history of the disease as seen through an American lens.
The oldest article is from 1889, a report on a malaria outbreak on the upper Hudson in New York: “An epidemic of a malarial nature is reported from towns along the upper Hudson, one physician in Newburg reporting more than seventy cases under his care. Newburg is famous for its breakneck streets.”
The article is notable because in 1889, very little was known about the disease. Of course, in 2012, we know much, much more, but the challenges (problems in diagnosis, complex and often contradictory observations on ecological factors and socio-economic infection gradients) are the same now as they were then.
“30 INSANE PARETICS CURED BY MALARIA; Long Island College Hospital Reports Marked Success With New Treatment. Thirty patients regarded as hopelessly insane are back at work and leading normal lives after being artificially inoculated with malaria, allowed to suffer chills and fever for two weeks or so and then treated with drugs, according to an announcement yesterday by the Long Island College Hospital.”
I don’t think that anyone really knew what the “paretics” were suffering from, but it was likely syphilis. Malaria was used briefly to treat a variety of neurological disorders caused by infectious agents, with varying degrees of success and failure.
Vaccines have long been “just around the corner,” only to die in sad failure. The most overly optimistic claim came in 1984 from then head of USAID, M. Peter McPherson (who later became President of Michigan State University):
M. Peter McPherson, administrator of the Agency for International Development, said he expected that a vaccine would be ready for trial in humans within 12 to 18 months and widely available throughout the world within five years. ”We think this is a practical schedule,” he told a news conference at the State Department today.
A classic case of overstatement, I’m sure that he regrets this event to this day. No wonder scientists have to be wishy washy with their predictions. Statement like this live in sad perpetuity. We still don’t have a vaccine, and the outlook for having one any time soon hasn’t gotten much better now than in 1984.
1889 North River Malaria
1925 30 INSANE PARETICS CURED BY MALARIA
1925 WAR ON MALARIA BEGUN BY LEAGUE
1938 MALARIA SCOURGE FOUGHT BY THE TYA
1943 Malaria Problem; Our Knowledge Is Still in an Unsatisfactory State
1944 us HEALTH SERVICE COMBATS MALARIA
1945 New Drugs to Combat Malaria Are Tested in Prisons for Army
1946 CURE FOR MALARIA BARED BY CHEMISTS
1948 NEW DRUGS TO END MALARIA SCOURGE
1951 Army Tests Drug as Malaria Cure; Doses Given Troops
1952 un GAINS GROUND AGAINST MALARIA
1957 World-Wide Battle On Malaria Mapped
1961 New Malaria Threat Is Studied At Infectious Diseases Center
1965 A ‘NEW’ MALARIA RAGES IN VIETNAM
1966 Leprosy Drug Reduces Malaria Among gi’s
1970 Malaria Up Sharply in Nation; Most Cases Traced to Vietnam
1971 Drug Users Spur Malaria Revival
1974 Prison Official in Illinois Halts Malaria Research on Inmates
1977 Malaria Spreading in Central America as Resistance to Sprays Grows
1984 MALARIA VACCINE IS NEAR, U.S. HEALTH OFFICIALS SAY
1987 Drug Combinations Offer New Hope in Fighting Malaria
1988 Scientists Report Advances In Vaccine Against Malaria
1991 Outwitted by Malaria, Desperate Doctors Seek New Remedies
1991 Hope of Human Malaria Vaccine Is Offered
1993 Mefloquine Is Found Best Against Malaria
1994 Vaccine Cuts Malaria Cases In Africa Test
1995 Vaccine for Malaria Failed in New Test
1996 Tests of Malaria Drug From China Bring Hope and Cautionary Tales