Category Archives: Culture

Marijuana is not gay marriage


It’s tempting to draw parallels between the legalization of gay marriage and legalization of marijuana. A pollster is quoted in today’s Boston Globe (Marijuana advocates lay groundwork for legalization in Mass.) doing just that:

“Opinion is changing very quickly on marijuana,” said Steve Koczela, the president of the nonpartisan MassINC Polling Group. He said a number of 2013 national polls found, for the first time, that a majority of Americans favor legalization of the drug. The rapid change, he said, “mirrors, in some ways, the same-sex marriage shift that’s taken place over the last few years.”

And the parallels go beyond that. Decriminalization of marijuana as Massachusetts has done is akin to allowing civil unions. The next step: full legalization, is viewed as a natural evolution of tolerance.

But there are serious differences. Civil unions lead to gay marriage because the rest of the population has a chance to discover for themselves that gay couples are no threat to heterosexual families. Contrary to some irrational fears, children are not “recruited” into homosexuality just because acceptance of gays goes up and is enshrined in the law. Once gay  couples are accepted and not feared, it becomes an equal rights issue –civil unions confer only partial rights and there’s no rationale to withhold full rights.

Time will tell, but I expect that experience with marijuana legalization will be different. Marijuana use is a health threat. Legalization does make underage use more acceptable, increasing harm. It becomes harder for parents to keep their kids from using pot.

It’s not inevitable that marijuana laws will become more and more lax. Cigarette smoking is becoming increasingly restricted and less culturally acceptable. The latest frontier is over smoking in public parks. Trans fats are being legislated out of use. New York City’s drive to limit soft drink sizes is not as crazy nor unpopular as it sounds. And beverages that mix alcohol and caffeine have been pushed from the market.

The abuse of prescription drugs is finally starting to get the notice it deserves. Parents are waking up to the fact that their kids –and if not them, their kids’ friends– are awfully interested in what’s in the drug cabinet, especially if that includes painkillers like Vicodin or Oxycodone. Something similar will happen with marijuana: barriers to its use will fall when the stigma of buying it from a dealer is removed and when its purity and freshness can be guaranteed by the retailer. I don’t want to see that happen in Massachusetts or elsewhere.

Having said that I do support decriminalization so people’s lives aren’t ruined by a marijuana possession conviction and so law enforcement loses the incentive to pursue property seizures.

photo credit: Eric Constantineau – via photopin cc

By David E. Williams of the Health Business Group.

Sleep: The new health craze?

The last few decades have seen various wellness fads and health scares. Some topics that come to mind are sodium, cholesterol, saturated fats, trans fats, carbs, acai berry, bran, oats, whole grains, organic, jogging, yoga and yogurt.

Maybe it’s time we focus on sleep as the key to health. After all we are a sleep deprived nation, with 50-70 million US adults having trouble sleeping. Two news articles today make me think it might be time for sleep to gain its due:

Regular bedtimes help kids’ behavior reports on a study of 10,000 seven year old kids. Those who went to bed at a regular time had significantly fewer behavior problems than those who didn’t have a regular bedtime. The effects were reversible, too: kids who started going to bed at a regular time started acting better, and those who reverted to more variable timing got worse.

Kids are one thing –and adults may not give that much attention to those little brats anyway– but when studies start linking sleep patterns with neurological decline, then people will take notice. Sleep takes out brain’s trash; buildup of refuse makes you sleepy offers a theory for why we sleep. According to a new study, all systems in the body build up waste products that need to be disposed of, but the brain is a bit different in how it deals with it.

“The lymph system collects metabolites from tissues throughout the body and dumps them into the bloodstream, where they’re carried to the liver for breakdown and removal. The brain’s metabolic waste concentrates in interstitial fluid present in all corners of the brain. A second slurry — cerebrospinal fluid — circulates throughout the brain, and where the two fluids flow together, the metabolic byproducts are carried away by the cerebrospinal fluid…

Scientists… found that the brains of mice — whether they are sleeping or anesthetized — showed more activity and volume at the “transfer stations,” where interstitial and cerebrospinal fluid meet, than did mice who were awake and active. The result was that by the end of a sleep period — around early evening — mouse brains had their lowest concentration of neural refuse of the day. By the time they were ready to sleep again, those concentrations had reached their peak.”

The researchers highlight the link between lack of sleep and neurodegenerative disease, and hint that not getting a good night’s sleep may lead to dementia, since the “trash” doesn’t have the chance to be taken out.

So my prediction: the next health craze may be sleep.

By David E. Williams of the Health Business Group.


Why are ObamaCare opponents so vehement?

A non-health wonk relative emailed me recently:

“Can you tell me in very brief terms, why the far right is so much against the Affordable Care Act?  To me, it makes good long-term economic sense, is immensely beneficial for the health and welfare of those currently without insurance, and puts us in sync with other advanced societies.  I just don’t get the opposition.”

For mainstream folks who aren’t health wonks or political junkies, it can be perplexing to try to understand why House Republicans are so eager to fight the Affordable Care Act that they are willing to shut down the government, possibly cause the government to default on its debts and steer us into a Constitutional crisis.

There are a variety of explanations. Among the more charitable readings:

  1. They feel the legislation was rammed down their throats and they were disenfranchised
  2. They honestly feel ObamaCare will be the ruination of the world’s greatest health care system
  3. They believe ObamaCare will bankrupt the country
  4. The bill is too complicated
  5. They want to appeal ObamaCare and replace it with something better

But none of those explanations hold water:

  1. The law is a moderate one and full of Republican ideas –like the individual mandate and marketplaces –that were included in the bill partly to try to bring moderate Republicans on board. The public option is out, there’s no single payer, and the use of comparative effectiveness research is neutured. And the notion of disenfranchisement rings hollow when we consider how President Bush acted like he had a mandate even though he lost the popular vote. Obama was re-elected and although the House stayed in GOP hands it’s only due to gerrymandering. The average voter voted for ObamaCare
  2. People who believe ObamaCare will ruing a great system don’t understand the US health care system and how broken it is. Those who actually work in it know it’s full of problems, is more costly than elsewhere in the world, and has less to show for the extra spending in terms of outcomes –never mind equity
  3. The GOP are the ones that wasted the Clinton surpluses and passed the Medicare Part D drug benefit without worrying about how to pay for it. ObamaCare was scored by the CBO as deficit-positive. Even if that doesn’t turn out to be the case it’s going to be cheaper than Part D
  4. ObamaCare is complex because it’s moderate. Single payer would be a lot simpler and shorter
  5. There’s very little substance to the so-called “replace” ideas, which anyway took two years to appear

A more objective read is that some opponents have whipped themselves into a lather over their revulsion to all things Obama and are living in an echo chamber where these views seem rational. It would be better for everyone if they went back to the Birther madness.

Patients should not be responsible for telling doctors to wash their hands

Hospitals struggle to get doctors and nurses to wash their hands. That’s a serious problem, since hand washing is one of the keys to reducing healthcare acquired infections that afflict more than a million patients a year and kill over 100,000. And it’s one of the reasons you should try your best to stay out of the hospital.

For the past few years I’ve heard suggestions that patients should take a more active role, and in fact have the responsibility to speak up. Today’s Wall Street Journal (Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’covers the topic again, with a pretty strong message that patients need to take charge.

I strongly disagree.

Here’s one excerpt from the article:

The CDC has provided 16,000 copies of a video, titled “Hand Hygiene Saves Lives,” to be shown to patients at admission. In one scenario, a doctor comes into a room and the patient’s wife says, “Doctor, I’m embarrassed to even ask you this, but would you mind cleansing your hands before you begin?” The doctor replies, “Oh, I washed them right before I came in the room.” The wife says, “If you wouldn’t mind, I’d like you to do it again, in front of me.”

And here’s another:

“We’ve been focusing on intensive interventions to improve hand hygiene among health-care workers for decades, yet we’ve really shown very little progress,” says Carol McLay, a Lexington, Ky., infection prevention consultant and chair of the committee that designed the campaign [to get patients to speak up]. “We are trying to empower patients and families to speak up and understand their role.”

Am I the only one that thinks the situations described above are absurd?

Here’s how I see it:

  • If infection control specialists have been failing to make progress with health care workers for decades then they need to figure out what’s wrong and fix it, not throw the problem onto patients. Here are some ideas: education to get more buy-in from clinicians on the idea of frequent hand washing, technology to track whether hand washing is occurring, harsh penalties for lack of compliance –like closing down a hospital floor, or firing or suspending staff, or making lack of hand washing subject to malpractice claims. If you believe the conventional wisdom (which I don’t –but that’s another story) then physicians will be so focused on avoiding lawsuits through defensive medicine that they’ll instantly get to 100% compliance on hand washing
  • The scenario in the video of first asking a doc if he washed his hands –and then not accepting his answer that he just did it but instead wanting to see him “cleanse” his hands again– is ridiculous. That’s not my vision of patient engagement
  • Lack of hand washing is reasonably visible to the patient, but what about all the other things that occur? Is it practical to verify that my doctor performed all the correct diagnostic tests, interpreted the results correctly, made the right differential diagnosis, prescribed the most appropriate antibiotic and dosing level,  that the hospital stored the medications properly and disinfected their equipment, that the nurses didn’t fake their credentials and that their immunizations are up to date, that I was referred to the right specialists, etc.? All of these things –and many, many others– are important, but I count on the hospital to deal with it and the regulators to oversee that it’s done. I want quality ratings that take into account these issues and I don’t mind payment incentives that reward certain behaviors and penalize others

Don’t get me wrong. I hate the idea of doctors and nurses not washing their hands. If I’m in the hospital and I see something I’m unsure of I do speak up. I bring an advocate when I’m a patient and act as one for others. I would even bring up hand washing in certain circumstances.

But I really resent the idea that I’m supposed to be the handwashing police. Hire someone else to do the job.

From war to bionic legs to immortality

For better or worse, war has provided the impetus for new medical technology. The latest wars in Iraq and Afghanistan have sent home many men and some women who suffered the loss of legs and arms. Although prosthetic limbs have been improving over the years, they are really no substitute for the real thing.

That’s starting to change now, as we learn from an LA Times article about a study published in the New England Journal of Medicine.

A report published Wednesday in the New England Journal of Medicine describes how the team fit [a patient] with a prosthetic leg that has learned — with the help of a computer and some electrodes — to read his intentions from a bundle of nerves that end above his missing knee.

For the roughly 1 million Americans who have lost a leg or part of one due to injury or disease, [the patient] and his robotic leg offer the hope that future prosthetics might return the feel of a natural gait, kicking a soccer ball or climbing into a car without hoisting an inert artificial limb into the vehicle.

[The patient’s] prosthetic is a marvel of 21st century engineering. But it is [the patient’s] ability to control the prosthetic with his thoughts that makes the latest case remarkable. If he wants his artificial toes to curl toward him, or his artificial ankle to shift so he can walk down a ramp, all he has to do is imagine such movements.

This is pretty remarkable stuff, and great news for the many people who have lost limbs and may benefit. But it also hints at ethical issues that society will have to deal with in the future as the technology gets better and better.

We’ve already witnessed the first signs of what’s to come with Oscar Pistorius, the so-called Blade Runner (and probably murderer) whose artificial legs propelled him in the Olympics at a rate that’s likely higher than what he would have been able to do with “real” legs.

Call me crazy (go ahead) but how long will it be until we have athletes who decide to get bionic replacements for legs, knees, arms, eyes –you name it? I think it will be just 20 years or so. After that, we may find a whole cadre of people taking on replacement parts –including internal organs– in order to improve their health and have a shot at something approaching immortality. If you think there’s a wide divide between rich and poor today just wait until the rich find a way to use replacement parts to increase their strength and extend their lifespans.

I hope I won’t be around to see that happen.


Rerun: What the Talmud teaches about drug company gifts to doctors

In honor of the Jewish New Year I’m re-running a post on Judaism’s insights into pharmaceutical sales and marketing practices. L’shana Tova!

Recently I heard a Rabbi discuss the prohibitions against bribes in Jewish law. He shared the Talmudic insight that “a gift blinds the eyes of the wise” and taught that this refers not just to obvious bribes but even to small, innocent-seeming gestures that appear too insignificant to influence another person but that actually do cause a conflict of interest. I told him this sounded very similar to contemporary relationships between pharmaceutical companies and prescribing physicians, where small gifts like pens and take-out lunches are tools of the trade –viewed as innocuous by their recipients but seen as a good investment by the givers.

I revisited a blog post I wrote on the topic back in 2006 along with a JAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennan et al. from the same era. I looked at the list of articles citing the Brennan piece to see if I could find something more current. Lo and behold I discovered Unconscious conflict of interest: a Jewish perspective by Gold and Applebaum in the Journal of Medical Ethics, which probes this issue in more depth. They write:

The Talmud [Tractate Kethuboth folio 105b] suggests that, due to the unconscious mechanism of influence between the giver and the receiver, the prohibition of receiving a gift is not limited to physical gifts, but extends to any other personal benefits, including ‘a bribe of words’:

Our Rabbis taught: ‘And thou shalt take no gift’; there was no need to speak of [the prohibition of] a gift of money, but [this was meant:] Even a bribe of words is also forbidden, for Scripture does not write, ‘And thou shalt take no gain.’ What is to be understood by ‘a bribe of words’? –As the bribe offered to Samuel (a Talmudic scholar who served as a judge). He was once crossing [a river] on a ferry when a man came up and offered him his hand. ‘What,’ [Samuel] asked him, ‘is your business here?’ –‘I have a lawsuit,’ the other replied. ‘I,’ came the reply, ‘am disqualified from acting for you [ie, as a judge] in the suit.’

In a meticulous reading of the story mentioned above, it is not clear whether Samuel, the Talmudic scholar, actually accepted assistance from that ‘courteous’ man. In fact, his reaction of disqualifying himself from serving as a judge seems to be related solely to the man’s offer. That man’s gesture –offering his arm– was a sufficient cause for the disqualification. The gesture alone was perceived by Samuel as a sort of speech-act that emanated –perhaps unconsciously– from the man’s desire to influence his judgement. In other words, the offering of the arm was ‘a bribe of words’.

To me this is fascinating stuff and suggests that to truly avoid the unconscious conflict of interest in the pharma/physician relationship it would be necessary to cut off all contact between pharma rep and doctor. Even when a drug rep is prohibited from distributing tsotchkes or tapping his restaurant budget, the physician still knows the rep would give him things if he could. Under this logic, the “no see” policies of some physician organizations toward pharma reps make good sense.

There is another solution, which is to educate physicians about unconscious biases and the objectives and tactics of pharma companies, device companies, health plans, and other would-be influencers. Even better would be to couple this education with conscious efforts to counteract any biases that are introduced.

Physicians are notoriously skeptical of the notion that they are influenced by gifts large or small. Therefor the article wisely concludes:

For those disinclined to accept either the insights of sociologists and anthropologists or the findings of modern neuroscience on the tendency towards reciprocity in response to the receipt of gifts and favours, perhaps the wisdom of the ancients provides a reason to rethink the unconscious influence of even small benefits on physician behavior.

Can violent sports survive the impact of concussions?

As studies and accompanying news coverage about the long-term dangers of head trauma have emerged over the past few years I’ve been thinking about what American sports will look like a generation from now. The NFL’s recent $765M settlement with retired players has me thinking about it again.

In the US, football players are our modern gladiators, and we love to watch. A century ago, the survival of football was threatened due to the uproar over 19 fatalities in 1905. Rules were changed and the game became somewhat safer, but as we now are starting to understand, signs of serious damage may not emerge for years after retirement.

Will football and other violent sports survive? And if so, how will they look compared with today?

At the one extreme, I think it’s possible that football and boxing will be banned and that the rules of hockey and soccer will change substantially as a result of awareness of head injuries. If that seems extreme, consider how dramatically social norms on an issue like smoking can change over time.  The Surgeon General first made noises about the danger of cigarettes in the 1960s, but when I was growing up in the 1970s and complained about secondhand smoke my mother told me to “get used to it.” It was inconceivable to me then that in 2013 smoking would be banned in so many places and so heavily stigmatized.

On the other hand, it’s been obvious forever that boxing is a dangerous endeavor. While there have been changes over time to ensure the safety of fighters the sport is still around and not all that different from what it was a generation back. So if boxing is the model then the modest changes we’ve seen so far in the other violent sports may be about as far as it goes.

One of the keys to the equation is what happens with youth sports. Parents of high school athletes are aware of the newer research on head trauma, and leagues and coaches have made reasonably strong moves to protect players with concussions from aggravating those injuries. But what of the parents who are having kids now? Will they be as eager as current and past generations to let their kids get involved in the more dangerous pursuits? I’m not sure.

An area to keep an eye on is technological change. Football helmets to protect players from death and serious injury inadvertently made things worse in some ways by encouraging spearing. With a better scientific understanding of head trauma and a desire to prevent it, equipment makers may be able to devise helmets and other gear to make the games safer without making them slower or less physical. That’s my hope.