Best of Last Year—The top medical  articles of 2018

It was a good year for medical science as a team at Cincinnati Children's Hospital Medical Center reported that the Epstein-Barr virus could be linked to seven serious diseases. Best known for causing mononucleosis, it was also found to play a role in systemic lupus, erythematosus, multiple sclerosis, rheumatoid arthritis, juvenile idiopathic arthritis, inflammatory bowel disease, celiac disease and type 1 diabetes.
And a team with members from the University of Milan and the University of Pavia found that leg exercise is critical to brain and nervous system health. In their study with mice, the researchers found that restricting movement for a period of 28 days led to a reduced number of neural stem cells by 70 percent, and neurons did not fully mature.

26 dec 2018--A team at the University of Reading found that bilingual children who spoke their native language at home had higher intelligence than did those who spoke only one language. They found that Turkish children who spoke one language at school and another at home scored better on IQ tests.
And a team at the Stanford University School of Medicine announced that they had developed a cancer 'vaccine' that eliminated tumors in mice. Injecting small amounts of immune-stimulating agents directly into solid tumors caused the immune system to attack the tumors, resulting in the elimination of all traces of them—including distant cells that had metastasized.
Also, a combined team of researchers from the University of Aberdeen and the Chinese Academy of Sciences announced that fat consumption is the only cause of weight gain. In their study with mice, they found that sugar and carbohydrates did not lead to weight gain no matter how much was consumed.
And a team with members from South Africa and Germany found that footwear habits influenced child and adolescent motor skill development. In studying children in South Africa, they found that children who went mostly barefoot from age six to 10 developed better motor skills. They found going shoeless improved balance and made them better jumpers.
Also, a study led by Eric Brewe of Drexel University showed that new parts of the brain become active after students learn physics. They found that a part of the brain not normally associated with learning science became active when students worked on physics problems. Their study using fMRI showed that learning physics activated the dorsal lateral prefrontal cortex.
And a team at the University of Cincinnati College of Medicine found that a ritual for orthodox Jewish men may offer heart benefits. They found that the practice of wearing tefillin during daily prayers could offer some cardiovascular benefits. Tefillin involves tightly wrapping the non-dominant arm with a strap, which could be protective against acute ischemic reperfusion injury.
Another team of researchers made headlines this past year when they announced that most popular vitamin and mineral supplements provide no health benefits. The group with members from St. Michael's Hospital and the University of Toronto conducted a systematic review of popular vitamins and supplements over the years 2012 to 2017 and found the majority offered no positive benefits whatsoever.
Also, a team at UC Davis unveiled human images from the world's first total-body scanner. Called EXPLORER, the imaging system captures 3-D imagery of the entire human body all at once. The images can be viewed as a rotating figure with internal organs on display. The researchers combined PET and CT scanners to create the new system and reports that image captures take just a few seconds.
And a team at the Max Planck Institute for Human Cognitive and Brain Sciences found that the brains of jazz and classical pianists work differently. Thirty professional musicians engaged in piano exercises while the researchers studied their brainwaves using EEG sensors attached to their heads. The researchers found that different musical genres require musicians to take different approaches to planning and weighing the steps involved in playing the piano.
Also, a team at the Medical College of Georgia found a link between probiotic use and brain fogginess and severe bloating. They found that patients taking probiotics had large colonies of bacteria breeding in their small intestines, which led to severe bloating and the production of D-lactic as a byproduct of fermentation. Prior research has shown that D-lactic can lead to problems with cognition, thinking and the perception of time.
And a pair of researchers with the Ragnar Frisch Centre for Economic Research in Norway found that IQ scores have been dropping since the 1970s. In their study of 730,000 men entering the national service between the years 1970 to 2009, Bernt Bratsberg and Ole Rogeberg found that volunteer scores had dropped by an average of seven points per generation.
Also, a team led by Sebastian Dieguez of the University of Fribourg, found that a core thinking error underlies beliefs in creationism and conspiracy theories. In their study, 150 college students answered questionnaires, and the researchers found a connection between belief in creationism and conspiracy theories. They suggest this example of teleological thinking is due to a perception of final causes and overriding purpose in naturally occurring events and entities.
And John Leach with the University of Portsmouth reported that people can die from giving up the fight. In his research efforts, he found instances of people simply losing the will to live—quite often after surviving a traumatic event. He notes that giving up the will to live is not the same as suicide, as victims do not cause their own deaths directly; their bodies simply react to their desire to cease living.
Also, a team at the Medical College of Georgia found that drinking baking soda could be an inexpensive, safe way to combat autoimmune disease. They found daily consumption of the common baking ingredient resulted in signaling to the spleen (or more precisely its mesothelial cells) that prevented it from setting off unnecessary autoimmune alarms.
And a team with members from several institutions in the U.K. and one in the U.S. reported that e-cigarette vapor disables key immune cells in the lungs and boosts inflammation. More specifically, they found that the vapor impaired the activity of alveolar macrophages that are responsible for keeping the lungs clean and free of dust, bacteria and allergens. With their activity impaired, a person would be more susceptible to infections and inflammation.
In an unrelated study, a team led by Silvia Balbo gave a presentation at the 256th National Meeting & Exposition of the American Chemical Society, reporting evidence that e-cigarettes can damage DNA. They identified three compounds in e-cigarette vapor that were responsible for the damage: formaldehyde, acrolein and methylglyoxal.
A team at the Sanders-Brown Center on Aging at the University of Kentucky found that the Ketogenic Diet appears to prevent cognitive decline in mice. The diet, which is heavy on fats and light on carbohydrates, has been popular in the media for most of the year, and appears to offer more than just weight loss. They found it improved neural blood flow, improved the gut biome balance, lowered glucose levels and resulted in weight loss in mice. They also found it helped clear amyloid-beta from the brain—the hallmark of Alzheimer's disease.
And a team led by Ido Kanter from Bar-Ilan University reports evidence that the brain learns completely differently than we've assumed since the 20th century. Since the 1940s, medical scientists have believed that the brain learns by modifying the strength of the synapse. In this new effort, the researchers found evidence of changes to the brain during learning in dendrites—the long arms of neurons. This finding suggests learning is more complicated in the brain than has been thought.
Also, Mel Greaves with The Institute of Cancer Research in the U.K. revealed the likely cause of childhood leukemia. He suggested that the disease happens due to a two-step process. The first is a genetic mutation and the second is exposure to some type of infectious agent. He further suggested that these findings indicated that the disease may be preventable by stimulating the immune system in infants.
And The Institute for Health Metrics and Evaluation in the U.S. produced a report for the Lancet claiming that there is no safe level of alcohol consumption. Their findings overturned previous studies suggesting that consumption of small amounts of alcohol might have health benefits. The study was part of the Global Burden of Disease effort, and concluded that there are no beneficial health outcomes from alcohol, only negative ones.
The World Health Organization added a revision to its classification manual that suggested compulsive video game playing could be a mental health problem. The problem, they said, was that it could lead to an adverse mental health condition in which a gamer becomes addicted and unable to stop playing. They suggested it is already adversely impacting gamers and their families.
And a team at Brigham and Women's Hospital reported that the gut influences neurologic disease. In studies involving animal models and human cells, they found a pathway between immune and brain cells that involved central nervous system cells in the brain. They also found that microglia can secrete compounds that induce neurotoxic properties in brain cells, leading to many neurological diseases.
And finally, a team at the University of Wisconsin reported evidence that yogurt may dampen chronic inflammation linked to multiple diseases
. More specifically, they found that the effect results from yogurt improving the integrity of the intestinal lining. Their study involved monitoring 120 pre-menopausal women, half of whom were obese, who ate yogurt for nine weeks.

The Cure

By SARAH MANGUSO
13 april 2008 -- For a year I worried that I might die having had sexual intercourse with only one person. Like many college students, I thought intercourse was the greatest thing in life. And it just about killed me to hear of everyone’s rambunctious affairs while I was in the hospital.
When I was 21, in the mid-’90s, my immune system filled my blood with poison. It was trying to destroy my nervous system — a misperception that caused me a lot of trouble.
When a medical student came by my hospital room after his rounds were over, with a book or a mix tape he’d recorded, I thought about inviting him to sleep with me if they told me I would die there in the hospital. But I went back to college in spring still sick, with a tube still implanted in my chest. It looked like something I should pull out — a white dart, a poison arrow — but I couldn’t pull it out.
I needed the big tube so my blood could be removed and cleaned and put back with the cells intact. I’d had it done with big needles, wide bores, in the crooks of my elbows, but my arm veins had long since blown. Then I had three catheters in my subclavian vein. The scar tissue from those still feels like hard cranberries buried under my collarbone.
The permanent line was a 20-inch tube that never clogged as long as blood thinner was shot into it every two days. From one direction it went into my right breast, under the collarbone and up, just under the skin, into my jugular, and then into my subclavian vein and toward my heart. On the outside it hung like two white drinking straws, six inches long, with one red clamp and one blue one, like a piece of jewelry.
I gave away my scoop-necked sweaters. I used big clear adhesive patches to cover the entry site when I showered. The catheter never got torn out in my sleep because I learned how to roll over slowly, even in deep sleep, while cradling the catheter in my left hand. Every month or so I went back to the hospital to have my plasma replaced or to have a bag of medicine infused.
My blood was removed and cleaned and put back more than 50 times. After that, my hematologist tried another treatment: massive gamma-globulin infusions. The second infusion kept me going for three months, and it was decided I wouldn’t have to have my plasma replaced again. My neurologist said I’d turned a corner, so after 11 1/2 months, my central line was pulled.
I believed, though, that I would stop secreting antibodies only after I had sexual intercourse. And though I looked worse than I ever had in my life, thanks to the steroids — I was fat and swollen, covered in acne, and had a gruesomely round face — I thought my legendarily promiscuous musician friend might still be interested.
So I called him and invited him to have a drink with me that night. We had our drink and walked back to our dorm and sat down in the courtyard, just talking. It was June, two days before commencement. He was graduating, and I was graduating, too, sort of, but the envelope I was getting wouldn’t have a diploma in it. I had another semester of course work to complete.
Only the seniors were left at school, and most of them were in the courtyard. I felt exposed. Finally, getting up from the bench we’d been sitting on, my friend said, “Your place?” And we went to my dorm room, which was a single suite I had all to myself, with my own bathroom, because my neurologist had written a note to the university.
We sat on my futon, drinking out of a plastic bottle of vodka. Eventually he said, “Do you have any other rooms in this place?” and walked me to the bedroom, and lay me on my bed, and had intercourse with me. Then he asked me about the scabs on my chest from where the line had just been pulled out and listened to the things I told him, and held me very tightly.
Two mornings later, when we were in the courtyard again, seated in rows for graduation, he was wearing a buttoned shirt and sweating, because his neck was covered with bite marks.
Years passed. He and I wrote almost every day. I lived in one city and he lived in another. He told me some of his secrets, and I told him some of mine. Our letters were intimate, but I didn’t get around to explaining to him that I recovered from my disease only because he had selflessly had intercourse with an ugly version of a girl he once had a crush on.
A little less than seven years after I was cured of my disease through the mystical power of intercourse, my friend died of a sudden illness. I never told him about my magical cure, his sweet medicine. And I wish I could have saved his life. I hope he knew somehow that he had saved mine.

10 Health Advances That Changed the World

By DAN CHILDS and SUSAN KANSAGRA
Whether it's the technology that allows us to peer deep into the body or medicines that extend the lives of those with chronic diseases, it's easy to see how advances in health and medicine have touched the lives of nearly every person on the planet.
Yet considering the ubiquitous nature of these developments, it is easy to see how many people take for granted the technologies and practices that, at one point or another, almost certainly saved their own lives or the lives of people they've loved.
The list below encompasses 10 advances in health and medical practices that have changed -- and in many ways continue to change -- the world today.
Vaccines
Throughout history, communicable diseases have had a tremendous impact on human history. So too, then, has the development of one of the most effective ways to defend against rampant viral infection -- vaccination.
Dr. Edward Jenner first introduced the idea of vaccinations in 1796, when he successfully prevented a young English boy from getting smallpox.
The concept of vaccination was propelled further by scientists such as Louis Pasteur, and in the modern era, when large groups of soldiers were successfully vaccinated in World War I and II against such diseases as tetanus, diphtheria and typhus.
"Polio vaccine is one that people think of because it had such an impact," said Dr. Jeffrey Baker, director of the history of medicine program at the Duke University School of Medicine.
But from the global health standpoint, Baker said Jenner's introduction of the smallpox vaccine may have had an even more significant impact in terms of lives saved.
Surgical Anesthetic and Antisepsis
Without a doubt, surgery used to be a much graver proposition than it is today. One of the chief reasons for this is that before the middle of the 19th century, anesthetic simply wasn't an option.
That changed Oct. 16, 1846, when William T.G. Morton demonstrated the mysterious wonder of ether -- a substance powerful enough to dull the pain and agony that had long been associated with surgery.
But while anesthetic was a great advance in and of itself, another advance that occurred at roughly the same time may have been even more beneficial -- antisepsis, or the creation of a sterile surgical environment.
"Anesthetic made it possible to operate on a patient without pain," Baker notes, "but without antisepsis they'd die anyway."
Clean Water and Improved Sanitation
Put them beside surgical advances and other cutting-edge technologies, and public health measures don't look so sexy. But the fact is that clean water and sanitation have likely saved millions -- perhaps billions -- of lives since they were widely implemented in the 19th and 20th centuries.
"It's something that's so important around the world and in America," Baker said. "It used to be that 15 percent of infants would die, and the biggest reason for this was diarrhea brought about by unclean water and milk."
Clean water and public health measures dramatically cut down the incidence of such deadly water-borne diseases as cholera and improved sanitation, drastically lowering the health impacts of parasitic infections and other health conditions related to the environment.
Antibiotics and Antivirals
As with vaccination, the advent of antibiotics hailed a new era in the treatment of communicable disease.
Interesting, then, that the concept of antibiotics may have been uncovered accidentally. In 1928, Sir Alexander Fleming left a petri dish of Staphylococci bacteria uncovered and later noted that the bacteria had been killed by a mold.
Upon further studying the mold, he discovered it was from a family called Penicillium notatum. Others soon saw the potential uses of what later came to be known as penicillin.
Today, antibiotics are used to treat a plethora of bacterial illnesses. And today, researchers are developing antivirals -- most notably, the AIDS-fighting antiviral AZT -- to deal with a host of viral illnesses as well.
The Birth Control Pill
Arguably, few developments have had as profound a social impact as the introduction of the birth control pill -- though its path to widespread use has been a rocky one.
Although the Federal Drug Administration approved contraception as safe in the early 1960s, it only became legal for married couples in 1965 and for unmarried couples in 1972.
But because of the Pill, countless women have been given control over their own fertility -- a concept that created a social revolution.
"Thinking about how it has transformed women's lives, in terms of family planning and the entry of women into the work force, its impact has been significant indeed," Baker said. "It was the first-ever lifestyle drug. It's not treating a disease, but it was making life better for women."
Improvements in Heart Surgery and Cardiac Care
Heart disease remains at the top of the list of the country's killers. Despite this, numerous important advances in its treatment have made a considerable impact, extending and improving the lives of its sufferers.
Not the least of these advancements is surgeons' ability to operate on and repair the heart -- without putting the patient at an unreasonable amount of risk.
"Maybe the breakthrough moment was the rise of the heart-lung bypass, which made it possible to operate on the heart for more than just a few minutes at a time," Baker said. "This was followed by coronary artery bypass grafting, which is, I believe, a most important procedure."
Randomized Controlled Trials
Another development largely unnoticed by the public at large, the advent of the randomized controlled trial -- what many refer to as the gold standard of medical research -- gave medical researchers an important tool in determining which treatments work, and which do not.
Randomized trials are conducted by dividing patient populations into two groups, where one group receives the intervention to be studied while the other does not. Examining the differences between groups in these types of trials has ushered in an era of evidence-based medicine that continues to guide clinical practice on a daily basis.
"I think this is huge," Baker said. "This is really what's changed how we deal with cancer and lots of other disease, too. In the future we'll look back at this as a huge step forward."
Radiologic Imaging
Before the development of radiologic imaging technologies, beginning with the use of the X-ray, doctors were usually relegated to looking only for external signs of injury or damage.
Today, the ability to peer inside the body and determine the cause, extent, or presence of disease has revolutionized the very way medicine operates and has saved countless lives in the process.
Much of the initial work surrounding the discovery of X-rays was done by Roentgen, a German physicist in the late 1800s. Initially, they were viewed as an invasion of privacy rather than a life-saving tool.
Its utility was soon realized, however, and many additional imaging technologies eventually followed.
"CT scans didn't come into the picture until the 1970s," Baker said, adding that this technology was brought to us by the company BMI -- the same BMI which had previously made a fortune off the British band known as the Beatles.
Advancements in Childbirth
Up until the middle of the 20th century in the United States, childbirth was considered to be the most feared part of a woman's life.
"Go into any old graveyard, and you always see a number of women who died in their 20s," Baker said. "That was in a large part due to childbirth."
With the advent of techniques in anesthesia, cesarean section, and forceps delivery, the chances of a successful have pregnancy improved, at least in developed countries. Unfortunately, many resource-poor societies around the world still lag behind in this arena.
Organ Transplantation
Few surgical interventions today carry as much complexity -- or as much ethical significance -- as organ transplantation.
"It's such a technically complex intervention that it's an amazing thing that it can even be done," Baker said. "It ties together both surgery and immunology."
The first successful transplant operation, which took place in 1954, removed a kidney from one donor and installed it in the body of his identical twin. Other organ transplants followed, including the first liver transplant in 1967 and the first heart transplant in 1968.
Today, there are more than 90,000 people awaiting a transplant in the United States alone -- a situation that also reveals the moral considerations that come entwined with such techniques.
"It represented an important turning point in the field of medical ethics," Baker said. "It really challenged physicians' ethic of 'first, do no harm.'"
What's Next?
Considering the progress that has been made in years past, it is tempting to view the state of health and medicine today as an endpoint.
"Medicine has made it possible to deal with many conditions," Baker said. "Our lives are longer. Still, we have to say in all honesty that our control over chronic diseases is somewhat mixed."
Additional research into how best to stave off these conditions -- even by delving into the secrets of the human genome -- could represent the next hopeful steps toward healthier, longer lives.
"In the future, I think we will begin to see more and more applications from genomic medicine, which will help us identify individuals at risk for chronic diseases and allow us to intervene earlier," Baker said.

A DOCTOR WITHOUT AN OFFICE

Let us be the latest but certainly not the last blog to spill a few pixels over Jay Parkinson, M.D., of Brooklyn. The good doctor and scarily accomplished photographer (see his work as a shutterbug here and here) has an offer to take care of you for $500 a year. And most of the time, you’ll be meeting online.
Parkinson, 31 and freshly licensed, has got no office, though he’s looking into renting a room. You’ll get two face-to-face visits a year (at your apartment, office or other mutually convenient place) and unlimited “e-visits,” his word not ours, for help with your health. Those e-visits could be IM chats, emails, or Web video sessions.
There are some catches. You have to apply online to be a patient (see his Web site here) and that system won’t be up and running for a few days. Also, you’ve got to be young and in lower Manhattan or hipster Brooklyn (not an oxymoron for those of you outside NYC, believe it or not, but the neighborhoods of Williamsburg and Greenpoint).
A friend tipped us to a post on Gawker about Parkinson, who was also noted on Boing Boing and Apohenia and who knows where else.
We IM’d Parkinson (pictured). He responded, well, instantly, and then we had a brief conversation by phone about what he’s got cooking. Here are highlights.
How did you get the idea to do this?Well, I’m not a typical doctor. I get along fine with other physicians, but I didn’t enjoy the hospital or clinic environment. I’m a photographer as well. I shoot for Men’s Journal and stuff like that.
Are there any special hurdles to running your practice this way?No, not really. You have to have your New York State license. The e-visits are more for things like acne, allergies and follow-up labs. Things that aren’t life-threatening. There’s no way in hell I would prescribed narcotics online. It’s a kind of telemedicine. People have traditionally used it for access [for care in rural areas]. I’m looking at it as a way to practice convenient medicine.
Is your service cash only?
If somebody has insurance, I’ll charge them less and provide them with receipts. You can get cheaper care. But you can’t get it immediately, nor will you get care where people will help you spend your money wisely. I’ve spent the the last two or three months calling physicians associated with the best hospitals in New York City and getting their prices. I called one radiologist and found he’d do a chest X-ray for $75 and another would charge, say, $300. For cash-paying patients the prices are all over the place. I’ll make referrals based on quality and price.
What’s your online process for taking a patient?
I have a few questions that I ask whenever patients contact me. Name, age, that sort of thing. If they’re over 40, I’m not going to see them. The disease profile changes after that. If you’re under 40 you have the same disease profile as an older child, adolescent or young person that I saw during my preventive medicine and pediatrics training. I’m not going to deal with people who have old-people diseases.
How many patients do you think you’ll take on?
I want to keep this small. About a 1,000 patients. It fails in its mission if it’s a large corporate thing.
Without an office, how will you pull this off?
I run this entire thing off my iPhone and a laptop. I can access any patient records from my iPhone. Patients can make an appointment on my Web site and it’ll text me and I’ll go see them. This is, to me, what’s missing from medicine: personalized attentiveness. Going to someone’s home allows you to get to know them ridiculously well.

Making Botox Both Medicine and Cosmetic

By BARNABY J. FEDER
David E. I. Pyott, 53, became president and chief executive of Allergan in 1998 after spending his earlier management career in the nutrition subsidiaries of Novartis and Sandoz. The stock stood at $15.74 and the company was best known for its contact lens care solutions.
Allergan, based in Irvine, Calif., spun off the lens care and eye surgery businesses into Advanced Medical Optics in 2002. Since then, its identity has been increasingly linked to Botox, its branded delivery system for minute doses of a bacterial toxin that can paralyze muscles for several months. Thanks to Botox’s growing portfolio of cosmetic and medical applications, Allergan has forecast Botox sales this year of up to $1.16 billion.
But the company also makes a range of pharmaceuticals for various eye and skin care products. Wall Street has applauded the company’s strong growth and strategic moves like the $3.4 billion acquisition last year of Inamed, which made Allergan a leader in silicone breast implants and implants to treat obesity in addition to giving it Juvéderm, a new injectable gel for combating wrinkles. Yesterday, the stock closed at $114.47, down $2.79. Mr. Pyott discussed these recent developments. Following are excerpts:
Q. How should we think of today’s Allergan?
A. We’re seen as a biologics company because of Botox. Our valuation is in line with Genentech. But we are a very small version of Johnson & Johnson in many ways. Wall Street likes that a third of our business is discretionary spending. It’s a hedge against Medicare and insurers tightening their coverage.
Q. You started out viewing Botox strictly as a medical product, right?
A. Yes. Dr. Alan Scott was treating crossed eyes and fluttering eyelids, which is how we got into the business. We thought we’d get $5 million in worldwide sales. Fortunately, we got that wrong.
Q. Botox’s medical sales will top $500 million this year. How does the medical market work?
A. Twenty indications have been approved in various countries. Cervical dystonia (a neck muscle disorder that pulls the head out of position) is the biggest approved medical use in the U.S. Excessive sweating — that’s hyperhidrosis — is another interesting application, which affects eight million people in the U.S. The price per vial for medical and cosmetics is the same almost everywhere in the world but you need 300 to 400 units to treat spasticity in a leg or arm, compared to 20 to remove a crease between the eyes.
Q. But far more people are now getting Botox for cosmetic purposes and that segment is growing faster, right?
A. Last year, worldwide, Botox use accelerated in cosmetics by 32 percent. Botox for therapeutics grew 17 percent. In the short term, cosmetics will become more than 50 percent of the use. But it could swing back at the end of the decade. We are working on headache relief and bladder control for people with spinal cord injuries. We’re looking at 2009 for approval on the headache and 2011 for bladder control.
Q. People have been opening storefronts in shopping centers for Botox treatments. Is misuse a concern?
A. Patients should receive their treatments in an appropriate medical setting from people who are well trained. If you are just looking for a simple removal of the crease between the eyes, most people can do that. If you are looking to change the shape of the eyebrows, it requires a very precise weakening of six or seven muscles and that’s where you need an expert.
We heavily discourage — we even mandate — that our sales people don’t go to places like spas. We will supply to anyone who can establish their credentials as a medical professional. If it’s someone new, we make sure they have a valid license through a state medical society.
Q. Isn’t the huge amount of money spent on Botox for cosmetic purposes — and your other products like dermal fillers and breast implants — a horrifying sign of misplaced priorities in American society?
A. This is a worldwide phenomenon wherever there is a buildup of wealth. The cosmetic use comes out of the entertainment budget.
Q. So how reliant are you on the state of the economy?
A. People ask and I have to tell them it doesn’t seem to have much effect if you look back to what happened after the Internet bubble burst. We go down to households with $50,000 but most have a lot more than that.

Prescribed Reading

By JEROME GROOPMAN
Medicine engages life’s existential mysteries: the miraculous moment of birth, the jarring exit at death, the struggle to find meaning in suffering. But medicine is practiced in the mundane world and involves concrete issues like the imbalance of power between physician and patient; the role of quackery, avarice and ego in molding a doctor’s behavior; and the demand for perfection in the face of human fallibility. No insight into its more existential aspects is found in clinical textbooks, properly devoted to physiology, pharmacology and pathology. Rather, it is literature that most vividly grapples with such mysteries, and with the character of physician and patient.
Each spring, I address these nonscientific dimensions of medicine with 12 freshmen at Harvard College in a seminar called “Insights From Narratives of Illness.” We read about a dozen works, from short stories by Turgenev to Samuel Shem’s Rabelaisian hospital novel “The House of God.” The students are generally surprised to learn how the experience of illness touches every corner of human emotion and behavior. But they are even more surprised to discover that even as they read the assigned books, they are often reading, in the background, one of the world’s oldest books. That book is the Bible. Whether read as revealed truth or as a literary work, the Bible is a sourcebook of human psychology and an enduring inspiration for authors trying to capture the drama and dilemmas of medicine.
The seminar begins with the Tolstoy novella “The Death of Ivan Ilyich.” A magistrate in 19th-century Russia, Ilyich leads a life guided by external expectations, steadily climbing the social ladder and relishing his control over plaintiffs. With no warning, he develops a painful condition that none of his celebrated physicians can diagnose, and he begins to slip from life. The narrative mirrors Christ’s Passion, with the climax following the three days before the Resurrection. These allusions are not subtle, nor is Tolstoy’s solution to the apparent meaninglessness of suffering and death: God’s abiding love. Yet each year, only one or two students recognize the resonance of the Passion in this novella, or the Bible’s influence in subsequent readings. The idea that the soul must be cleansed through pain, prevalent in Tolstoy’s era, unsettles most of the class. They wonder whether such extremes of suffering are needed to shock a complacent character out of his narcissism. But I have seen this happen in the clinic, again and again.
We move on to Turgenev, Chekhov and Kafka before reaching Richard Selzer’s “Letters to a Young Doctor,” a set of autobiographical essays first published in 1982. Selzer, a retired Yale surgeon now approaching 80, helped usher in the modern genre of medical writing in which the physician puts his experiences under the microscope for the lay reader’s scrutiny. Medicine, Selzer contends, is an almost holy calling, a priesthood in which the “sacred process of divination” called diagnosis occurs. Indeed, for centuries the healing arts were largely the provenance of priests and other holy men.
In one story, Selzer tells the tale of Imelda, a young woman with a grotesque harelip and cleft palate whom he encountered as a medical student working in Honduras. Imelda is described as “still attached to the unshaped clay from which she had been carved,” a metaphor that recalls Genesis and God’s creation of Adam from the earth. Hugh Franciscus, an eminent plastic surgeon scheduled to operate on her, is depicted as a deity, omniscient and omnipotent. As he prepares to make the first cut, Imelda has a toxic reaction to the anesthetic and dies on the table. The next day, when Imelda’s mother arrives to take her body for burial, Selzer notices that the facial defect has been fixed; in the middle of the night, Franciscus secretly operated on the dead body. After they return to the United States, Selzer observes that his mentor is changed. “He seemed vaguely convalescent,” he writes, “as though a fever had taken its toll before burning out.” Franciscus “operated a good deal less, then gave it up entirely.” Patients seek perfection in a physician, and often we pretend to have achieved it. It precedes our fall from grace.
Later, Selzer himself falls. In “Brute,” another story in the collection, it is he who is in charge as the surgeon in the emergency room. A delirious, combative man is brought in by the police with a large gash in his head, perhaps the result of a beating by the lawmen. Exhausted and unable to restrain the struggling man, Selzer snaps. He sews the man’s ears to the mattress.
The students are repulsed by the story. But as an intern, I tell the class, I often felt at the end of my tether, and though I never had a violent response, at least once I made a grave error out of irritation. An older woman complained of discomfort under her breastbone, and I assumed it was indigestion. The antacids I prescribed afforded only meager relief. Her voice soon sounded to me like a nail scratching across a chalkboard. My mind closed to her complaints, and I dismissed her as a whiner. Several weeks later, I was urgently called to the emergency room. The woman was in shock. She had a tear in her aorta, the large vessel that carries the blood from the heart. She died. Although my fellow physicians told me that such a problem can be hard to diagnose, and is usually fatal, their words provided cold comfort. Like Selzer, I have never forgotten my mistake, or forgiven myself.
Later in the semester we shift to New Age writing, examining the message of books like the surgeon Bernie Siegel’s “Love, Medicine and Miracles” and, new this spring, Rhonda Byrne’s “The Secret,” the runaway best seller that asserts you can solve all your problems, including “eradicating disease,” by correctly aligning your thoughts and aspirations. The psychological underpinnings of these popular books are hardly “new,” I tell the students. The ancient redactors of the Bible also saw disease as a kind of punishment for sin, a consequence of flawed character. Consider the story of Miriam, who gossips about Moses with her brother Aaron. Her words of envy bring on a case of leprosy. Although later theologians took her transformation as a metaphor for the way slander and jealousy eat away at a person and at the social fabric, more literalist readings still see sickness as the wages of sin. Most people may associate this view with the likes of Pat Robertson calling AIDS divine punishment for sexual transgression, but the concept is also at the core of many more benevolent-seeming books. Both Siegel and “The Secret,” for example, suggest that even cancer arises from anger, resentment and other “negative” emotions. Miraculous cures occur when sick people fix their disease-causing psychology.
Magical thinking is a common malady as we strain to find moral or metaphysical explanations for why, say, some cells mutate and grow abnormally. But there is not a shred of scientific evidence to support the enduring view that patients bring such events on themselves through incorrect thinking. While the Bible contains the seeds of this idea, later religious thinkers like Maimonides, who was deeply influenced by Greek and Roman physicians, drew sharp distinctions between magic and empirical medicine. The New Age writers confuse them anew.
This semester, the class will end with a short novel that can be seen as a modern-day “Ivan Ilyich,” Philip Roth’s “Everyman.” In contrast to Tolstoy, or the medieval morality play whose title Roth borrows, there is no religious consolation for our encounter with decline and death. At the novel’s climax, the unnamed protagonist addresses the bones of his parents at their grave site. “Between him and those bones,” Roth writes, “there was a great deal going on, far more than now transpired between him and those still clad in their flesh. ... The bones were the only solace there was to one who put no stock in an afterlife and knew without a doubt that God was a fiction and this was the only life he’d have.” This echoes Hamlet’s pondering of Yorick’s skull, and also, ironically, Ezekiel’s prophesying over the dry bones of the dead; the only solace for the secular man, Roth says, lies in memory.
Some of the students will go on and become doctors, others journalists and teachers, mathematicians and financiers. All will one day be patients. They will then consult clinical textbooks or the Internet to learn about their disease, and some may also turn to self-help books. But it is in literature that they will find the sharpest revelations about the dilemmas of physicians and the yearnings of a patient’s soul. And, for believer and atheist alike, the Bible should be a book to turn to.

Jerome Groopman is a staff writer for The New Yorker and the author of “How Doctors Think.”

Medicine and the Drug Industry, a Morality Tale

Abigail Zuger

It was in 1949 that Elvin Stakman, president of the American Association for the Advancement of Science, issued the membership their marching orders: “Science cannot stop while ethics catches up.”
And sure enough, from bombs to clones, the ethicists have generally kept to the rear of the scientific parade: they are the ones with the big brooms trying to restore order after the floats and the elephants go by.
Those brooms sweep slowly. Often, by the time the ethicists finish laying out facts and weighing relevant moral values, the worst of any given crisis has passed. But recently, those who work in medicine have moved closer to the fray: they staff acute-care hospitals and monitor events in real time, aiming for a little less retrospective philosophy and a little more damage control.
In this proactive spirit Howard Brody, a medical ethicist, has brought his discipline’s tools to the relationship between the medical profession and the pharmaceutical industry. This problematic tangle of moral compromise (or triumphant health-promoting collaboration, depending on your point of view) has inspired several polemics by physicians in recent years, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs.
Dr. Brody is also a physician, but he aims for the measured cadences of the ethicist instead, calmly laying out the relevant facts and then reasoning from basic principles to determine whether the medicine-pharmaceutical relationship, as it stands now, is an ethical one or not.
That Dr. Brody manages to deliver a hundred-odd pages of determinedly objective analysis before he, too, lets the righteous indignation roll should not really be called a failure of methodology: even as he carefully lays out the facts in this impressively comprehensive book, those facts begin to speak damningly for themselves.
The small-time operations that grew up into modern medicine and Big Pharma joined together back in the late 19th century, allied in the name of scientific medicine against a variety of dubious health-care entrepreneurs. The A.M.A. actually called the early pharmaceutical companies the “ethical” drug makers, to distinguish them from unscrupulous patent-medicine peddlers.
Over time, this casual alliance has been reinforced with such complex and often invisible bonds that, in Dr. Brody’s title metaphor, medicine and pharma are now “hooked” like two pieces of Velcro, tethered by a million barbs and as dependent on each other as any addicts are on their substance of choice.
Dr. Brody systematically analyzes the levels of connection, from the lowly drug salesman buying lunch for a roomful of medical students (future customers all) to the lucrative contracts and patents that simultaneously fuel medical research, fill corporate coffers and give us, as the industry doggedly and quite correctly points out, dozens of truly miraculous life-saving drugs.
Many of these interactions are probably now familiar to most readers: the omnipresent logo-bearing trinkets festooning medical offices, the free samples of the latest, most expensive drugs, the “ask your doctor” television ads.
Less familiar may be some of industry’s other friendly overtures: the lavish junkets and cash rewards for some “high-prescribing” doctors; the subtle manipulations of research data; the way-too-generous financing of postgraduate medical education; the very cozy relationship with the Food and Drug Administration and its physician consultants; and a casually Orwellian interference with the average physician’s prescription pad.
A drug salesman recalls for Dr. Brody the time his company asked a local doctor to evaluate various sales presentations for a particular drug: “He’d been selected because our data showed that he was a relatively low prescriber. ...Basically, the company was willing to bet $500 or $750 that if he heard the same drug pitch all day, by the end of the day he’d be so brainwashed that he could not possibly prescribe any other drug but ours.”
All this mutual back-scratching would be fine if patients’ interests were indeed being served. But ample data indicates quite the reverse. Patients, after all, are the ones who pay for expensive drugs when cheaper would do as well, and the ones who swallow dangerous drugs nudged to market by their manufacturers.
Many individual problematic drugs make an appearance here. Chloromycetin, a toxic antibiotic from the 1950s, was relentlessly promoted by its manufacturer for routine use until the day its patent expired. (Still available in generic form, it is now used only as a last resort.) Thalidomide never caused an epidemic of birth defects in this country, as it did in Germany, only because a single stubborn F.D.A. officer was dissatisfied with the drug’s safety profile, despite the manufacturer’s repeated assurances that everything was fine.
The epitaph of the recently withdrawn painkiller Vioxx, whose virtues were subtly spun to the medical community in prestigious research journals, is still being written in litigation around the country.
“Research that is driven by marketing rather than by scientific aims would seem, in the end, to be low-quality research,” Dr. Brody comments mildly about the Vioxx fiasco.
His overall conclusion is similarly low-key: “A profession is not just a way of making money; it’s a form of public trust. ...Medicine has for many decades now been betraying this public trust.”
It is not a particularly surprising conclusion, and, in fact, there is relatively little in this book to surprise anyone familiar with the territory. Rather than new material, it provides a meticulously referenced compendium of all the relevant history and commentary (including, for full disclosure, excerpts from one of this reviewer’s columns in this newspaper).
Its breadth translates into a lack of depth in some areas, especially the final section, in which Dr. Brody tries to outline a feasible solution to the mess. His suggestions are cogent but a little skimpy, given that absent an act of God, it will probably take an act of Congress to pry medicine and industry apart someday, preferably as part of thoroughgoing health care reform.
Still, for a detailed overview of this very jagged terrain, if not for a map of the pathway out, a better general guide than this one is hard to imagine.