Monday, February 19, 2007

Blaming the bug, again

The battle for, or against a vaccine for the Human Papilloma Virus has begun. It is getting so intense, that it made it to the front page of the New York Times, Saturday, February 17th, 2007. Those who advocate for it focus on the suffering of 9,710 women getting cervical cancer, and 3,700 dying from it in the USA, and 233,000 worldwide. Their argument for a vaccine is very compelling, as it is for every other disease that has, or will soon have a vaccine for it. My opinion against this vaccine acknowledges these points, but, highlights some points that I have not seen in the debate, so far.

Some oppose vaccinations on the grounds of not liking vaccinations in general. This is not why I oppose the HPV vaccine, although, I agree with the basic philosophy behind this stance: they may have side effects that we are not dealing with. Merck has been so aggressive about this vaccine, that some claim not enough time has transpired to see if it indeed will be safe, and productive.

Some oppose the HPV vaccine because it is too expensive ($400 for 3 separate inoculations), and because it seems to have been pushed too hard, and too fast by Merck.

Analysts have calculated that Merck may make about $5 billion/year with this vaccine.
Some fee the “HPV” stands for “Helping Pay for Vioxx,” since Merck lost mucho dinero with that drug. Merck has acknowledged a sense of urgency in the production and marketing of the HPV vaccine, but they are silent about how much money, and how many palms they have been greasing.

The Governor in Texas is in hot water for pushing the vaccine through, once it was discovered that his former chief of staff is now a lobbyst for Merck. Even though the Medical Association in Texas, and the American Academy of Pediatricians are opposed to the vaccine, 31 states are now considering funding it.

Some oppose it because it may encourage sexual activity in girls too young, as if there isn’t enough encouragement for them, now.

These are all great points. Still, my opposition to the vaccine goes back to Pasteur himself, who came up with the whole vaccination concept. It is not generally known that Pasteur had a slight change of heart shortly before his death. “Ce n’est pas le germ, c’est le terrain” (it is not the germ, it is the terrain).

There is no question that HPV is associated with cervical cancer, and that H. Pilory is associated with ulcers. But, the problem is not as clear as that. Let’s start with a book, well received by the Journal of the American Medical Association 2006;295:2891, The War on Cancer: An Anatomy of Failure, a Blueprint for the Future. Here are the main points in the book:
  • The top 5 cancers (prostate, breast, lung, colon, and pancreas) have changed little since 1995. Mortality has improved only 1% for 10/28 most common cancers, mostly due to food refrigeration, better diet and hygiene, better supportive care, and early detection.
  • 19th century bacteriology influenced cancer theory. The misunderstandings perpetuated by this science have had lingering consequences: “generation of scientists and scholars, misguided by flawed hypothesis, often commit their talents and energy as well as human and financial resources, in an unproductive pursuit of a false lead.”
  • “More pervasive and counterproductive [idea] developed… that cancer cells, like bacteria, are foreign invaders that must be eradicated at any cost. The result has been more aggressive cytotoxic chemotherapy with few cures and an inefficient trial-and-error drug development strategy that continues today.”
  • In other words, the main two ideas of modern oncology are to exploit differences between normal and cancer cells, and drugs must be cytotoxic to be successful.
  • “Drug development… remains mostly anchored to this century-old, conceptually antiquated, technically inefficient, labor intensive, costly, and low yield ‘hit-and-miss’ (mostly miss) screening approach engineered and sponsored by the National Cancer Institute.”
  • “The cell-killing paradigm has failed to achieve its objective… how does this system persist? … the increasing prominent role of the pharmaceutical industry in drug development… career advancement, relationship between productivity and job security, salary sources, and growing dependence on pharmaceutical companies for funding.”
  • “The information pipeline, generated by clinical researchers and supported by their sponsors and publishers, fosters standards of care that are reinforced by financial incentives and the extraordinary capacity of physicians for self-delusion, and by unrealistic expectations of consumers nurtured by the media.”
A better approach would be prevention, targeting underlying molecular genetic defects, and focusing on patient-outcome, not tumor measurements.

Granted, the book does not get into vaccines for cancer, but it does address the flawed approach of blaming the bug, instead of the patients’ terrain that allows the bug to take up a stronghold.

In my opinion, political and economic factors are often ignored in the etiology of cancer. Consider that affluent men, who are able to afford better food, education and better environments, had less cancer than less fortunate men from 1950 to 1998 (J. Nat’l Cancer Institute 2002;94:904). “We really need to work at linking the environment to behavior, behavior to physiology and physiology to carcinogenesis. [We need] better efforts to integrate work across these domains” (JAMA 2003;290:2790).

The vaccine approach for HPV, which was prophetically panned at its inception (NEJM 2002;347:1645), is not without its merits. But, it does not consider these basic issues. It is really simple: think of a skin infection. Does it mean that all of a sudden some bug got in there, and gave you an infection? No, it turns out that your skin is teeming with bugs, but they don’t get to you, unless you get a cut, particularly if your immune system, which is mostly in the tissues (“The danger model: a renewed sense of self,” J. Science 2002;296:301).

So, if the tissues that compose your skin, or any other tissue, like the cells of the cervix, are T.O.I.L.ing, the bug will get in there, and start colonizing to the point of overwhelming your local, and systemic defenses. T, toxic, O, oxidized, I, inflamed, L, lacking in energy (JAMA 2004;291:358). These are the general mechanisms of all diseases. Why should it be different for cervical cancer, and HPV?

In other words, HPV finds the cells of the cervix already “toiling.” This is why Indole-3-Carbinol, I3C, the chemical in cruciferous vegetables can help the immune system get rid of this virus (J. Cancer Research 1994;54:1446, J. Gyn Oncol 2000;78:123), mostly by stimulating the 2OH detoxification pathway in the Liver, since xenoestrogens, or toxins that mimic estrogen in the environment contribute to the toxicity of sexual tissues (J. Biology Chemistry 1998;273:3838). I3C, then relieves the stress on the cervical tissues’ dependance on the 16 OH pathway of Estrogen detoxification (British J. Cancer 1996;74:488).

Women with cervical lesions have lower 2OH/16OH hydroxyestorne ratios, which shows their Liver’s don’t get rid of xenoestrogens that irritate the cervix. This is why Indole-3-Carbinol is beneficial to heal these lesions, since it promotes 2OH hydroxylation to detoxify Endocrine disruptors (J. Gyn Oncol 2000;78:123).

When the liver detoxifies Estrogen and chemicals, such as endocrine disruptors, then the immune system is less burdened, and more likely to rid itself of the HPV. Not surprisingly, anything that helps the Liver work better, like I3C, will help abnormal paps revert to normal. This is what happens on diet high in vegetables and fruits (J. American Dietetic Assoc 2001;101:1167). By the way, how many of these young women getting cervical cancer are eating broccolis, cabbage, cauliflower, brussel sprouts, etc.?

Human Papilloma Virus resolves on its own in 1-2 years, but it becomes a problem (warts, cancer) in 28% of women (J. Nat’l Cancer Instit 1993;85:934) when the infected tissues are lacking antioxidants and inflammation (J. Nat’l Cancer Institute 2003;31:29 and J. Alternative Medicine Review 2003;8:157). Vitamin A is 4.5 times lower in women with CIN lesions in the cervix (J. Cancer Investigation 1999;17:253,) which is why topical applications of Vitamin A enhances regression of CIN II lesions (J. Nat’l Cancer Institute 1994;86:539).

Lack of folic acid, a B vitamin, also predisposes to cervical injury, so its replacement enhances healing (JAMA 1992;267:528). It turns out that our atrocious diets are lacking in B complex vitamins. A lack of antioxidants do the same thing, so, replacing them has been shown to decrease the chances of cervical cancer. This why Alpha Lipoic Acid, COQ10 and Glutathione help. They are antioxidants that help our cells have more energy to do their jobs (J. Alt Med Rev 2003;8:163).

Escharotic treatments, or topical applications of ZnCL2 Sanguinaria mixture with Calendula twice a week until pap is clear of lesions is a good alternative for those women not wishing to undergo surgery or Cryotherapy. It usually takes 5 weeks and it includes topical Vitamin A and oral treatment with Vitamin C 6-10 grams a day, beta carotene 150,000 IU a day and Selenium 400 mcg a day and a vegan diet (J. Arch Surg 1941;42:279).

It is not that I recommend all that, since cryosurgery is so easy, but, I mention all that to prove the point: “ce n’est pas le germ, c’est le terrain.”

Friday, February 2, 2007

A surprising secret to a long life

The article “A surprising secret to a long life: stay in school,” New York Times, January 3rd, 2007,) was prominently placed on the front page. Perhaps it struck me with more force than it did most people, because I am the only one in my known genealogy who went to college. No doubt, it is the reason why “going to school” was the only advice I gave my children as they grew up. I figured all the other lessons that a father may need to impart, were best exemplified in they way I led my life, particularly how I related to people around me, especially my own children. The greatest lesson of all, that is, loving one another, is not believable, especially to children, unless they sense it, and see it in the daily behavior of their parents. Everything else, in my opinion, is peripheral, and easily available through a good education.

No doubt some of you will disagree with these brain-droppings, and may, by now, be wondering what does all this have to do with health. I can only say that it has been shown that children do best when they are loved, regardless of the parental tools, or dogmas used. Besides, an education avails children, and adults with the tools to explore both their inner, and outer worlds.

The main reason I chose medicine as a profession, is that I felt called to this noble work. Other reasons pale in comparison. But, after the obvious desire to be of service to others, I felt that medicine would satisfy my insatiable thirst for “further light and knowledge.” Insatiable means I am still learning. Now you may see why I read voraciously. In fact, from now on I would like to include comments on the 4-5 books I read each month in this blog. Since I alternate between fiction, and non-fiction, I will be recommending to you world literature as well.

Before I get back to the subject of reading, books, and growth, let me finish reporting on the article in the NYT about living longer through education. Since most of you are baby-boomers like myself, you are likely deeply interested in not only living longer, but better. Well, it turns out that “education” was the factor most associated with longevity: the more years of education, the longer people live. If you are thinking that good relationships should be number one, you are not wrong. It turns out that the more education one gets, the better their relationships are. No doubt there are those who are so emotionally gifted, and so advanced in their ability to love, who did not need an education to shine their wonderful light on us all. I know a few people like that, and I am sure you do, too.

But, most of us mortals had to learn, through sound education, to listen, to communicate, to respect others, and to question the outer-world, while favoring the exploration of our inner-world. No doubt those lucky enough to be raised by loving parents understand these concepts readily, and likely have a steady, and calm mind that allows them to buckle down to get an education, to explore their own souls, and the material world with equanimity and open mindedness.

A higher education allows us to earn more money, too. It sounds a little crude, but, the more money we have, the better food we buy, the more we read, and the less we stress about providing for our loved ones’ and our own basic needs. We are likely to have more time to exercise, to relax, to travel, and devote more time to enriching our lives, and the lives of those around us. We also may afford living further away from polluted environments. Recently, we learned that our kids’ lungs’ development is hurt by living near freeways, which is the equivalent to living in the most polluted cities of the world (J. Lancet, February 2007.)

Perhaps the most glaring example of these points, is the fact that those in the lower socio-economic segments of our increasingly polarized society, tend to eat mostly at fast food venues. Also, they tend to have less access to the dismal health care system we have developed in the USA. The number one reason for going bankrupt is an inability to pay for health care bills. There is no question that poverty deeply handicaps our fellowman from enjoying good health (“Status syndrome,” JAMA 2006;295:1304 & “Poverty and health,” Robert Sapolsky, J. Scientific American, December 2005, p92.)

No doubt there are a lot of people with lots of education who have very poor health, due to bad relationships, too much work, poor diets, and questionable lifestyles that are facilitated by their good fortune. But, the article in the NYT is talking about averages, and trends. So, I am sure we all know poor people who are deliriously happy, healthy, and wise. This is where we interject that “money does not buy happiness,” to which Will Rogers would reply, “I have been poor, and I have been rich. I would rather be rich.” Tavia (“Fiddler on the roof”) would agree.

Before you jump to conclusions, I must tell you that a significant percentage of the money I make, I give away. I live “a threadbare and genteel existence,” in a very humble neighborhood, drive a 2000 Jeep Wrangler, and I have no expenses, other than an occasional book. I am deliriously happy with my simple life. I only work two days a week, enough to pay the bills. I wish you could say the same, I really do. By now you have figured that my education has allowed me to command a high enough salary to live like this.

This reminds me of a book that borrows from the dreaded sentence we hope we don’t hear in some dark alleyway: “Your money, or your life,” by Joe Dominguez, 1992. Sadly, this is the choice that too many of us may have to make. In other words, I wish you the food fortune to simplify your life, so that your expenses are reduced, then, you may get away with less of a need to work so hard.

There was one odd comment in the NYT article, which I paraphrase: those who live to enjoy the present day, cannot invest the time to get an education. The philosophy of living for the moment is destructive. OK, I can understand the sentiment that a sign of maturity is to postpone pleasure, so that we may have more intense, and durable pleasure in the future. Investing one’s life in long, tedious hours of schooling, especially with lots of kids, and working at the same time is no fun. Believe me, that is exactly what I did to get through my 13 years of post high school education (I know, I, too feel I am overly educated!)

But, another sign of maturity is the ability to take contrasting points of view, and hold them in one’s mind at the same time, to end up with a composite of both ideas, or extremes. Hopefully, that middle ground enriches your life, and the lives of those around you, before the tension of the extremes drives you mad. And, who said all this? Christ, Budda, Kierkegard, and even F, Scott Fitzgerald. A whole lot of other people have said the same thing, even myself, in my up-coming book “The fence boy.” In other words, “carpe diem” is just as valid. Ask Robin Williams in the film “Dead poets’ society.” Enjoying the present moment may be done while we engage ourselves in the quest for further light and knowledge. And, such is life, which beckons us to incorporate contrasting ideas with courage, and determination to develop our greatest potential.

I was saddened to see that the Utah legislature voted down a proposal to charge in-state tuition in our universities to illegal aliens. In my opinion, this is penny wise, and pound foolish. The same goes for investing in our children’s education. I feel we ought to heavily subsidize higher education in our country. “Reducing poverty by investing in young people” (J. Lancet 2006;368:1128) has this to say:
Investing now in better education, preventive health care, and vocational training for children could produce substantial economic growth and sharply reduce poverty. Failure to do so may lead to disillusionment, social unrest and fragmented societies.”

Reading is fundamental” (J. Archives of Internal Medicine 2005;165:1943) adds that low literacy leads to worse health and more chances of depression. There are 30 million Americans with educations below basic, 63 million basic, 95 million intermediate, and 28 million proficient. Surely we can do better. I urge you to vote for candidates who will invest in the future of our children. And I urge you to join me in my quest for further light and knowledge. Now, enjoy the words of Sir William Osler, M.D., the father of modern medicine, who happened to be president of the American, Canadian, and British Library Associations. Coincidence?

Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought, the true poetry of life, the poetry of the commonplace, of the ordinary man, of the plain, toil-woman, with their loves and joys, their sorrows and their grief.”

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

“To carefully observe the phenomena of life in all its phases, normal and perverted, to make perfect that most difficult of all arts, the art of observation, to call to aid the science of experimentation, to cultivate the reasoning faculty, so as to be able to know the true from the false, these are our methods. To prevent disease, to relieve suffering and to heal the sick, this is our work
.”

While on the one hand I would encourage you with the firmest faith in a few drugs (the friends you have and their adoption tried,) on the one hand I would urge you to cultivate a keenly skeptical attitude toward the pharmacopeia as a whole.”(“The quotable Osler.”)

The calling” (NEJM 2005;352:1845) was written by a doc who felt called to medicine by reading “Lady Chatterley’s lover,” where he learned about Phillip, a club-footed medical student who did very well with patients: “There [Phillip] was humanity there in the rough.” His readings of “Of human bondage,” “Lolita,” “The Citadel,” Arrowsmith,” and “Love in the time of cholera” also contributed to his decision to pursue the healing arts. Out of all those books, I would recommend the last one, by Gabriel Garcia Marquez.

The author of “the calling” feels that today’s students may be missing out: “Entering classes don’t seem to include as many avid readers as they once did… A prevalent form of blindness, caused by the terrible and crippling atrophy of the imaginative faculty... where will their sense of calling come from? ‘ER’ and’ Scrubs’? The thought is chilling.”

He concludes by saying that “A good novel can offer a formative experience to prospective doctors,” and for patients, too. “The writing cure: can understanding narrative make you a better doctor?” (New York Times, April 18th 2004) agrees. In fact, medical students at Columbia, and Harvard are asked to read world literature. The doc who wrote “Compassion’s way: a doctor’s quest into the soul of medicine” (JAMA 2003;290:1645) tells us that he grew up on Don Quijote, Pickwick papers, David Copperfield, and Mark Twain.

I have a statue of Don Quijote on my desks at home at my clinic. Many feel it was not a coincidence I played Don Quijote in a neighborhood adaptation of “Man of La Mancha.” Do you want to hear me sing “the impossible dream?” I am sure now some of you feel this is the proof you were looking for that I am nuts!

Could these ideas truly lead to a better, longer life? Are these the things missing from our chaotic health care system? “Goethean science: an alternative approach” (J. Alternative and Complementary Medicine 2003;9:311) would agree:
The human being is the most sensitive instrument…[this is a] profoundly different way of looking at nature that celebrates the subjective and relational to perceive the whole... [which is] implicit in integrative medicine philosophy... [which] cannot be understood by the intellectual mind.”

Narrative Medicine: a model for empathy, reflection, profession and trust” (JAMA 2001;286:1897) recommends the close reading of literature to understand patients, and humanity:
Physicians have turned to a study of the humanities, especially literature, to grow in their personal understanding if illnesses... The teaching of literature in medical schools has become widely accepted as primary means to teach about the patient’s experience and the physician’s interior development...Students already gifted with narrative skills are better able to develop into effective physicians than are students deficient in them… Unlike logico-scientific knowledge, narrative medicine leads to an understanding of particular situations… to establish a therapeutic alliance… "

If the physician cannot perform these narrative tasks, the patient might not tell the whole story… The resultant diagnostic workup might be unfocused… The physician’s most potent therapeutic instrument is the self, which is attuned to the patient through engagement... Physicians have learned to practice medicine through detachment.”

Ouch!

Sadly, many docs resemble those remarks. I am in contact with medical students on a weekly basis. Although most of them resonate with the concepts in these pages, we sometimes fail to screen out students (I am on the admissions committee,) whose only concern is to make a living. Valid as that is, medicine is a calling, not a regular job.

So, we want to live longer: let us commit to continuos learning, and to keeping an open mind, and open heart to new ideas, and people.

Hugo Rodier, M.D.