Thursday, January 28, 2021

Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems

Near the end of December, Tiffany Hsu, writing in the NY Times, discussed “Dubious COVID Cures”. She compared them to the similar nostrums popularly recommended for the 1918 influenza epidemic, when ‘a spate of ads promised dubious remedies in the form of lozenges, tonics, unguents, blood-builders and an antiseptic shield to be used while kissing.’ She quotes the head of research at MyHeritage, Roi Mandel as saying “So many things are exactly the same, even 102 years later, even after science has made such huge progress.”

Even after all this scientific progress and all the advances in health care, people are still fascinated by over the counter magic drugs, things that seem easy, and are often cheap (although usually very profitable), and somehow better than the treatments being offered by the medical community. This is, of course, even more so when that medical community does not have a whole lot to offer in terms of treatment, a particular issue for virus infection, and mostly talks about prevention, about such things as isolation and physical distancing. Wouldn’t it be better if you could just take something that would cure it or make it better or at least decrease the seriousness of an infection? And, you know, there are ‘studies’ that show it works (although of course I haven’t actually read them and would have no idea how to understand if the research was legit) and, you know, there are doctors who recommend it!  Like ‘Dr. Pierce’s Pleasant Pellets promised that the pills — made from “May-apple, leaves of aloe, jalap” — offered protection “against the deadly attack of the Spanish Influenza.”’ Oh, wait, that was from 1918 – but we have Dr. Oz!

This is not to say that some popular treatments do not have benefit, and this is especially good if they do not harm you, and if they are cheap. One such could be Vitamin D, which has been advocated (most recently for COVID-19, but for a lot of things) by many people, some of whom are actually experts. As with many “natural” remedies, most of the basis for this is in syllogism. You extrapolate from something that is known about a substance (commonly, as in the case of Vitamin D, that it “promotes immunity” – a pretty general, non-specific claim), but such claims are uncommonly backed up by rigorous testing to see if it actually does work. (Freeman’s Second Law: Something that makes sense is properly called a “research question”. You wouldn’t want to study something that didn’t make sense. However, to know whether it is actually true, you have to actually do the studies!)

Recently, The Guardian had an article titled “Does Vitamin D Combat COVID?”. It is very positive about the vitamin, citing many important people (unsurprisingly, being The Guardian, many from England), but does stop short of claiming that it will definitely work. The claims for benefit vary: it makes it less likely that you will get infected, that if you get infected you will get less sick, that if you get sick you are less likely to die. Not really quantified though. The reason is that there are studies that show both benefit and not, and none of them are definitive. There is also concern that people with more melanin in their skin, presumably a genetic adaptation to being from areas with more sunshine (and thus more vitamin D) can become vitamin D deficient when they live in areas in northern latitudes with less sun. Obviously, this is confounded by the existence of a variety of other social and medical health risks accruing to dark-skinned people in northern latitudes. Maybe it is an additional one, but it is unlikely that just taking Vitamin D will solve the problem of inequity.

The actual evidence is summarized in a recent piece in JAMA, “Sorting out whether vitamin D deficiency raises COVID-19 risk”. The first thing that you note here is that it is answering quite a different question – whether people who have low vitamin D levels have greater risk (and, thus, presumably, should take vitamin D supplementation), not whether everyone should be taking vitamin D. ‘Research findings about vitamin D and COVID-19 have been mixed and sparse,’ is the key finding, and the ‘Upshot’ of the pieceis a quote from Dr. Catherine Ross, a nutritionist at Penn State: ‘“Avoiding vitamin D deficiency is always a goal.”

So you should take vitamin D supplements if you are deficient (Dr. Fauci says this also), although knowing if you are deficient would require both your having your level measured, something which is not recommended by the most reliable source, the US Preventive Services Task Force (USPSTF) for asymptomatic adults (although it is by many who are consultants to vitamin D advocating groups), as well as to know what the level below which you are deficient is: 20? 30? 50? You can find all of these in the “literature”. And it is concerning when advocates have industry ties. Nonetheless, vitamin D is available cheaply and generically, is safe if you don’t take too much (as a fat-soluble vitamin you CAN overdose on it), and Dr. Fauci takes it (same article). I took one this morning.

But the really big question is not vitamin D, even if the evidence is not absolutely clear. Overall, it is pretty safe and pretty cheap and has a conceptual justification and at least some studies show some benefit. The really big issue, as put forth early in this piece, is why do people continue to search for magic treatments that are not mainstream? Why do they often trust their friends and neighbors and strangers on the Internet more than doctors? I don’t know for sure, but in Hsu’s article comparing today to 1918 he quotes Jason P. Chambers, associate professor of advertising at the University of Illinois: “Human beings haven’t changed all that much. We’d like to believe we’re smarter, that we’d be able to spot the lies, but the ability of advertising to maintain its veneer of believability has only become more sophisticated over time.” Unfortunately, we’re probably not. That is why advertising is so successful.

This fear is related to not only mistrust of science (it is hard to understand) but to conspiracy theories in general; recently the “political” belief in a “deep state”, that “they” are lying to us and trying to keep important information and benefits from us. Of course, “they” may be; I certainly do not trust the leadership of our country (or any country) to necessarily work in the best interests of the people, except of the richest, most powerful and well-connected people. I absolutely believe that Big Pharma is only interested in making as much money as possible and selling us drugs which may not be any better than cheaper ones, or none at all. But the suspicion that science and medicine are working to harm us often segues into pretty odd stuff (I was recently sent this nonsense about the COVID vaccine being a plan to engender female sterilization!) (On the subject of conspiracy theories, Andy Borowitz’ recent satire – QAnon merging with the Elvis-is-Alive groups -- is, as usual, not far off the mark.)

I am sure that some of this is the fault of the arrogance of scientists and doctors. A good friend was recently diagnosed with breast cancer and was told by her doctors to “not go on the Internet, to not talk to anyone who has had it, because everyone’s cancer is different”. This is ridiculous, although I understand that they probably get frustrated by people coming up with silly or, worse, dangerous treatment ideas that they have heard from someone, or stories from their sister-in-law’s neighbor. This can of course be much better addressed, with something like “You’ll hear a lot from people who have had breast cancer; it is a common disease. You will certainly look things up on the Internet. Listen to them, but remember you are you, and your experience is not likely to be exactly the same as theirs. Please don’t take any treatments without discussing it with us, so we can make sure there is no danger. Welcome the support.” And, I would be wrong to omit, the big reason that doctors feel so pressured and don’t have enough time to talk to and discuss things with folks is in large part because the big corporations they work for (for-profit or “non-profit”) are about maximizing income, not health.

Still, people seem to find themselves drawn to “alternatives”. They like “natural”. OK, keep your mind open, but remember than “natural” is not necessarily better. Any substance that has any effect, positive, negative, or neutral is because of chemicals in it. That they occur naturally does not make them safer than those that are manufactured.

And watch the conspiracy theories and think about what is important. Life on earth could be extinguished by climate change. That is real. War which leads to nuclear war could do it first. People all over the world are starving, are without housing, without basic health care, subjected to natural disasters and man-made ones. They are being killed, often in genocides. In all countries, including ours, there is structural oppression of people based on race, religion, gender. Wealth is being transferred from regular and even poor folks to the richest at an astounding rate. Authoritarian leaders, and even fascists, are proliferating.

These are real problems, that need real concerted efforts to combat. Work on these. Don’t be distracted by non-issues.

Tuesday, January 19, 2021

Emergency services, COVID, and the health system: Your life could well be at risk

I recently had a very unpleasant health event, involving severe abdominal pain for most of a day and night, and many days of recovery. The details of my specific condition are not particularly important, other than to say it is a chronic, recurrent problem, resulting from an event decades ago; it could well need emergency surgery and can have serious results. The point is that I had to decide whether to go to the emergency room that night, and to discuss the issues, both personal and structural, that impacted that decision, and what it demonstrates about our healthcare system, made even worse by the stress of COVID.

Considerations on the side of “go to the ER” were 1) I was in a lot of pain that was lasting longer than it generally has (say twice a year), and wanted to not be, 2) I knew pretty well what was causing it and that, while it had happened before and usually resolved, it could also NOT get better and maybe require emergency surgery, or worse. Considerations on the side of “don’t go to the ER” were 1) it has usually in the past resolved, eventually, on its own, and 2) the idea of getting in the car to go to the ER, and then waiting to be triaged and seen, and maybe imaged, which was likely to take many hours, all while in such pain, was a very negative incentive. If I was going to be writhing in untreated severe pain, I would prefer it to be in my own bed than in the waiting room of an ER. Plus, COVID. Both because it has made the crowding and wait times in ERs and hospitals much worse than “normal”, and because being there increases the risk of exposure and infection. I happen to live in what is currently a “high COVID” state, but nowhere is a really “low COVID risk” area. As it turns out, I didn’t go, and by morning, after about 18 hours, the worst was past. This time. But it will happen again and I will again have to decide what to do.

As do many, many thousands of others, every day, in the US. For many people, a major concern is cost – because visits to the ER are costly for those with no or poor insurance (really a lot of people). Fortunately for me, I’m not in that group. For others, it is because of fear of finding out what the problem is, and that it will be something really bad that they don’t want to know about. That also wasn’t really my issue; as a physician who has dealt with this, I knew what the problem was. Unfortunately, that can make it worse, since my fears and realization of the possible outcomes are based in evidence and not just fear. For yet others, it is the expectation that because of who they are (not White, poor, poorly insured, not well-dressed, have a history of alcohol or drug use or mental illness, or something else that doctors tend to associate with making one of less value) that they will be pushed back in the line, not believed, have their stories discounted, and generally be treated badly. Not really me either, although my physician privilege is decreased now that I am retired in another city, and do not get to go to the ER in the hospital where I work every day and people know me. For a lot of people, it is a combination of these, synergistically making their experience, and expectation of that experience, worse.

In case there may be anyone who is skeptical about my saying it is likely to be hours of waiting even when one presents with an emergency condition and is obviously educated and “respectable” (as a physician or nurse), it happens, and is happening much more continuously in the Age of COVID, when facilities are completely stretched to their limit and resources and people who work there are stressed to the max. Just recently, the last few months, two people who are close to me and are healthcare professionals have been through this experience. One had acute appendicitis, and needed emergency surgery, and after waiting many hours at home before venturing to the ER, waited there for 7 more hours before being seen. Luckily, they are now OK. It was not a positive experience! The other had a similar serious need, a ruptured diverticulitis causing peritonitis. She also waited in excruciating pain for hours, despite the fact that she was accompanied by her husband, a physician from the community who has practiced here for decades who was reduced to screaming at staff before she got her necessary emergency surgery. (For the record, these two people and I are all “seniors”, but these scenarios can and do affect everyone; my initial crisis was when I was 40 years old.)

The best advice anyone can give me is “get an ambulance”; they’ll see you sooner than if you arrive by car. This may well be true, and it may be good advice for me or for any other individual who is not worried about an additional $2000 bill, but in no way addresses the systemic problems that obviously exist.

The first of these is the incredible stress put on the system and the individuals working in it, doctors, nurses, and other healthcare workers, by the COVID pandemic. The burden on hospitals and healthcare workers has been phenomenal. In this sense, doctors and nurses and others on the front line are our heroes, as they are often portrayed. Yes, sometimes they can exhibit inappropriate behaviors. These can even be exhibited by folks in whom they rarely manifested before as a result of the continuous stress of working in the situation that they, and we as patients and as a society, find ourselves in. The governmental response to the pandemic, led by a federal administration who acted as if their intention was to do everything completely wrong, was shockingly inadequate. Yes, building new hospital capacity is possible and usually slow, but some localities did it, and yes, training and equipping more healthcare workers takes time. But there is no conceivable justifiable excuse for not having sufficient PPE, for example, months into the pandemic. This could only happen because of the worst possible management. Remember that this is the country that put a person on the moon 8 years after the first suborbital flight, that built the interstate highway system, that could assemble battleships in weeks during WW II, that has enough money to give trillions of $$ in tax cuts to billionaires and corporations. It only did not happen because of more than ineptitude; it happened because of an intent to do evil. We can hope that at least much of this can be reversed by a Biden administration.

The other big structural issue is our terribly designed and implemented healthcare nonsystem that discriminates against people based upon wealth and insurance status, race and ethnicity, age and pre-exisiting conditions, geographical location, and in appropriate allocation of resources that in the best of (non-COVID) circumstances sends a hugely disproportionate number of true emergencies (medical, surgical, trauma) to some hospitals while others have relatively low, and more mild, usage of their emergency facilities. It is also the fact that many people cannot get into see their primary care physicians promptly, or do not even have primary care physicians (or other providers, such as NPs) so end up waiting until they are severely ill and going to the ER. These are people who, if they get hospitalized, can be considered “primary care preventable” hospitalizations. That is, if they had been able to easily and promptly see a primary care doctor for their illness, and at least as important, had their chronic diseases effectively managed and controlled, would have not needed hospitalization – or emergency care. This needs another set of structural solutions. It needs, first off, a universal national health insurance system. Every single person in the country needs to be completely covered for every medical necessity, without copays, deductibles, etc., and we all need to be in the same program.  The pandemic has clearly demonstrated the vulnerability of employer-based coverage. It is long past time, if it ever was, for ideas of gradual piecemeal expansion of Medicare, ACA, Medicaid, etc. If everyone is not in the same system, it is not a possibility but rahter a certainty that some will get better care than others. Separate, the Supreme Court ruled in 1954, is not equal in education, and separate insurance systems cannot create equality in healthcare.

A universal health insurance system, such as Medicare for All, is not going to fix all of the things that I discussed above. We need to ensure that there are hospitals and ERs available to all people. We need to ensure that all hospitals are welcoming to all patients, and that there is a rational system of referral from smaller to larger hospitals.  We must ensure that there is adequate primary care capacity so that everyone can have a provider that they can see regularly, and promptly when needed, and do not need to access ERs for either primary care or for urgent conditions that could have been prevented by good primary care. And we need to make sure that there is adequate emergency capacity for all emergencies to be cared for emergently, and that ERs, and hospitals, and health systems, are designed and funded and run based solely on what best needs the health needs of the entire community, and not on what makes the most profit for the owners. A universal health insurance system is necessary but not sufficient.

We need all that, and need it yesterday.

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