After the homebirth death

The message boards at Mothering.com contain one of the largest repositories of homebirth death stories that can be found anywhere. It's rather ironic that Mothering continues to promote homebirth as completely safe when they have more evidence than most that it leads to unnecessary deaths.

Consider the following stories gathered over the past few months:

I want to start by telling you that homebirth is a wonderful thing and I think it can be done by first time moms with breech babies. I also want you to know that I am NOT trying to scare you. But - I am a first time mom, with fantastic, educated midwives and I had my first baby at home in June. He was breech, which we were pretty sure about beforehand, his head got trapped, he suffered a lack of oxygen and was declared brain dead. He lived 4 days on a ventilator in the NICU.

I know this is completely terrifying. I also know that statistically we should have been fine. I have researched this TO. DEATH. and the three big risk factors for vaginal breech birth are 1) preemie - my son was 40w5d; 2) large babies - my son was 6lb 12oz; and 3) first time moms with "unproven" pelvis. We cannot point to any one definitive thing that led to this issue. [My son’s] head was actually pretty small and my pelvis is just fine. I know that we did the best we could for our son, and that there are no guarantees in a hospital either. The risks of epidural and c-section are about equal to a vaginal birth. I just want you to know that it can be done, but it can also end in tragedy. I know that hospital births sometimes end in tragedy too so I refuse to allow myself to think about what would have happened to me or [my son} in a hospital.

I find it particularly sad that this woman who supposedly research the topic "to death" did not know that C-section is safer than vaginal breech delivery.

At the following homebirth, the baby was born with a serious undiagnosed congenital anomaly. It is not clear if the baby would have survived the necessary surgical repair, but the baby was certainly doomed by being born at home:

My peaceful homebirth turned into a full-out trauma complete with dozens of officers coming in to take pictures of the "crime scene" before I could even get covered or stitched or anything. They kept telling me that there will be nothing doctors can do- he was born wrong and you caused this- it was absolutely my worst nightmare come true. I kept passing out on my way out of the house and there were officers and firemen just standing there watching me- not offering to help at all. It was absolutely horrendous.

Now, I still support homebirth and know that it was not the cause of my son's death- my midwife is very competent and did what she could- his condition was undiagnosed or else we would have delivered at a hospital. However, I suspect that many people (this being their first/only experience with home birth) think that the home birth is the cause, or at least contributed to, his death. My DH is still passing over the born at home part when he tells the story and I feel like it all has to be some dirty little secret or something. My relatives were whispering about it at the graveside service.

I guess I just wish in a way that I hadn't had a home birth- because losing my son is hard enough without dealing with these aspects of the trauma… I will never have the home birth experience I was hoping for. I guess I'm mourning that loss as well as the loss of all the experiences I expected to have with my son.

Another mother replied with the story of her loss:

... I too had fire and police arrive and turn what was also a beautiful HB (until that nightmarish moment when my son was born dead) into a seriously traumatic event. They treated it like a crime scene, wanting to take the placenta and videotape as evidence ... [A]fter a battery of tests, placenta pathology and a full autopsy they found no proof of an abruption and nothing wrong with my son which several doctors have come to the only conclusion, that is was a cord-compression.

I too felt my midwives were very capable and I have been told babies die in hospitals too. I don't want to add insult to injury here but babies die in hospitals for different reasons... most stillbirth occurs [before] arriving at the hospital ... whereas intrapartum loss is rare at hospitals. I feel if I had been on consistent monitoring they would have been able to track the HR decels better and probably done a c-section (my worst fear) but he would have LIVED (most probably)!

There is not a day that goes by that I don't feel the pain of being guilty for killing my son. I have been told over and over again it was not my fault which I have come to accept [as] different than the HB being at fault ...

The decision to HB is not something someone enters into lightly, it is usually well researched and considered and a decision made out of a deep intense love for what we believe to be best for our babies ... and I unlike you was very vocal about our decision to HB for this proudful reason shooting my mouth off like we were better than all my friends who I thought were radical but chickened out and have to have their epidurals, etc. and now I feel like I am eating crow, BIG TIME! ...

The mother of the baby who died of a congenital anomaly sums it up most poignantly:

It is so hard. We both chose homebirth because we believed in making the best choice for our babies - and we thought this was it. To have that belief snatched from us, along with our babies, is so very, very hard.

Should doctors fire families who refuse to vaccinate?

We are currently in the midst of an epidemic. No, not the H1N1 epidemic, though that's the most immediate threat. What threatens the long-term health of our nation, particularly our nation’s children, is an accelerating epidemic of ignorance. Vaccine rejectionism, the flat-earth theory of the 21st Century, previously the domain of the crazies, has gone mainstream.

Doctors are frustrated. As Dr. Nancy Snyderman angrily declared on her NBC show, we are just a "stone's throw" from witnessing a return of polio to the US. Measles and pertussis (whooping cough) are already making a comeback. Although the absolute number of cases is still in the hundreds, the effects of vaccine rejection on medical practice extend beyond the number of children who are sick.

Pediatricians and family practice physicians are wasting extraordinary amounts of time counseling parents contemplating vaccine rejection. Counseling is, of course, part of any doctor's job, and we routinely counsel against ignorance in other areas of medicine (HIV, sexually transmitted diseases, etc.). But in those cases we counsel against prejudice and lack of knowledge. What makes vaccine rejectionism extraordinary is that we are forced to counsel against the ignorance deliberately disseminated by professional vaccine rejectionists.

Within the medical community, doctors are beginning to debate the possibility of “firing” families who refuse to vaccinate their children for deadly illnesses like polio and pertussis. Dr. Gary Marshall speaking at a recent American Academy of Pediatrics conference explained that it is both legal and ethical to refuse care:

In the middle of treatment, you can't just say, I'm done, ...

But if it becomes obvious that you and the family will never see eye to eye on a specific issue, there's no reason not to "fire" them, providing you follow the steps necessary to avoid charges of abandonment. Those include providing written notice that you will no longer treat their children and giving them a set time frame -- at least 30 days -- to find another physician.

Doctors are and have always been legally entitled to refuse to care for specific patients as long as they did not abandon them in the midst of an acute event. This drastic step is usually reserved for patients who are difficult, disruptive or openly disrespectful. It is an acknowledgment that every doctor is not right for every patient.

It is rarely used merely because patients disagree or are non-compliant. Patients have every right to disagree with recommendations or to ignore them. Non-compliance is a serious problem, but it is often a case of "the spirit is willing, but the flesh is weak." Smokers know they need to quit and generally make good faith efforts to do so. Alcoholics are often more distressed about their conditions than their doctors, but they are addicted and have great difficulty doing what they know is right.

There is something fundamentally different about vaccine rejectionism because it is a rejection of the principles of science and medicine. It is illogical and "evidence resistant." When the patient does not agree with the doctor on the absolute requirement that medicine should be based on science, there is no common ground. And since vaccine rejectionism depends on absurd conspiracy theories regarding the financial motives of doctors and vaccine manufacturers, it destroys the trust necessary in the doctor patient relationship.

While individual doctors are certainly free to legally "fire" families who reject vaccination, it is a poor way to address the problem. It places children at risk for being unable to obtain good medical care in a crisis. Those most likely to suffer, the children, are not the ones who made the foolish and uneducated decision. Moreover, at this point, the problem has grown too large to be solved by physicians acting individually.

This is a public health problem of the most basic kind, and should be solved with government based public health measures. The government should more strictly enforce vaccination policies. Technically children cannot go to school if they are not vaccinated, but it has become all too easy to obtain vaccination waivers on the grounds of religious or personal beliefs. The government should end the policy of allowing philosophical exemptions.

All children should be fully vaccinated against fatal childhood infectious diseases as a requirement for being allowed to attend school. It makes particular sense to apply a vaccination requirement to attending school because schools are where non-vaccinated children posed the greatest threat to other children.

In an effort to placate parents with religious and philosophical objections, the government has fueled the epidemic of ignorance. It is time to address that ignorance head on. If you want your child to go to school, your child must be vaccinated. Period.

The time for endless discussions about irrational, non-scientific claims is over. The rest of the population deserves to be protected from the effects of this ignorance. Individual doctors cannot, and should not be expected to, handle this serious problem alone. The government must step in and put an end to this nonsense.

Alternative dentistry

We survived almost all of human history without it. Yet in the last 100 years people have allowed themselves to be hoodwinked by a huge corporate conspiracy into believing that we "need" their products. They cite studies and claim we don’t understand science; they ignore ancient folk wisdom and have no respect for our intuition. They peddle their products without regard to the dramatic increase in chronic diseases and weakened immune systems of recent decades. I'm speaking, of course, of "Big Floss."

It’s time to take our mouths back from corporate domination. It's time for alternative dentistry.

To hear the corporate "tools" of Big Floss tell it, we need to use their products not simply every day, but many times a day. They've created a seemingly limitless array of products that they are forcing, literally, down our throats. Toothbrushes, toothpaste, floss, mouth wash! There appears to be no end to the number and type of products they insist we must buy to fuel their corporate ambitions. And even if we behave like sheep and buy their tainted wares, their allies the dentists insists that we must visit them not merely once a year, but twice.

We're supposed to believe that we benefit from this meddling with the natural order. Really? So please explain how the human race survived just fine to this point without Big Floss. Clearly we didn't need toothbrushes to survive and even thrive. So why, suddenly, should we be gullible enough to believe that every person should brush his or her teeth after every meal? Has there been even a single randomized controlled double blind study that proved that brushing saves teeth? No, there hasn't.

Big Floss insists that it has a product for every person, often more than one. Toothpaste to prevent cavities, toothpaste for kids, toothpaste for dentures. Is there any limit to what they will sell in order to increase their profits? And are we really supposed to believe that four out of five dentists recommend Crest? Where’s the data for that claim?

They tricked people into brushing ever day and using toothpaste each time, but that’s not enough for Big Floss. They say that toothpaste prevents plaque buildup and then they turn around and insist that we need mouthwash, too, to kill the harmful germs that cause plaque. Do we look that gullible? And what’s wrong with plaque anyway? It's natural and probably exists to strengthen our immune system, which has been weakened by constant exposure to toxins and Frankenfood.

Big Floss is not content with tricking us into buying toothbrushes, toothpaste, floss and mouthwash. They insist that we see a dentist twice a year. If their products are so great, why would we ever need to see a dentist? We wouldn't, but the unholy alliance of Big Floss and Dentistry has colluded to increase the profits of both. Don't believe me? The dentist always tells you that you should brush every day, and Big Floss always recommends dental checkups. What more evidence do you need?

It's time to end our reliance on Big Floss. It's time for alternative dentistry. Those who truly educate themselves about teeth in nature know that toothbrushes and toothpaste are unnecessary. If our ancestors didn't need them, we don’t need them, either. We can care for our teeth with a diet of fruit, vegetables and vitamin supplements.

In the rare situation in which more is needed, we can dose ourselves with ancient herbs or pull out rotten teeth the natural way, by tying a string around the both the tooth and the doorknob and giving the door a big shove. Forget novocaine. Why would we dose ourselves with medication to numb the pain of a tooth extraction? Those who really care about their teeth want to savor every natural feeling, not deaden it with chemicals.

And let's not forget preventive care. If you want to be sure that you have healthy teeth, all you need to do is buy powdered Bio-identical Teeth®. Unlike artificial toothpastes or mouthwashes, powdered Bio-identical Teeth® is all natural, made from human teeth with no fillers or animal products. Because it is "bio-identical" it is more effective than artificial toothpaste could even be.

It's time to unite and fight the corporate conspiracy of Big Floss. No more toothbrushes, no more toothpaste, and no more visits to the dentist. Let's live as Nature intended with no artificial colors or preservatives. Let's care for our teeth naturally for as long as they last.

Brought to you as a public service by the American Pureed Food Industry

Adopt a clitoris!

This has got to be the greatest fundraising slogan of all time. That's one of many superlatives that can be applied to an amazing organization, funded by the strangest source, engaged in a most poignant quest.

The organization is Clitoraid and the name was chosen for accuracy, not shock value. Clitoraid raises money to pay for reconstructive surgery on women who have undergone female genital mutilation. The procedure was pioneered by a most extraordinary humanitarian, Dr. Pierre Foldes. According to a profile in the New Scotsman:

Dr Foldes first encountered the traumatic effects of excision 25 years ago ... in Burkina Faso, West Africa.

"Some women came to me complaining of scarring which was very painful for them every time they moved," he recalls. "A special type of scar tissue called a keloid can develop on black skin and in these cases it grows hard and thick and attaches itself to the pubic bone. The women asked me if I could do something about it. While I was operating I began to do some reconstruction surgery on the vagina and labia as well as clearing scar tissue."

The surgery had to be carried out secretly because of death threats from community members. Later, when it became known he was continuing his operations in France, the death threats continued. "The police take them very seriously," he says, "but I won’t let them stop me doing this." ...

Foldes trains other surgeons to perform the procedure. Dr. Marci Bowers had 20 years of experience as a reconstructive surgeon before she journeyed to Paris to learn Foldes' technique. She now performs the surgery in Trinidad, CO.

The location has special significance. Trinidad is known as the "sex-change capital" of the world, and Dr. Bowers herself was born male and underwent sex reassignment surgery to become a woman 11 years ago. Like her mentor, she charges nothing for the delicate and complex surgery and the hospital caps its fees at $1700. According to Bowers: "As Dr. Foldes has said, you cannot charge money to reverse a crime against humanity," she says. "Sexuality is a right."

Newsweek described Dr. Bowers operating on a patient named Sila:

Dr. Bowers cut away the thick scar tissue that had formed over Sila's wound and had obscured the remains of her clitoris. She then scraped away layers of a black, sooty material—the decades-old remnants of the ash poultice the local women had used to stop the bleeding. It had caused a low-grade infection that still hadn't healed—one reason Sila was always in pain… The root of the clitoris, which extends several centimeters beneath the surface of a woman's skin, is much larger than … ever suspected. Bowers exposed the remaining flesh of the organ and drew it out, securing it in place with delicate stitches that eventually dissolve. Finally, Bowers also did some cosmetic work to restore the appearance of Sila's labia.

In France, the surgery is covered by the national health surface, but insurers in the US have balked at paying for the procedure. For some women, even $1700 is too much to pay. Enter Clitoraid.

The organization is managed and funded by the Raelian movement described by Newsweek as "the pleasure-promoting "UFO religion" whose members believe life on Earth was created by a race of advanced aliens and who emphasize human sexuality." They have concentrated their primary effort in building and running a hospital in Burkina Faso dedicated to surgical repair of female genital mutilation. In addition Clitoraid provides financial assistance to patients and funds the training of doctors like Marci Bowers.

According to the Clitoraid website:

The goal of Clitoraid's "Adopt a Clitoris" program is to create real, long lasting changes for women who have been forced to experience clitoral excision or genital mutilation against their will... The procedure takes 6 weeks for a woman to completely heal, with sexual pleasure and genetic normality being the end result.

Most of the women in Burkina Faso cannot imagine having the money for such an operation. For most of them, it would be like spending two year's salary!

Clitoraid is committed to provide these operations for free to as many women as possible.

The results are extraordinary:

A California nurse, Ngozi, who was circumcised as a newborn in Nigeria and also had her labia entirely cut away, came to Bowers in August. She is already feeling results, she tells NEWSWEEK. "Before, I would look at my textbook and look at myself and they were two different things. I wasn't even human." Bowers performed not only the clitoral operation but also plastic surgery to create labia for Ngozi, 34. "Now when I look at myself I feel like a woman," says Ngozi, who says she has even experienced orgasms for the first time in her life. "It's beautiful, I just love it, it feels like you're melting. Before it irritated me when my husband tried to touch me, now I reach out to him."

To learn more about Clitoraid or to adopt a clitoris visit the website at Clitoraid.org.

When did B movie starlets become medical experts?

I'm dismayed to discover that I apparently wasted 8 years in medical training. Four years of medical school and four years of residency were over-kill (pardon the expression). It seems that in 2009 the most important requirement for a medical authority is to be a former B movie starlet.

That's right. Ricki Lake is evidently an expert on childbirth, Jenny McCarthy is an expert on immunology, and Susan Somers is an expert on chemotherapy (in the immortal words of Orac of Respectful Insolence, she is currently carpet bombing the media with "napalm-grade stupid about cancer").

What, you might ask, are the qualifications of these experts beyond their tawdry celebrity? Well, Ricki Lake completed two (count 'em, 2) semesters at Ithaca College; Jenny McCarthy dropped out of Southern Illinois University in favor of a career at Playboy; and Suzanne Somers dropped out of Lone Mountain College after 6 months.

All three had advanced training as well. Ricki Lake has actually given birth to two children. Jenny McCarthy has a child she believed was afflicted with autism. And, Suzanne Somers actually had cancer. If that’s not enough to make you a medical authority, I don't know what is.

It's hardly surprising that celebrity has gone to the heads of these women and made them think they are medical experts (look at Kate Gosselin if you want to see what celebrity can do), but what is the matter with the millions of people who appear to believe the drivel fabricated and spouted by these women? What has happened to us, America?

How can anyone believe anything they have to say on any medical topic? Does anyone seriously think they are qualified to dispense medical advice? Aren’t you embarrassed to be consulting actresses for information on sophisticated medical issues?

Is this part of the dismaying strain of anti-intellectualism that has longed plagued our country? Do people honestly think that those smarty-pants doctors don’t have any knowledge that couldn’t be acquired on "Three’s Company"?

Or should we blame this farcical behavior on the American penchant for conspiracy theories, the more outlandish the better? Do people really have so little faith in organized medicine that they consider Suzanne Somer's cancer advice more likely to cure them than medical treatment?

Personally, I blame it in part on the Republicans. For the past 30 years we have been subjected to a relentless drumbeat of propaganda insisting that government can do nothing right, while they simultaneously distributed the contents of the public coffers to their personal friends or themselves.

I am a cynical person, but really folks? The government is paying for and recommending the distribution of injectable poisons? Big Pharma wants to create of generation of autistic people? Chemotherapy is a plot to keep you from the real cure for cancer? That's not cynicism; it is credulousness.

Inquiring minds want to know: How can anyone claim with a straight face to believe that Ricki Lake knows anything about childbirth? How could anyone possibly believe that Jenny McCarthy knows about immunology simply by dint of having a child who she thought was autistic. And Suzanne Somers? Does anyone seriously believe that the purveyor of the "Thigh-Master" just happened to discover the cure for cancer in her spare time?

Someone please explain it to me, because for the life of me I, like other doctors, cannot figure it out.

Cancer screening: too much of a good thing?

Doctors have understood for some time that it was inevitable. The American Cancer Society acknowledged today that cancer screening has been oversold.

It seems like every day you read in the newspaper that what was standard medical care yesterday is now no longer recommended. Don't doctors know anything? Well, actually they do. And what seems like paradoxical behavior, no longer recommending aggressive screening for certain cancers, actually represents a more sophisticated understanding of the way in which cancer behaves.

The classic understanding of cancer is that once a cancer forms it will continue to grow steadily until it kills the patient. Cancer was viewed as if it were an infectious disease like syphilis. It starts small and easy to treat, may remain hidden for long periods of time, but eventually spreads to other parts of the body becoming incurable along the way. If cancer did indeed spread like that, the aggressive screening programs would make perfect sense.

But decades of research and clinical experience have led to a more sophisticated understanding of cancer. It has always been known that cancers from different parts of the body behave in very different ways. Ovarian cancer is extremely aggressive, while basal cell cancer of the skin grows very slowly. Breast cancer can and does spread to bones and brain, while colon cancer is most likely to spread only to the liver.

More recently we've learned that each cancer can be broken down into different subtypes, some more aggressive than others, and some better treated with one regimen instead of another. For example, breast cancers are now analyzed for the presence of hormone receptors on the outside of the cancer cells. The presence or absence of certain receptors tells us whether specific treatments will be helpful or useless, making it easier to target the cancer with the treatment most likely to work.

We have also learned that some cancers follow the model of an infectious disease like syphilis, starting small and curable and ending up throughout the body and incurable, many do not. Some cancers start small and explode aggressively. Others start small and stay small for decades. This more sophisticated understanding is a direct result of being able to diagnose cancer earlier. We now have a much better and far more nuanced understanding of the natural history of various cancers. It has become apparent that rather than finding all cancer, we need only find cancers that are aggressive and can ignore those that are known to grow very slowly if at all.

What's the big deal? Isn't cancer screening beneficial regardless of the natural history of the particular cancer? No, it's not and therein lies the reason for the American Cancer Society’s call for less screening of certain cancers.

The goal of cancer screening is and has always been to reduce cancer deaths and disability, and therefore, that's how cancer screening should be judged. By that standard, some forms of screening are total successes. For example, the Pap smear, the screening test for cancer of the cervix, has been an unalloyed bright spot in the war against cancer. The test is inexpensive and reliable, the follow up test to actually diagnose cancer (biopsies of the cervix) is harmless, and very few if any women are treated unnecessarily. Screening for cervical cancer saves many lives and has few long term side effects.

By the same standard, prostate cancer screening has been a terrible disappointment. The PSA blood test, the screening test, is notoriously unreliable. Even more problematic is the fact that many prostate cancers grow extremely slowly and are unlikely to spread. Most problematic is that the treatment has very serious side effects, impotence and incontinence. Screening for prostate cancer with the PSA test (and finding tiny cancers) saves no more lives than screening with a prostate exam (which can find cancers that are somewhat larger) and leaves many men with unnecessary long term side effects.

Whereas every cervical cancer is probably dangerous to the patient and the treatment has few long term side effects in any case (since cervical cancer is most commonly diagnosed in women who have completed childbearing), most prostate cancers are not dangerous to the patient and the treatment is often undertaken unnecessarily. It’s bad enough to endure impotence and incontinence as the side effect of life saving treatment. It is tragic to endure it as the side effect of unnecessary treatment.

Breast cancer is similar to prostate cancer. While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths. Treating many more women with chemotherapy, lumpectomy and mastectomy has produced very few additional lives saved.

The solution to this conundrum, of course, is to develop more sophisticated screening tests, tests that can discriminate between life threatening cancers and non-life threatening cancers. In the meantime, the existing screening tests should be judged on their ability to save lives, not on their ability to diagnose cancer, since many cancers don't need to be treated.

Screening everybody for everything and screening them often is a very blunt tool that seemed appropriate when we had an unsophisticated understanding of cancer. Now that our understanding of cancer has deepened, the use of screening tests should reflect our new knowledge.

Simply put, screening tests should be reserved for situations in which they save lives. Dialing back on screening tests is not a step backward, it is a step forward in treating only those who need to be treated and not harming anyone else in the process.

The latest "argument" of vaccine rejectionists

I blog in a variety of places with a variety of different audiences, but I am struck by the uniformity of the arguments of vaccine rejectionists. It's not surprising, though, when you consider that they are not reaching their conclusions independently, but rather regurgitating seemingly "impressive" arguments they have read on vaccine rejection websites.

The latest such "argument" is that the safety and efficacy of vaccines have never been proven because they have not been subjected to a controlled randomized double blind study against a placebo. This "argument" is designed to impress those with a minimal knowledge of statistics. In other words, it is designed to impress those who know enough statistics to realize that anecdotes are not a substitute for scientific studies and are familiar with the concept that a controlled randomized double blind study against a placebo is the "gold standard" in some areas of drug research.

Unfortunately, they don't know enough to realize that controlled randomized double blind studies are unethical in certain circumstances, including the testing of vaccines. So what is presented on vaccine rejection websites as a startling and inexplicable refusal of scientists to test vaccines is actually the inevitable result of complying with ethical rules for scientific investigations.

There are many situations in which controlled randomized double blind studies are unethical. Consider infant carseats:

Do carseats minimize the risk of injury and death of infants?

There never been a controlled randomized double blind study of carseats. Why not? Because it is unethical to randomize some infants to be unbelted in cars simply so we can check how many will be injured and die.

Does that mean we don’t know if carseats reduce the risk of injury and death? Of course not. There are a myriad of statistical investigations that allow us to determine whether carseats reduce injury and death, including large scale population studies, retrospective cohort studies and many others.

So the fact that there are no controlled randomized double blind studies of vaccines is a red herring. It works only on those who don’t understand science and statistics. On them, of course, it works very well.

Vaccine rejectionists, like many Americans, simply don't understand statistics. This is a serious problem because Americans are exposed to a tremendous amount of statistical information and are required to make many decisions based that information.

An article in the journal Public Understanding of Science explains:

We live in a statistics-rich society: statistics permeates many aspects of life—from media, health, and work to citizenship. In the media, we can observe a growing emphasis on statistical results. This is particularly the case in health and medical reporting which tend to be the most compelling scientific issues for citizens ... The understanding of these statistical components is crucial to help citizens participate in public debate and arrive at political decisions.

Statistical misunderstandings are very common and lead to cynicism about science and medicine.

Statistics requires the ability to consider things from a probabilistic perspective, and to employ quantitative technical and abstract concepts such as significance, margin of errors, and representativeness. Since these concepts are difficult to understand, statistical misunderstandings can often be observed in the everyday but also in the media and research results. It is important to clear up these misunderstandings, as they lead to the misuse of study results, and the development of a distrustful or cynical attitude toward statistics.

Vaccine rejectionists, you've been tricked ... again. How many times do you have to be tricked before you realize that you are being victimized by your lack of knowledge of science and statistics?

H1N1: We report, you decide

Sometimes the best way to understand a situation is to see a graphical representation of it.

Below is a graph of pediatric influenza deaths over the past 4 years. I have adapted it from a graph created by the CDC that can be found here. The graph shows the number of pediatric deaths each week for the past 4 years. The green bars represent seasonal flu deaths; the pink bars represent deaths from confirmed H1N1 influenza.



The graph represents in the starkest possible way the difference between the H1N1 flu and the seasonal flu.

Seasonal flu can and is fatal in some children. Each year, primarily from February to May, some children will die of the seasonal flu.After that, pediatric deaths typically drop off to almost zero until the next flu season.

Something entirely different happened this year. Not only did flu deaths not drop off, but H1N1 flu is claiming children in higher numbers than the seasonal flu ever did. The graph does not show it, but unlike the children who die of seasonal flu who typically suffer from underlying medical conditions, healthy children are also dying of the H1N1 flu.

Could the H1N1 flu still burn out? Certainly that could happen, but there is no evidence that the tide has turned. Based on the fact that incidence of the flu typically rises dramatically in the winter, we are on track for an especially deadly flu season.

We could wait and see what happens, or we can attempt to head off disaster with a vaccination program. Look at the graph. What would you do?

A modest proposal: no insurance for vaccine rejectionists

Healthcare conspiracies are powerful and long lived. How can we combat health conspiracies among people who don't understand or don't believe scientific evidence? I suggest a simple expedient. Insurance companies should refuse to pay for vaccine preventable illness and their complications.

Why are health conspiracies resistant to scientific evidence?

All health care conspiracies --- vaccine rejectionism, claims that conventional medicine is suppressing inexpensive alternative "cures", the insistence that obstetricians want to ruin women's birth experiences --- share one critical feature. They are unfalsifiable. They can never be proven wrong by factual evidence because conspiracy theories predict that there will be reams of evidence contradicting their claims, but that evidence is itself part of the conspiracy.

Basham in the paper Living with Conspiracy published in the Philosophical Forum, Fall 2001, offers a definition of conspiracy:

A "conspiracy theory" is an explanation of important events that hypothesized the intentional deception and manipulation of those involved in, affected by, or witnessing these events... [T]hese deceptions and manipulations are usually thought to express nefarious, even insanely evil, purposes.

Best of all, the conspiracy theory can never be proven wrong:

...[B]ecause conspiracy theorists naturally invoke the idea that the official explanations are in part or whole deceptions, they can rationally interpret evidence against their accounts --- official reports, public statements and court of law testimonies ... --- as evidence for the conspiracy. Falsified evidence is precisely what a conspiracy theory predicts will be produced by the government and other players in ample amounts...

It's an absolutely brilliant tactic. The vaccine rejectionist responds to the copious evidence against the claim that the government is deliberately poisoning people with vaccines by declaring that the massive amount of evidence proves that there is a conspiracy by the government to poison people with the vaccine. Only a nefarious actor could assemble such overwhelming evidence. The sheer volume of the evidence demonstrates that the evidence is manufactured as part of the conspiracy.

The unfortunate consequence is that it is impossible to show a conspiracy theorist that he is wrong. All evidence, whether bolstering his claims or undermining them, is viewed as supportive evidence of something. It either supports the claim of harm, or if not, supports the existence of the conspiracy to do harm.

Perhaps we should stop trying to prove anything to health conspiracy theorists. Instead, we should let them live with the consequences of their decisions. I have a modest proposal:

In the case of vaccinations, insurance companies should deny coverage for vaccine preventable diseases and their complications in anyone who did not get the recommended vaccinations.

If vaccinations are worthless or harmful, vaccine rejectionists have nothing to worry about. They will never have to pay because they won't get sick. On the other hand, if they are wrong, they mistake will be illuminated in a way that is very easy to understand; they will literally have to pay for it.

How do vaccines work?

On the face of it, suspicion of the new H1N1 vaccine is incomprehensible. Vaccination has been one of the biggest lifesavers of the past 200 years. It is the cornerstone of public health, directly responsible for the dramatic drop in infant and child mortality and the dramatic extension of lifespan we have enjoyed over the last century. Despite countless conspiracy theories advanced by vaccine rejectionists in the past 200 years, not a single one has turned out to be true.

True, there are side effects, some serious. However, serious vaccine side effects like brain damage or death are so rare as to be measured per 100,000 people or per 1,000,000 people. There has been no effort to hide these serious side effects. Indeed parents are required to sign consent forms acknowledging the risk of serious side effects before their children can be vaccinated.

So why are people suspicious of vaccines? There are many reasons including the American love for conspiracy theories, the public campaigns led by prominent celebrities, and the desire to assign causes to diseases like autism where the cause remains unknown. The most important cause of the suspicions, though, is one that is very easy to address. Most people don’t know how vaccines work.

To understand how vaccines work, you need to understand how the body defends itself from bacteria and viruses. Just like the body has a dedicated system to digest food (the gastrointestinal tract) or to remove waste products (the kidneys and urinary tract0, the body also has a dedicated system to fend off bacteria and viruses; it’s called the immune system.

The body actually has three layers of defense against bacteria and viruses. The first is the physical barrier presented by the skin or the lining (mucous membranes) of interior passages like the mouth and nose. Although we are surrounded at all times by bacteria and viruses, most of them never make it beyond the skin. Of course the integrity of the skin and mucous membranes can be disrupted by a cut or puncture, allowing bacteria or viruses to be introduced directly into the body.

The second line of defense is a non-specific immune response. If bacteria colonize a cut on your hand, your body reacts in a predictable way. There will be swelling, redness, and pain, a response that does not depend on the identity of the threat. Special immune cells will race to the site and engulf the offending bacteria. When they die in the attempt, they accumulate as pus.

Even primitive animals have non-specific immune responses, but higher animals and human beings have an additional, more powerful response. We can produce antibodies. Antibodies are proteins that recognize specific bacteria or viruses and bind to them, thereby signaling to other immune cells that they are targets for swift neutralization. Each antibody binds to a specific site on a specific bacteria or virus.

We’re not born with those antibodies, though. We make them in response to a threat. For example, we are not born with antibodies to the chickenpox (varicella) virus. When exposed to the varicella virus, though, we can learn to make antibodies to it. It takes time, but gradually we can produce enough antibodies to fend off the disease.

Unfortunately, we don’t always get the time we need. We can make antibodies to smallpox, for example, but many individuals are overwhelmed and killed by the virus long before they could make enough antibodies to fend it off. Those who do win the race and manage to produce enough antibodies to survive are now permanently protected. That’s because the immune system retains the ability to make the specific antibodies against the smallpox virus. Whereas it may take days to produce smallpox antibody when first exposed, a second exposure will be met with rapid and massive production of antibody, generally preventing the individual from getting sick at all.

So in order to be protected from the disease, you had to get the disease, and you might die before you were able to make enough antibody to protect yourself. Imagine, though, if you could learn to make the protective antibodies without actually getting sick. That’s the theory behind vaccines.

In order to make antibodies to a virus (or bacterium) the body need to “see” the virus. In other words, it needs to have direct exposure to the virus, but that virus doesn’t have to be functional, and it doesn’t even have to be whole. A virus can be inactivated (live attenuated) or killed and still produce an immune response. It can also be broken down into its constituent parts and the parts can produce an immune response. Any future exposure to the live virus (though contact with others who have the disease) will be met with rapid and massive production of antibody, preventing the individual from getting sick at all. A vaccine is merely and inactivated or dead form of the virus, letting you learn to make antibody without getting sick in the process.

Vaccines do not produce perfect immunity. The dangerous part of the virus might be the part that evokes the most powerful immune response. Rendering the virus harmless by inactivating it, killing it or breaking it up, may remove that part and the immune response to the less dangerous parts might be weaker. So actually getting the disease may produce a better immune response than the vaccine … but only if you survive the disease.

Successfully fighting off a disease depends on being able to produce enough antibody before the disease kills you. Until vaccines, the only way you could learn to produce antibody was to actually get the disease. Now, instead, you can learn to make antibody by being exposed to a harmless form of the virus or bacterium.

Is breastfeeding a moral imperative?

Feminist scholar Michele Crossley's recent paper in the journal Feminism Psychology raises important questions about breastfeeding, and by extension, about unmedicated childbirth. Breastfeeding as a Moral Imperative: An Autoethnographic Study makes a controversial claim:

...[F]ar from being an 'empowering' act, breastfeeding may have become more of a 'normalized' moral imperative that many women experience as anything but liberational. Accordingly, an uncritical appropriation of the idea that 'breast is best' may not only be disempowering for women, but also problematic for babies.

Crossley begins by exploring the place of breastfeeding within our culture:

Many contemporary social movements ... highlight the risks associated with modern technology with the consequence that the rhetoric of the 'natural' has proliferated... This whole idiom of the 'natural' has surrounded childbirth and child-rearing and has been a key theme in the 'alternative birth movement.' As Oakley argued, 'like natural childbirth, natural infant feeding has become fashionable in a society that is technological "by nature"'.

...[B]reastfeeding has been associated with women's personal agency and empowerment. The promotion of breastfeeding has constituted part of an attempt to 'demedicalize' life events (such as pregnancy) and to return such processes to the 'rightful moral domain under the control of women themselves.'

Crossley's paper isn't really a study. It's just a description of her personal experience, which has led her to re-evaluate the rhetoric she previously accepted. Like many white, Western, well off women, Crossley uncritically embraced the bizarre notion that there is a "right way" to give birth and to "bond" with a newborn:

Related to my desire to establish a strong 'bond' was my desire for a 'natural' childbirth. I had read that if a delivery entails a lot of intervention, then the baby emerges into the world potentially traumatized by the effects of drugs and bright lights, all of which make the bonding process more difficult...

In preparing for labour, I totally discarded any notion of interventions such as a caesarean ... After over fourteen hours of labour, when the baby was eventually delivered by emergency caesarean section ... the first thing I remember was that I 'had to get that baby to the breast'. Because I had not had the opportunity to bond at the moment of birth as I had been anticipating, it made me all the more determined to ensure that breastfeeding happened in the way I wanted.

But the actual experience of breastfeeding was nothing like she had been led to believe. From the very beginning, the baby did not appear to be getting enough milk. Despite growing evidence that the baby was failing to thrive (his weight had fallen from the 75th percentile at birth to the 5th percentile at 10 weeks), and desperate entreaties by the baby’s father, Crossley refused to relinquish the fantasies promoted by breastfeeding advocates.

...The message that had been 'drilled into' my head at the antenatal classes and from the books I had been reading was that 'you always produce enough breastmilk', 'breastfeeding is a perfect system'. In fact, I had even asked the health visitor at the time if the baby’s constant screaming could be explained by the fact that he wasn’t getting enough milk. Her response was that 'you always produce enough breastmilk, always, there’s always enough ...'

The baby's father became frantic:

...I had to confront you about the breastfeeding. I felt at that point that we were gonna kill him or do him some serious damage ... and I just thought he is not gonna survive this. I felt as if I was, I suppose, I was the only person who could see this ...

They began bottle feeding the baby and he began to thrive. Crossley, however, was torn by feelings of guilt and shame:

I felt like a failure because ... I had 'taken on board' the message that breastfeeding was really difficult, it was hard work and 'many people didn't manage to do it'. One had to be 'really determined' to succeed, but if 'you tried really hard, you could manage it'... [M]y experience was entirely consistent with a woman in Lee and Furedi's study who commented that women who 'succeed at breastfeeding are made to feel like it's such an achievement, they have done so well, they deserve a medal…' As Lee and Furedi argue, some women have come to view breastfeeding as a 'measure of motherhood and consciously or unconsciously judge other mothers accordingly'...

Crossley's personal experience has led to an epiphany:

...[A]s with other health-related behaviours, the act of breastfeeding can become inextricably interrelated with the construction of identity and the creation of a sense of morality, values and orientation to 'the good.'

[T]he act of breastfeeding came to symbolize all that was important about being a 'good' mother. It meant 'bonding' and forming emotional connections, 'being there' for the infant, learning to 'go with the flow', 'letting go of the instinct to control' and 'learning to trust in one's own body'. Dykes has previously characterized this understanding of breastfeeding as deriving from the 'natural' discourse that has been popularized in recent years.

Crossley concludes:

Breastfeeding, far from being the 'resistant' body-project that advocates of demedicalization and 'women-centred' alternatives originally promoted, may have become more of a 'normalized' moral imperative that some women experience as anything but liberational ...

Death panel: no way. Deadly medical error: happens every day.

Sarah Palin's assertion that healthcare reform would bring "death panels" empowered to kill sick people in order to save money is pure fantasy, but the idea resonated with the American public. It speaks to people's deepest fears, that when they are frail and ill, society will take the opportunity to do them in. The irony is that the fear is entirely misplaced. They don't need to worry that the healthcare system will kill them deliberately; they should be worried that the healthcare system will kill them accidentally.

It is difficult to deliberately die within the American healthcare system. Far from convening "death panels" to withdraw care, providers and hospitals are ignoring the wishes of those who want to die. Advance directives and healthcare proxies have allowed Americans to forgo care at the end of life, yet the majority of these arrangements are ignored, primarily because of fear of lawsuits, and often in the face of intra-family conflicts.

Unfortunately, it is all too easy to die by accident within the American healthcare system. Although claims that "doctors are a leading cause of death" are vastly exaggerated, the number of healthcare errors is extraordinarily high, and the death toll from those errors is far too large.

Dr. Donald Berwick of the Institute for Healthcare Improvement detailed the experience of his wife Ann, hospitalized for a rare spinal problem:

An attending neurologist said one drug should be started immediately, that "time is of the essence." That was on a Thursday morning at 10 a.m. The first dose was given 60 hours later, on Saturday night at 10 p.m... One medication was discontinued by a physician's order on the first day of admission and yet was brought by a nurse every single evening for 14 days straight. "No day passed--not one--without a medication error," Berwick remembers... "The errors were not rare. They were the norm."

After he publicized his experiences, Berwick was besieged by other doctors saying, "If you think that's terrifying, wait until you hear my story." One distinguished professor of medicine whose wife was hospitalized in a great university hospital was too frightened to leave her bedside. "I felt that if I was not there, something awful would happen to her," he told Berwick. "I needed to defend her from the care."

The problem first received widespread attention with the publication of Dr. Lucian Leape's paper in JAMA in 1994, Error in Medicine:

Autopsy studies have shown high rates (35% to 40%) of missed diagnoses causing death. One study of errors in a medical intensive care unit revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury. Operational errors (such as failure to treat promptly or to get a follow-up culture) were found in 52% of patients in a study of children with positive urine cultures.

Given the complex nature of medical practice and the multitude of interventions that each patient receives, a high error rate is perhaps not surprising. The patients in the intensive care unit study, for example, were the recipients of an average of 178 "activities" per day. The 1.7 errors per day thus indicate that hospital personnel were functioning at a 99% level of proficiency. However, a 1% failure rate is substantially higher than is tolerated in industry, particularly in hazardous fields such as aviation and nuclear power...

It is hardly surprising that errors have become a prominent feature of a system designed to "process" as many patients as possible, as quickly as possible. Doctors are being compelled to see more patients in less time, despite the fact that many more people are living with complex medical conditions. Nurses are compelled to care for many more patients at one time, despite the fact that their medical needs, particularly the need for sophisticated monitoring technology, have grown dramatically, and the patients themselves are sicker.

Most importantly, in an industry where mistakes are a matter of life and death, the underfunding of medical care means that hospitals do not have the money to acquire technology that can reduce errors.

In an update of his report on medical errors published earlier this year, Dr. Leape explains:

Errors and injuries can, in fact, be prevented by redesigning systems to make it difficult, and sometimes impossible, for caregivers to make mistakes. A classic example is the elimination of accidental (fatal) intravenous injections of concentrated potassium chloride by removing the medication from the nursing units and requiring it to be added to intravenous solutions when they are prepared in the pharmacy.

Another example is computerized physician order entry systems (CPOE), where the physician must enter all orders, including all prescriptions for medications, by computer. This ensures that the order is complete, it is not a medication the patient is allergic to, and that the dose is within usual limits… CPOE can reduce serious medication errors by 60–80%.

The healthcare system as it currently exists unwittingly conspires to increase errors. When it comes to medical errors, we should take Dr. Leape's most important insight to heart:

We need to move from looking at errors as individual failures to realizing they are caused by system failures. This is the driving principle.

The ultimate irony of Sarah Palin's "death panel" fabrication is that healthcare reform represents the best chance of reducing medical errors, while opposing healthcare reform virtually insures that medical errors will continue apace. No one should worry about being killed deliberately by a "death panel" but everyone should fear being killed accidentally by a medical error.

The truth about thimerosal

Vaccinations have been around for over 200 years and vaccine rejectionists have been around for nearly that long. Over the years, the basis for claims of harm from vaccines have changed, but one factor has remained constant. Vaccine rejectionists have never been right. The current fear mongering surrounding thimerosal is just the latest iteration in an ongoing effort. That fear mongering rests on two factors, ignorance of basic chemistry and ignorance of the existing research on thimerosal.

To hear vaccine rejectionists tell it, all mercury containing compounds are dangerous and therefore thimerosal is dangerous. But that’s not how chemistry works. The toxicity of a substance depends on how atoms are arranged, not simply which atoms are present. The fact that some mercury compounds are dangerous does not mean that thimerosal must be dangerous because it contains mercury.

Consider the example of sodium. Sodium is both poisonous and explosive. That does not mean that compounds that contain sodium are either poisonous or explosive. Table salt (sodium chloride) contains sodium, yet we do not worry that salting our food will result in an explosion at the dinner table.

Similarly, mercury is poisonous, but that does not mean that any compound that contains mercury is also poisonous. Some mercury containing compounds, like methyl mercury, are poisonous. Methyl mercury is the found in fish and is the reason why restrictions of fish consumption are recommended for certain groups. Thimerosal is ethyl mercury and is not poisonous.

Though methyl mercury and ethyl mercury might sound like they are very similar, one is poisonous and the other is not. How can that be? Consider the case of alcohol. Methyl alcohol (methanol), also known as wood alcohol, will lead to blindness or death if you drink it. Ethyl alcohol (ethanol) is the alcohol found in wine and spirits. Chemical structure is more important than the identity of the individual atoms that make up the compound.

The safety of thimerosal is more than simply theoretical. Contrary to the claims of vaccine rejectionists, thimerosal has been studied extensively in large populations. There have been many studies that demonstrate the safety of thimerosal.

Consider the study Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United Kingdom does not support a causal association (Andrews et al. Pediatrics 114. 584-591.2004). This was a retrospective cohort study was performed of 109 863 children who received thimerosal containing DPT vaccines. The study found no evidence that thimerosal caused developmental delays.

Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United kingdom does not support a causal association (Heron et al. Pediatrics 114. 577-583.2004) followed 14,000 children for up to 7+ years. The authors found:

Contrary to expectation, it was common for the unadjusted results to suggest a beneficial effect of thimerosal exposure. For example, exposure at 3 months was inversely associated with hyperactivity and conduct problems at 47 months; motor development at 6 months and at 30 months; difficulties with sounds at 81 months; and speech therapy, special needs, and "statementing" at 91 months… CONCLUSIONS: We could find no convincing evidence that early exposure to thimerosal had any deleterious effect on neurologic or psychological outcome.

The bottom line is that the vaccine rejectionists are wrong once again. The fact that thimerosal contains mercury does not mean it is dangerous because the chemical structure determines the danger, not the identity of the individual atoms. More importantly, thimerosal has been studied extensively in large populations over time and has been demonstrated repeatedly to be safe.

Family docs: Have a Coke and a bribe!

I'm torn.

I can’t decide whether it was greed or stupidity that led the American Academy of Family Physicians to accept a corporate sponsorship from Coca Cola.

Greed is certainly behind the AAFP decision to create its “Consumer Alliance program.” I love the Orwellian title! AAFP is not allying with consumers. It is partnering with businesses. The businesses will provide money and the AAFP will provide legitimacy. Yet said AAFP President-elect Lori Heim, M.D. disingenuously claims:

The Consumer Alliance program is a way of working with interested companies to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle.

No, it isn’t. The Consumer Alliance solicits money from corporate sponsors to enrich the AAFP coffers.

A partnership with Coca Cola defies comprehension. The American Academy of Family Physicians has been out front in calling attention to the link between soft drinks and obesity, particularly childhood obesity.

Soft drink consumption has increased dramatically in recent decades. The increase corresponds with the rise in obesity and diabetes in the United States. Some evidence suggests that sugar-sweetened beverages increase the risk of childhood obesity. No study has shown that these drinks increase the risk of diabetes, although this relationship is plausible not only because of the added sweeteners but also because the caramel coloring may increase insulin resistance.

The official position of the AAFP is to minimize Coke consumption; the official position of Coca Cola is to maximize Coke consumption. In fact, everything the Coca Cola Company does is designed to maximize Coke consumption and, therefore, profits. If they are giving money to the AAFP it is because they believe that the legitimacy they will gain in exchange will lead to increased profit. The conflict of interest could not possibly be more stark.

I suppose it shouldn’t matter how much you are asking for your soul when you auction it off, but I find it galling that the AAFP had sold its soul so cheaply. AAFP President-elect Heim says the payment "in the strong six figures." In other words, it took less than a million dollars to convince the AAFP to ally with a purveyor of a product does not improve health and may actually impair it.

The AAFP has clearly learned nothing from the example of other medical organizations that have compromised their credibility with inappropriate corporate sponsorships. The American Medical Association suffered a major blow when forced to renounce a partnership with Sunbeam, a maker of home electronics. According to Quackwatch:

…[T]he American Medical Association announced that it would pay $9.9 million to the Sunbeam Corporation to settle a breach-of-contract suit… The suit was filed … after the AMA announced it would not honor an exclusive 5-year royalty agreement under which the AMA logo would have been placed on Sunbeam's "Health at Home" products, which included heating pads and humidifiers. The endorsement plan, … had no requirement that the AMA test the products… An investigative report on the management decisions leading to the contract led the AMA's chief executive officer and two other top AMA executives to resign.

The AMA has never fully recovered from the scandal and has seen its membership drop to less than one third of American physicians.

The American Academy of Family Physicians has made a terrible mistake. It has compromised its integrity and credibility by accepting money from Coca Cola. It should follow the example of the AMA and renounce the partnership. President-elect Heim has managed to besmirch the reputation of the organization even before taking office. Hopefully it is not too late for her to undo the damage.

What would you do if you were the CDC?

I've been writing about the H1N1 flu for the past few days, and have been asked repeatedly if the Centers for Disease Control (CDC) has reacted precipitously by ordering the production of millions of doses of vaccine and strongly recommending that individuals at highest risk get vaccinated as soon as possible.

To understand why the CDC has taken the aforementioned actions, you need a little background in history, epidemiology and virology. No one including the CDC knows what is going to happen, but they are using experience as a guide. Let me share (in a simplified form) what is known, then you can decide what you would do if you were the CDC.

History shows that the influenza virus, while typically mild, can mutate to forms that are deadly. The great influenza outbreak of 1918 (the Spanish flu) killed tens of millions of people. Curiously, the hardest hit were those who were young and healthy. They would come down with the flu, develop lung complications, and quickly drown in the fluid that filled their lungs. So although such outbreaks are uncommon, recent history shows that a flu outbreak can easily and quickly kill millions.

Epidemiology has shown us that two important factors are necessary for influenza to kill millions. The first factor is that the specific influenza virus must trigger severe disease. The second factor is that the specific influenza virus must be able to spread person to person.

Influenza also occurs in bird, and pigs, among other animals, and it probably jumped to humans thousands of years ago when they domesticated animals. Various influenza viruses can still jump easily from animals to people. However, when that happens, the disease, which may be quite severe, is self limited. In our increasingly urbanized world, very few people have direct contact with animals. Those who do may pick up dangerous strains of influenza and may die of them, but they won’t pass them on to other people, and no epidemic will develop.

Virology holds the third, and perhaps most important clue. When we think of genetics, we think of offspring inheriting genetic material from parents. Viruses (and bacteria) can exchange genetic material with each other. If both your parents have blue eyes, you might have blue eyes, too. Imagine, though, if you could acquire blue eyes simply by standing next to someone who has blue eyes. Viruses can acquire new traits that way.

The "perfect storm" in the world of influenza viruses is when a virus that is particularly deadly in animals comes in contact with a virus that can easily be transmitted from one human being to another. When that happens, the result can be a new virus that is particularly deadly and is now contagious.

Fortunately, that "perfect storm" does not occur very often, but the possibility always exists that it will happen. The CDC is greatly concerned that the new H1N1 variant of influenza is a "perfect storm" virus. It has the three deadly characteristics that we would expect in such a virus: it is new, so people are not immune to it; it can cause severe illness and death; and it is contagious from person to person.

Viruses can mutate very rapidly. For that reason they can become more dangerous, but they can also become less dangerous. No one knows what is going to happen with H1N1.

So we know the virus is here and the virus is lethal. What should we do about it?

We could do nothing and wait to see what happens. The virus could become less deadly and the danger will be over. Of course, the virus could remain lethal or even become more lethal as it is transmitted from person to person.

You can think about it as if it were a house fire. The fire could burn out of its own accord. It could burn down only the house involved. Or it could jump to neighboring houses and burn them down, too. In fact, fire, like viruses, tends to expand exponentially. It doesn't jump from one house to the one next door. It jumps to all the houses nearby and then jumps to the all the houses near those. Pretty soon, the entire town is on fire. So waiting to see what happens makes as much sense as waiting to see if a house fire goes out on its own. It means taking a terrible risk.

In the case of viruses, as in the case of fire, prevention is the best strategy. Obviously it’s better if the fire never gets started in the first place. Similarly it is better if no one else gets the H1N1 strain of influenza. Vaccination is the only way to protect people from getting the disease. So vaccination is the first and best line of prevention.

In large fires, firefighters don't simply attempt to save the houses already on fire. They try to set up firebreaks to prevent the spread of fire before it happens. Vaccination, in addition to preventing individuals from getting sick, also acts like a firebreak. If everyone around an infected person is has been vaccinated, no one can catch the virus. The spread of the virus is stopped cold. Vaccination protects not only those who are vaccinated, but everyone else in the population.

So imagine you are the head of the CDC. You know that H1N1 is here, and it is a particularly deadly form of influenza. You know that it can be passed person to person. And you know from history that similar viruses have killed 10 of millions of people in one epidemic. What would you do? Would you wait to see what happened? Or would you vaccinate against the disease and hope to save lives and halt the spread of the virus?

Extraordinary death toll of H1N1 in pregnant women

Doctors are often compelled to make quick decisions in life threatening cases with only limited information. Unfortunately, pregnant women are now going to be put in the same situation.

The H1N1 flu has taken an extraordinary toll among pregnant women. A new vaccine will be available within the next few weeks. Because of the nature of the emergency, there has not been time to do any long term studies of the vaccine. Yet pregnant women will need to make a decision as soon as possible on whether to be vaccinated.

Many illnesses are more severe during pregnancy, but the H1N1 influenza has had an unexpectedly devastating impact among pregnant women. According to the CDC, there have been approximately 700 reported cases of H1N1 in pregnant women since April. Of these, 100 women have required admission to an intensive care unit and 28 have died. In other words, 1 out of every 25 pregnant women who contracted H1N1 died of it. By any standard, that is an appalling death rate.

There seem to be two reasons for the dramatically increased death toll. The first is the altered immune status of pregnant women making them particularly vulnerable to the virus. The second is that pregnancy compromises lung function. If a pregnant woman gets pneumonia as a complication of the flu, it is particularly difficult to insure that she gets enough oxygen.

We should ensure that pregnant women do not get H1N1 influenza and the best way to do that is by vaccination. The new H1N1 vaccine is similar to other influenza vaccines. We know that other influenza vaccines are not harmful in pregnancy, and there is no reason to believe that the H1N1 vaccine will have any side effects that differ from those normally expected after vaccination. There are no adjuvants added to the vaccine, either, so there will be no danger from adjuvants. However, there has been no time to study the long term effects of the vaccine, so no one can be sure about side effects.

Pregnant women are rigorously counseled to avoid any drugs, diagnostic tests, or treatments that might impact the developing embryo or fetus. Most women reflexively fear the idea of vaccination in pregnancy, although vaccination for many diseases presents no problems in pregnancy. The Centers for Disease Control and physicians are very concerned that pregnant women will refuse vaccination, with potentially lethal results.

How should pregnant women decide what to do? The best place to start is with what we know for sure. We have a great deal of evidence that H1N1 influenza is particularly lethal in pregnant women. To put it in perspective, the chance of a pregnant woman dying from H1N1 is greater than the chance of a heart patient dying during triple bypass surgery. That is not a trivial risk.

We have no evidence that the vaccine will cause any harm to pregnant women or their unborn children beyond the side effects associated with other flu vaccines, such as local irritation at the vaccine site, or the rare complication of Gullain Barre Syndrome. We have no reason to expect that the H1N1 vaccine will be any different.

It would be much easier to make the decision if we knew more, if we had some idea of how extensive the fall outbreak will be, if we had longer experience with the specific vaccine. Unfortunately, that information is not available to us and by the time it becomes available may more pregnant women may sicken and die unnecessarily.

Given the dramatic threat and the fact that we know of no unusual complications of vaccination, the decision seems clear. Every pregnant woman should get vaccinated as soon as possible.

Mental health in mothers of Down Syndrome children

The small minority of women who elect to continue Down Syndrome pregnancies have vigorously asserted that the burden of raising a DS child has been exaggerated and that there would be fewer terminations if women were given more accurate information. However, the scientific research does not support those claims and, in fact, demonstrates the opposite.

Physical and Mental Health in Mothers of Children with Down Syndrome by Bourke, et al, was published in the Journal of Pediatrics in September 2008. It showed that mothers of DS children scored lower on measures of both physical and mental health. Indeed, mothers' the decrease in physical and mental was closely associated with the functional level of the child.

According to the authors:

This study found that the most important predictors of maternal health, particularly mental health, were the child's behavioral difficulties, the child's level of everyday functioning, the child's progress in community participation involving shopping and travel, and to a lesser degree, the child's current health status...

We found that the mental health of mothers was strongly influenced by child behavior and care-giving demands. These results are similar to studies of psychological stress in caregivers of children with disability or chronic disease... [T]he average mental health score of the mothers in our study was significantly lower than the average score reported for both South Australia and Western Australia. Interestingly, the effect of care giving on maternal physical health appeared less dramatic...

In our multivariate analysis for maternal physical health we showed that mothers of children who scored higher on the disruptive/antisocial subscale of the DBC displayed worse physical health... Our study has corroborated earlier findings that behavior problems are the single most important child characteristic that predicts maternal psychological well-being...

Intellectual disability appears to predispose individuals to emotional or behavioral problems... Eisenhower et al showed at age 3, behavioral problems in children with Down syndrome are comparable to those of typically developing children. However, over the next 2 years there was a relative increase in behavior problems in their Down syndrome cohort and, in turn, maternal stress.

In our study, mothers of children with higher everyday functioning experienced better mental health. In particular, mothers reported better mental health if their children required no help or supervision in dressing, problem solving and, for children over 12 years, using the telephone. Similarly, mothers reported better mental health if their child aged over 12 years required supervision but no help in using the telephone, using public transportation, and attending social events...

These results are hardly surprising. A child's disability has an impact on the mother's physical and mental health and that impact is correlated with the child's level of functioning. Instead of experiencing a DS child as "enriching," mothers experienced the child as a significant stress, particularly if the child was low functioning. The authors did not investigate the impact of a DS child on marital happiness or the well being of other children in the family. However, it seems reasonable to assume that a stress large enough to impact both the physical and mental health of mothers is likely to have effects that extend to her roles as spouse and as parent to her other children.

None of this is an argument for termination. That is a decision that is and should be left to the mother. However, it is an argument for opposing the attempts of current DS parents to "educate" women facing the termination decision. Those parents who are anxious to "counsel" others are not representative of DS parents and therefore, could not possibly provide unbiased, accurate information.

What Sarah Palin can teach us about hate

Sarah Palin burst onto the national scene slightly more than a year ago at the Republican National Convention. Since then she has gone from disaster to disaster: she fatally weakened the Republican ticket, committed countless ethical violations, and couldn't even manage to govern the State of Alaska. Through it all, she has demonstrated herself to be simultaneously a blithering idiot and a confirmed narcissist.

On the eve of publication of her new book, it is worth examining Palin's one outstanding talent, her ability to incite hatred. The contemporary GOP is a party fueled on hate. Hate is the stock in trade of O'Reilly, Limbaugh and Beck, so it is no small feat that Sarah Palin could claim to be the hater-in-chief. In her rapturously received speech to the Republican convention she gave what amounted to a clinic in inciting hatred. It is worth looking back at that speech and how she did it.

Psychologists have recently published findings on the five steps in the development of collective hate (Making a Virtue of Evil: A Five-Step Social Identity Model of the Development of Collective Hate, Soc Per Psych Compass 2/3 (2008): 1313–1344) and Palin seems to have embraced the model enthusiastically. According to the researchers:

The five steps are: (i) Identification, the construction of an ingroup; (ii) Exclusion, the definition of targets as external to the ingroup; (iii) Threat, the representation of these targets as endangering ingroup identity; (iv) Virtue, the championing of the ingroup as (uniquely) good; and (v) Celebration, embracing the eradication of the outgroup as necessary to the defence of virtue.

Let's look at how Palin accomplished those aims.

Identification, or I'm just like you: Palin led with a description of her family, proudly proclaiming, "Our family has the same ups and downs as any other ... the same challenges and the same joys." She emphasized her large family size, her family members in the military, her special needs child, her husband's blue collar job and her parents' background as farmer and small business person.

Exclusion, defining the other: Palin was quick to claim that her opponent talks one way in Scranton to working people (us) and another way in San Francisco (them, and they're gay, too) supposedly deriding religion and gun ownership. Palin invokes the Washington elites (them) as if the Republicans didn't hold the presidency, vice presidency, Supreme Court, and other major positions of power.

The threat: Her opponent supposedly wants to turn his back on victory in Iraq; her opponent wants us to be threatened by oil producing nations; and, worst of all, terrorists are trying to attack us and her opponent still cares about the Constitution.

Virtue: Her group is uniquely good. She implies that they, and they alone, are the people who care about family, about religion, about patriotism, about sacrifice, and she is sure that God cares uniquely about her group.

Celebration: Finally, the call to action, the insistence that the defeat of the other is required to defend the values of family, religion, patriotism and sacrifice.

Not only was the structure of the speech designed to evoke hate, the very words and the delivery were chosen to ridicule, demean and denigrate. She made is quite clear that her opponents are not merely political opponents, they are people unworthy of the basic respect that should be due to any individual, let alone two Senators who have served their country well.

Sarah Palin was perhaps more honest than she intended to be when she described herself as a pit bull with lipstick. She implied that she is vicious, immoral, bred to attack, and fed on misery and hate. The crowd lapped it up. She carefully followed the script for inciting hatred and the audience responded with thunderous applause. It was a virtuoso performance in the art of hate.