While the back-to-school news may cover lots of articles about how to treat head lice, there just aren’t very many about how to prevent it. Other than, of course, the tired and true obligatory phrase: “don’t share combs or brushes.” I’m not sure about you, but I don’t see that many kindergartners fluffing and tossing a shampoo-commercial head of hair at school. The underground market for “pre-owned” brushes during recess just doesn’t seem that large. So what reasonable steps can you take to reduce your chances of bringing home head lice? Without being all paranoid and nit-picky, that is?
First, before we dive into this infested topic, brace yourself. The more you know about the wonders of head lice, the more likely you are to spend the next two weeks scratching your head from time to time and shuddering. Thinking about lice too much provokes that kind of reaction. It’s what we highly-skilled professionals in the world of homeless healthcare term, with diagnostic precision, a case of “the heebie-jeebies.”
CDC
Second, try to channel a bit of helpful fatalism. People don’t die from head lice. Sure, if you find a louse crawling on your teeny child’s scalp, you might end up flapping your hands and running around in circles while emitting an airless eeh-eeh-eeh scream. But unless you trip, fall and impale yourself on one of Urban Outfitters’ invisible toy sticks, no one’s going to get hurt. Or sick. Maybe nauseated. But not sick.
Even when it comes to changing your life to avoid head lice, it’s important to maintain perspective. As a doctor who works in a homeless clinic, I can tell you that we staff see it all – things that crawl and creep and slither across human skin. What you realize is that reasonable precautions are important. But staying happy, and productive and (frankly) sane means that you’ve just got to shrug and, after taking reasonable precautions, think that hey, what will be will be. Every living creature on this earth has its own version of lice (aphids are plant lice). But I’ve seen friendships and social events and classrooms literally destroyed by the emotional fallout of a head lice outbreak. Which makes you wonder if, really, should we let the little suckers have that much power over us? Instead, we can focus that energy into anti-louse action.
The first way to prevent head lice is to arm yourself with some knowledge. Here are a few important head lice facts to keep in mind:
1) People are infested, on average, four to six WEEKS before they discover they’ve got lice. That means it can be essentially impossible to know who got what, when, from whom. The blame game, in a world of lice, is meaningless. Take it out on the lice – those little creepers are sneaky beyond belief. How sneaky?
2) Lice, except in florid cases, can be harder to diagnose than you might think. Hey, theoretically, all you need for a self-sustaining infestation is one fertilized female louse. They’re tiny. And sometimes speedy (6-32 cm/min). On-going cases exist with as few as 10-15 live lice on a person’s entire head (average = 12).
Same-color nit casing cemented to hair shaft. Sneaky…
3) Nit cases are how most diagnoses are made. The louse glues an egg to the base of a hair shaft and the heat of a person’s body incubates the egg. Lice (being nobody’s fool) lay eggs that are, generally, the color of the person’s hair. Only when the egg has hatched, and the hair has grown out, and the “husk” that’s still glued to the hair-shaft pales, can you reliably see the empty cases. But even that is sometimes difficult to be sure about. Telling the difference between normal scalp fluff or skin, and an old nit case, is a job for someone with experience.
4) Shampoo and conditioner won’t help. Keep in mind, getting head lice has nothing to do with hygiene. Trust me, lice don’t actually care how often you wash your hair. They like a nice invigorating shower as much as the next person. You get lice when lice from one head move to another head. That’s it. There’s nothing more to it. Lice has nothing to do with poverty either – they don’t know how much is in your bank account. Lice can be more common when people are living in crowded settings, though, purely because the lice can more easily spread to more heads. Our only saving grace is that they can’t live very long on another surface (max = hours, but not more than 2 days). Lice have to feed (urk – your blood) frequently. Five times a day. And lice can’t jump. They’re not fleas. High heat works to kill them, but we’re talking clothes dryers here. If you try to treat lice by blow-drying high heat on someone’s head, you can burn and/or kill the child (true – there are reported cases where treatment solutions on a head ignite), but the lice are fine – they just move to the other side of the head.
5) Are they dead yet? When it comes to lice treatment the question is (as people in the Oval Office have been known to ask), exactly how do you know when the war is won? From the situation room, here’s the scene, based on what we now know: So we’ve got a very few stealth lice, nearly invisible, dodging and zipping around hair shafts like a SWAT team. But from our command central post, our most reliable visual clue that lice-invaders are still in forbidden territory is a dead husk (or three) from 6 weeks ago (which may, *cough*, be lint). AND you’ve got, among the civilians, a school-wide epidemic of the willies (aka lice PTSD). Every single person is scratching and shuddering constantly. How are you ever going to be able to tell if increasingly toxic and desperate measures have cured…anything?
All of which is to re-enforce the need, when it comes to lice, for calm. And some perspective. Especially when the urge becomes almost overwhelming to either a) grab a pitchfork, some torches and mob up, in order to go after that family you know is to blame, or b) cancel all human activity and eliminate all possible human contact – just to protect your loved ones from this scourge.
Instead, here are some practical, sensible approaches to help you and yours avoid head lice.
6) Use the star pattern for sleeping arrangements at sleepovers. First, make it a habit, if it’s not already, to have sleeping bags and sleeping-on-the-floor an expected part of sleepovers. No sharing pillows or beds. Second, when night-time comes, instead of putting kids side by side, or lying in a circle with their heads in the middle, try to get kids to lie in a circle with their feet in the middle. A good PR move for encouraging this arrangement is to tell kids that this way everyone gets enough room, and no one is left sleeping on the ends.
7) Beware performance culture! Adults who wouldn’t dream of letting their kids share a comb or a hat seem to forget all precautions when it’s time for a performance. Schools with strict lice policies will hang posters for a production of “Annie!” where 37 kids in two casts swap 6 wigs between 5 scenes. Make-up and hair volunteers will style all kids with the same implements, hair-bands, and hair-ties. And the hats! Don’t get me started on the hats! Make sure your kid’s joy of performing isn’t marred by a 4-6 week delayed mega-infestation. It’s important to have performance programs develop sensible anti-lice precautions. Cosmetic grade disinfectant should be mandatory for hair styling. If that’s not possible, at a minimum, each kid should have their own brush/comb with strict non-sharing supervision. Keep in mind that lice tend to be dead if left on a surface for more than a couple of days, so those elaborate hats for “Dolly” can probably still be used between separate casts, as long as they perform on different days.
 Safety (equipment) first! Let’s take a moment here and play the Worst Case Scenario Game-show! Which of the following would you choose? What’s behind Door #1 – Skull fracture and death; or Door #2 – Head trauma with a lifelong seizure disorder; OR Door #3 – Itching. Not really much of a comparison, is it? That’s why, when it come to your kid’s long-term health, helmets trump head lice fears any day of the week. Sure, in terms of avoiding head lice, it’s best if everyone has their own, individual head-protection. But if your nine year old son is at a friend’s house and they’ve decided to take on Dead Man’s Cliff with a borrowed skateboard, you want to make sure he knows it’s better to borrow the helmet too – rather than avoid head protection because of lice fears. It gets a bit trickier when expensive protective head gear is shared constantly on a team, and passed among players during the same event/day/tournament. While the practice may not be optimal for lice avoidance, it’s definitely better than having someone forced to take what’s behind Door #1.
10) What’s the deal with movie seats and airline headrests? Once you’re aware of head lice transmission patterns and risks, you’ll probably start to wonder about those cushy movie theater seats. You know, the kind where hundreds of people lean their head back against them, over and over again all day. Can you get head lice from leaning your head back against them? The same question applies to airplane seats. Planes are emptied and refilled rapidly, with only cursory trash removal. Many airlines no longer use (or change!) those flimsy paper headrest covers – and who knows if those even “worked” in the first place? And, since most people can’t know they’ve got a case of head lice until 4-6 weeks after exposure, how would you know one of those seats is where you got it? Unfortunately, I don’t have a definitive answer for you there. What’s reassuring is that most clusters of head lice occur in the same predictable ways – among elementary to middle school kids and their siblings/family members. But if you’re worried, you can do like a nurse friend of mine does – carry a scarf to toss over the seat back, then shove it in a plastic bag afterward to launder and dry on high heat. Does that work? Reasonably, it could, but sorry, again, I don’t have a definitive answer for you there.
Bottom line: We humans are uniquely prone to infestations. Hey, it may be the real reason we’re, as a species, essentially hairless. Which leads me to wonder if the only difference between us and chimps, over time, is that we ARE hairless. After all, if you have to spend all day, every day, picking nits, it’s hard to find time to paint the Mona Lisa. When it comes to recognizing, treating, and containing the spread of lice, we’re all in this together. Be sure to email, tweet or share this information with others, including school officials. But if lice happens in your community, try to avoid the blame game. After all, anyone can have a lousy day.
What do you think? Is it possible to avoid head lice without making yourself crazy? Do you have any lice stories you’d be willing to own up to? Are we only an “advanced” species because we’re less lousy than our ape-relatives? Share in the comments section below. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
It was kind of amazing how little coverage the recent report on healthcare in our prison systems got. Heck, you may be thinking, I don’t think that’s amazing – why waste airtime on that topic – why should I fret and worry about the healthcare that prisoners get when my child is burning up with fever and coughing up a lung and I can’t even afford to take her to the ER?
It’s true, that in the universe of lack-of-healthcare, there are fewer groups who elicit less sympathy than felons. But here’s the deal – when you’re 21 years old, should you really be forced to lie locked in a cell, gasping for air until you die, purely because no one will give you your asthma inhaler?
That, my friends, is a recent, true scenario. Not something that happened long, long ago in a distant galaxy, far, far away. We’re talking right here – an event paid for by your tax dollars.
See, here’s my bias. Way back, when I was in fellowship training, I read most (if not all) of the medical charts that were part of the Pelican Bay lawsuit that put the California prison system into receivership because our prisons’ medical care was so medievally appalling. That fact that our modern prison cells are pristine white with electronic doors, and aren’t, instead, made of dripping black stonework – that doesn’t change the Dickens-era horrors that I read about. Back then, as part of the lawsuit, there was the story of another young man aged 21, in prison since he was 19. This young man’s medical experience was charted, point by point, in detail. He had a stable history of seizures, and before being incarcerated, was well controlled on non-addictive medication. But, just like our recent young man’s death from asthma, Tyler Henderson also couldn’t get even something as simple as his presecribed medicine. How’d that work out? He kept begging for help, locked in a cell, as he seized and seized and seized to death. He knew what was happening right up to the horrific end.
The prison medical chart accused him of “hoarding” his seizure pills because, since he was repeatedly denied access to his medication, he’d hide pills and try to space his doses apart, because he knew when he ran out completely he’d start seizing again. Sure, he was hoarding – at 21 years of age, he was desperately trying to just live a little bit longer.
Are these cases unusual? As the Southern California NPR reporter who covered this story states, “Between 2003-2004, one inmate a week died as a result of poor medical care in state prisons.” That’s on our dime.
Here’s my bias: if you’re being paid $49,000 each year for each prisoner – which is enough to raise two entire families of four above the poverty level (with thousands of dollars left over) – AND you’re being paid over ONE BILLION dollars a year more than when the original lawsuit was decided, purely to improve prison healthcare, then you damn well ought to be able to do something as simple as giving out prescribed pills on a regular basis. At least that. Right?
Um, apparently not. The recent report on prison healthcare shows that giving out medicines regularly, despite the glut of cash from you and me, is beyond what our bloated prison system can do. In fact, one of the specific groups who are unable to get their medicines regularly is (drum roll please) tuberculosis patients. There’s no better way to breed wildly resistant Tb than to have patients taking pills erratically. Just ask any Third World country.
Here’s the exact language of the report – “nearly all prisons were ineffective at ensuring that inmates receive their medications. Sixteen of the 17 institutions either failed to timely administer, provide or deliver medications or failed to document that they had done so. The 17 prisons’ average score of 58 percent in medication management was significantly below the minimum score for moderate adherence.”
“Numerous prisons were significantly noncompliant in the following medication management tasks: delivering sick call medications (new orders) to inmates; providing chronic care medications; providing medications to inmates within one day of arrival at the prison; delivering medications to inmates upon discharge from an outside hospital; and administering tuberculosis medications.”
So what does this have to do with you and me? Other than the looming issue of widespread pan-resistant tuberculosis being spread around the state, that is? See, the danger when it comes to prison healthcare, or to prisoners in general, is that we’re all so overwhelmed with badness in the news, and with struggling to just make ends meet, that we’re already tapped-out, sympathy-wise. For many of us, the gut response to this kind of news is that we kind of just wish it would all go away. Hey, we all know people in prison have done some bad things. Probably some skin-crawlingly bad things. But so often, with so many people incarcerated for not-so-horrible crimes, lock ‘em up and throw away the key is not just a revenge-response, it’s also a symbol of our collective, profound, compassion-exhaustion.
The fact is, however, that none of those people in prison will just go away. All those people who are so often addicted, brain-damaged, developmentally delayed, many with poor impulse control – we’ve got no plan for them, nowhere we expect them to be, no way for them to live. Even among the many staggering thousands upon thousands of Californians who are very functional and are in prison purely because of drug and non-violent offenses, prison still becomes (with a recidivism rate of 70%) a truly revolving door experience. Even if we want to think of prisoners as some type of “Other” category of person, all ex-prisoners are people who will end up in our homes, our healthcare systems, our neighborhoods, and, in many, if not most cases, lying on our sidewalks. They don’t just go away. They can’t.
When we decimate the lives, and health, of a significant group of ourselves, these same people do, inevitably, come back home to us. Even if, after years of prison, we’ve rendered them homeless, we are still the place to which they return. Poorly-treated tuberculosis won’t just go away either. It stays and breeds and simmers. And spreads. Kind of like rage. Or despair.
So what can any of us do? I personally believe it’s past time to ask ourselves whether a prison culture – particularly one which has been given, for many, many years, an essentially unlimited financial windfall with minimal accountability – can ever render basic, non-lethal healthcare. Keep in mind, if a government-funded clinic or hospital was unable to deliver doses of medication in a consistent, reasonable manner, their license would be yanked so fast, heads would spin so rapidly there’d be a state-wide epidemic of vertigo.
And don’t even start on the topic of psych medication dosing and diagnosis. Right now our prison system is the state’s largest provider of mental health care services – and funds are being tidal-waved into building more and more expanding prison-mental-health (is that an oxymoron?) facilities. This expansion is occurring even as line-item budgets are X-ing out those same services to the non-incarcerated general population. And the expansion is continuing to occur even as the track record of prison healthcare just gets more and more littered with bodies. Back in the 1960′s, when we closed our locked psych wards, did we really, as a society, deliberately choose to replace Nurse Ratchet with Guard Nick-with-a-nightstick?
CDRC website
Grand grand-breaking of the first of many new prison mental health facilities.
There is something deeply, deeply wrong with this picture. It’s time for someone to point out that, when it comes to healthcare, our Prison Emperor has no clothes.
One simple, important thing we can all do is spread the word. Talk about, email, share or tweet this topic. It’s time we all began discussing what we’re paying for, medically – behind locked cell doors.
What do you think? Should we just lock ‘em up and throw away the key? Or are you appalled – either because of the suffering, or the dollar amounts involved? Do you think a prison system can be reformed, healthcare-wise? Share in the comments section below. If you’d like to hear more details on this topic and some of the challenges of reporting on it, check out this BlogTalkRadio broadcast hosted by the USC/Annenberg’s Reporting On Health. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
Doc Gurley is going back to Haiti in October and this is your chance to go with her! If you are a medical or related professional who would love to spend a week in Haiti helping deliver medical aid and relief then get in touch with Dr Enoch Choi – enochchoi at gmail dot com – to volunteer. The trip is October 8th to 16th and is part of a well-run series of trips – by a group that has months of experience doing this at this point and great infrastructure in place to make it worthwhile.
If you want to know more check out the Enoch Choi Foundation visit the Facebook page – http://www.facebook.com/pages/Enoch-Choi-Foundation/417718500061?v=info
First, it was the opening of a Kroger in East Oakland. Now it’s the announcement that Tesco’s Fresh and Easy is heading to the Bayview. What exactly, you may be asking yourself, makes these stories major headline news?
And why is a doctor spending time writing about grocery stores too?
Turns out, as obesity rates soar to epidemic proportions, even among small children, researchers have been furiously busy trying to find out the factors behind the pandemic’s recent explosion. And, just as importantly as in clusters of other diseases, trying to find out why it is that you can even map the distribution of obesity between specific neighborhoods.
As you might imagine, poorer neighborhoods, regardless of race, do worse. Poverty, obesity, and type two diabetes are all closely correlated. Researchers were surprised, however, to find that they could also map, along the same lines, access to a decent grocery store. In other words, they found entire neighborhoods where it was virtually impossible to buy fresh fruits or vegetables. Much less buy them at an affordable price.
Sure, there were a gazillion-humongo-trillion (that’s an epidemiologic term) fast food outlets. No shortage of those. And there were even an eye-popping number (that’s an opthamologic term) of what’s often called “liquor stores,” or “package stores.” But a Safeway? Or an Albertson’s? No such thing – not within an hour or two (each way!) of transit time.
These areas have become known, in the public health literature, as “food deserts.” Kind of like being stranded in the Sahara, dying of thirst, but all there is to drink is trans fats. So how bad is it? This is how extreme it’s gotten – did you know there’s not a single chain grocery store in the entire city of Detroit?
And researchers have found that the problem’s not just lack of retail access. Even when larger stores (with better prices and more selection) exist, the quality of the produce, compared to more affluent areas, often, well, sucks. The only things green are the cheeses and breads. The heads of iceberg look like squishy softballs – the rotted outer leaves may have been cut off so many times, all that’s left is a flabby anemic core.
And the prices for this type of lame quality, are often higher. Kind of like paraphrasing that Woody Allen joke – the food was terrible, but at least it was expensive.
And at the one-on-every-corner package store, a half-gallon of soda may cost 99 cents, and a gallon of expired milk will cost 4-5 times that price, with not a fruit or veg to be seen anywhere, except for that geriatric orange and bruised-to-the-point-of-coagulation apple. And the poor choices may not all be grocer’s fault. The equipment and inspection requirements for fresh produce and meat can be prohibitively high for a closet-sized shop. On the other hand, stocking that furry orange, and those Salmonella-tainted eggs may be enough to qualify a corner store to accept food stamps – while a farmer’s market vendor is not allowed to accept them, because of a lack of required food elements that are necessary to qualify as a vendor.
Regional variations in food access have become a big topic in public health, on both a micro and macro level. On a personal note, I know for a fact that my life literally changed when a Trader’s Joe’s opened up a few blocks from my house. We eat better, and cheaper. We just bought a box of a dozen peaches for $4.99. Still not cheap if you’re trying to spend only $30 a week on groceries, but these are the kind of peaches that bring back a flood of memories from growing up in farmland in Georgia, the kind of perfect, blemish-free peach where the sticky juice dribbles down your chin as you bite it and you learn to eat them with a paper towel in your other hand, or hanging over a sink. In the next town over, however, which is not nearly as affluent, their Trader Joe’s often has browner, more shriveled produce. And not nearly as many organic options to choose from – despite being the exact same chain, and both stores within five miles of each other.
The opening of Kroger’s in East Oakland is the first major chain store there in 20 years. The move by Tesco’s to open new outlets in American may mean more access to eating WELL for more people. Grocery stores, and equitable access to healthy food, as our obesity epidemic rages out of control, have become major news indeed.
What do you think? Is obesity an environmentally-induced disorder, caused by retail markets? Do YOU live in a food desert? How long does it take you to get access to decent food? And how does that impact your food choices? Share in the comments section below. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is also a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
Another in a sobering series of food-borne outbreaks is recognized. This time, Typhoid Mamey was identified as the cause of smoothie (and milkshake) induced episodes of life-threatening typhoid fever here in California, as well as in Nevada.
Why the big alert, if only a few cases have been identified? First, typhoid is a serious infection. Five of the seven cases required hospitalization. Second, the cases that have been identified are not likely to be the only ones out there. Finally, it pays to be informed – you may need to be the one to connect the dots and make your own diagnosis because your average overworked and underpaid primary care provider might not even have “typhoid” on the radar when you, or a loved one, show up feeling really sick, sometimes as long as seven weeks AFTER being exposed.
So what is Mamey? And what the heck does the Victorian-sounding typhoid look like when it strikes? Here’s a checklist for you to store in your own personal diagnostic databank. Be sure to spread the word, so we can all, together, try to stop Typhoid Mamey in her tracks.
1) Mamey is a fruit pulp that is added as a thickener. As the AP reports: “The CDC said five of the victims drank milkshakes or smoothies made with frozen mamey (ma-MAY’) fruit pulp. Four of them used pulp sold by Goya Foods Inc. of Secaucus, N.J.
Mamey is a sweet, reddish tropical fruit grown mainly in Central and South America. It is also known as zapote or sapote. It is peeled and mashed to make pulp, the CDC said.
The company has recalled packages of the pulp, sold in mostly western states. A sample from one package found in Las Vegas tested positive for the bacteria that causes typhoid, the Food and Drug Administration reported Wednesday.” There is now a recall on this product. Be sure to check your shelves at home and discard any that you find. This is the second time mamey has been identified as a cause of a domestic typhoid outbreak, so maybe it’s time to thing about thickening smoothie’s with another ingredient – perhaps psyllium, instead?
2) Typhoid is a disease caused by the Salmonella germ. Many people have heard of Salmonella as a cause of diarrhea. But typhoid is a different type of Salmonella germ. Instead of causing primarily diarrhea, this one causes primarily a fever – hence the name, typhoid fever. In fact, the most distinctive sign of the infection is a sustained, high fever – as high as 103-104 degrees. Not everyone, however, has a typical course. And, even for people who DO have a typical, sustained fever, the fever can, after several days, go away on its own, but then return later (and stay for days again). As the usually understated CDC’s website succinctly puts it, “typhoid fever’s danger doesn’t end when symptoms disappear.” It can become a cyclical fever. And, the person suffering from the infection can become a chronic carrier too – even without symptoms.
3) Important reminders. A person with typhoid can develop a rash – flat, rose colored, speckled blotches on the skin. It’s one of the reasons doctors get more agitated by fever plus rash (as opposed to only fever, or only rash) – the rash can mean an unusual or serious infection (like typhoid). Also, keep in mind that typhoid is pretty common outside the industrial world, all because of poor sewage (and probably poor handwashing too). That’s where Typhoid Mary’s story comes in. Check it out for some interesting insights into how typhoid and its history are still pertinent today. If you ingest an infected milkshake or smoothie, handwashing won’t protect you – but handwashing is still crucial in preventing the spread from and infected person to their family, kids, roommates and (especially if you’re a cook or food-handler) many, many other people. When it comes to typhoid, consistently good handwashing is important for us all since the onset of symptoms can be as late as seven weeks after exposure, and a person can have absolutely zero symptoms and still be shedding the bacteria. Typhoid Mary is just another reminder, as we head into school and flu season, of how very important handwashing is for all of us!
4) Bottom line (so to speak): Clean out your cupboards, be aware of symptoms, spread the word, and get your handwashing groove on.
What do you think? Is the legend of Typhoid Mary still pertinent today? Or is the whole recall a tempest in a smoothie blender? Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
The last two days’ news have made it feel like cocaine week: President Obama finally signed a long-overdue law equalizing mandatory sentencing between powder cocaine and crack cocaine users. On a truly tragic note, a 21 year old UC student is reported to be brain damaged and living on life support after lying for three hours unresponsive in a UC Berkeley cooperative house, after suffering an irreversible heart attack, with cocaine and marijuana in his blood. Cocaine is a well-documented cause of heart attacks, even in the very young and healthy. And Lady Gaga apparently told Vanity Fair that she still uses cocaine “occasionally,” adding that she really doesn’t want her fans to follow her example. She also told Rolling Stone about struggling with a drug habit in her past, including a time when she bottomed out in New York “laying in my apartment with bug bites from bedbugs and roaches on the floor and mirrors with cocaine everywhere and no will or interest in doing anything but making music and getting high.”
With cocaine so much in the news, is Lady Gaga right? Can a person – or most people – use cocaine “once or twice a year”? And be fine?
Cocaine
That, my friends, is the 20-kilo question. Before we go into the scientific frenzy behind this issue, we must take a moment for a word from our ethics sponsor: I am obligated by numerous oaths, karmic clauses, legal hand-wringers, and crushing waves of my own personal angst to remind each and every one of you that, yes, you can die from using cocaine. Even once. Just once. When you “try” cocaine, what you’re doing is actually beginning to “use” cocaine – which can also destroy your life in oh so many other longer-suffering, tortured-beyond-human-endurance, eighth circle of humanity-stripping-hell-ish ways. As we see so tragically in the news, it happens.
But someone will probably tell you (most likely the person handing you the mirror and a line) that cocaine-related death (or rapid, malignant addiction) is rare. I’m here to say that it’s not that rare – numerous case studies are reported. In fact, it’s so common that most doctors wouldn’t think it merited a new report. More importantly, my experience has been that telling a grieving family that death was statistically unlikely is not actually that reassuring. To anyone. Or, if you’re still pondering the absolute risks, you could think of the issue this way – when something rare happens to you, it happens to you 100%. In fact, as you’re suffering untold torment, it doesn’t feel rare AT ALL.
The specter of death haunts any discussion of cocaine use. For the young, that specter may seem vague and distant. But there’s a certain comfort in reaching an age, or a level of self-awareness, where you’re able to frankly ask yourself – really, what am I willing to die for? In fact, when it comes to addictive substances, a “yes” answer (“yes, I’m willing to risk dying for that”), could be a sign that you have a problem.
If that thought occurred to you – congratulations! Now you’re thinking like an addiction-medicine-specialist. One of the most studied, and reliable ways to define addiction (whether you’re talking about cocaine, or exercise, or porn, or any other human endeavor) is by its impact on the rest of one’s life. Are you aware that you’re risking a lot by doing something – but you’re still unable to stop yourself? Is your habit interfering with your family, your friends, your health, and your job? Are you able to walk away and stay away?
By these criteria, most people – even the purists – would probably say that Lady Gaga has a problem, no matter how “occasionally” she’s using cocaine. You could make an excellent argument that her cocaine use already is threatening her livelihood (just by announcing it), and that she’s been unable to stop completely, even after her own bottoming out experience – one that ripped her family apart.
Or, if you’re just looking for cocaine use’s possible impact on her health, check out the difference in her body between her first popular video (Just Dance) and her more recent ones (Bad Romance, Telephone). She’s become, in a very short time, more and more appallingly skeletal (even by Hollywood’s warped standards). Given the pressures of her Fame Monster life, her past history of drug use, and the visual evidence of her physical changes, many of us weren’t surprised by her cocaine-use admission. But a little of your heart breaks when you hear her – not just by the fact that she’s using again when she knows she has a problem, but also because she’s trying to justify and exonerate her use (“only once or twice a year” – as though that’s somehow within the range of “normal”).
Anecdotally, those of us who work in this field hear this kind of talk every day – “how much do you use?” Answer: “not much.” “Well, sure, but how much is that to you?” Real answers: “Only on weekends.” Or “only at night.” Or “only when my check comes in the mail.”
The definition of “normal” gets re-set and re-set over and over to accommodate the user’s shame and need.
But what about our original question – can someone just use every now and then? What if you’re not talking about someone who had a serious problem before, and is risking a lot, and says she understood how horrible it was, but is still using and showing the effects of using? Say you’re not at all like that person. CAN you (or me, or your cousin Kevin) use cocaine “occasionally”?
You may be surprised to know that’s a question, after almost half a century of illicit drug culture, that scientists have yet to answer. What is known is surprising to a lot of lay people, but not that shocking to people who’ve been exposed to drug culture – either professionally (in many capacities) or personally. Let’s start with what kind of drug are we talking about. Most people who use a drug frequently tend to use a “class” of drugs – you’re either a stimulant user (cocaine/meth), or a narcotics-type user (heroin, prescription drugs like OxyContin). Alcohol, as another category, can be the exclusive drug-of-choice for many people, regardless of relatively easy access to other types of street drugs. In fact, statistically, the people who use anything and everything – willy-nilly – are actually not as common as users who stick to one class of drugs. Lady Gaga fits this profile, saying she “mostly” uses cocaine and is “terrified” of heroin. So is there something in the brain driving the desire for one type of addiction? After all, if you have an “addictive personality,” and money is no object, shouldn’t you be addicted to anything and everything? Why abstain from anything, ever? Again, the answer’s not altogether there, but it is very well known that long-term exposure does change the morphology (or cellular shape) and firing of the brain – and many scientists are saying it may change the brain forever, even if you quit and never touch the stuff again.
And, each substance probably has it’s own addiction pattern. What does that mean? Well, the speed of developing an addiction is both substance and age-of-the-growing-brain dependent. For example, it’s clear that most people become addicted to cigarettes in a fairly predictable way – first, through relatively rare, group-social use, than to more regular, but not daily, social use (every weekend, for example), then on to daily use and then to unable-to-go-a-day-without-smoking multiple times use. The younger you are, the more rapidly (or inevitably) you march through these steps. For some drugs (anecdotally, heroin and cocaine) it only takes a few exposures to accelerate your way through all the steps. It’s not quite the One Hit And You’re Hooked legend, but very close to it for many people. And, if you’ve had a problem before with many, if not most types of addiction (cigarettes, alcohol, illegal substances), you’re likely to jump to using constantly without any stages in-between. It’s like you’ve become hard-wired to use. Which science is showing, more and more, your brain probably is, at least after a certain point.
And it’s clear that identifiable risks for addiction exist, even before a person has been exposed. These risk factors are remarkably consistent – almost regardless of the substance, even though some substances are WAY more addictive to a population of people than others. If you have a family history of addiction, if you have a past history of trauma (emotional and/or sexual/physical), if you have a tendency to become obsessively out-of-control with rewarding behavior (whether it’s the Internet, or exercise, or texting) to the point where it is affecting your relationships and work – then you, my friend, are at high risk, with even minimal exposure, to potential addictions.
But also surprisingly, studies (historical, natural history, and animal) show that most people who quit highly addictive drugs do so on their own. Usually over time. Without any formal substance abuse treatment. Here’s a study looking at the natural history of cocaine and meth use in rural communities. And many people may not know that most soldiers who used heroin in the Vietnam War quit on their own – although we see every day, often on the streets, the Vietnam vets who weren’t able to self-recover. What role environment, trauma, family and/or brain/genetics played in long-term outcomes to heroin exposure/addiction, no one (yet) knows. No one even knows if, among a population of drug users, the observed gradual (or cold-turkey) reduction in use over time is based on bad drug experiences, increased awareness of negative effects of a habit, or even just a change in social dynamics.
So is Lady Gaga working her way out of her addiction? Or hopelessly trying to hide a rapid slide back into one? Since judgment is, by definition, destroyed by addiction, and secrecy is the norm, probably no one could say for sure – perhaps not even her. But it’s one or the other – because a stable-erratic drug habit is very very rare. In other words, people often will be using at a high-intensity stable (addicted) rate (half pack a day of cigs, cocaine three times a week, etc. – usually limited by finances). Or they may use sporadically and then quit. But it is extremely rare for a person to NOT, over time, experience a creeping increase in their drug use. They may claim otherwise, and be, intentionally or unintentionally, oblivious about the change over time. But the old saying holds true – the more you use, the more you use. That is, by definition, the nature of an addictive substance. The act of using changes your brain over time, in its most basic structure and signals.
Keep in mind that science shows that our brains are capable of changing like this, throughout our lifetime, for any repetitive task, including driving a taxi. The difference between an addictive substance and any other re-enforcing task is basically, in its simplest terms, two things. First, how much more rapidly and responsively the brain change occurs. And second, whether or not, over shockingly rapid, or relatively long, slow periods of time, a repetitive act causes brain changes that are ultimately destructive, or are, instead, ultimately rewarding for our lives, relationships and health. It’s the difference between lying in bedbug-riddled twitching stupor, versus the longer, slower burn of exercise endorphins, altruism or stand-up comedy. In the end, neuron-wise, we all, literally, become what we do.
And clearly, the easiest way to recover from a destructive addiction is…to never start. So if the siren song of “occasional” cocaine use sounds alluring to you, thumping its way into your thoughts like a Bad Romance earworm, here’s refrain you may want to chant to yourself. It’s the brainstem bottom line: choose your addictions wisely.
And pass along the info! An informed choice is a better choice.
What do you think? Is the legend of the “occasional” cocaine user a myth? Or reality? Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
Has the recent six-month post-earthquake Haiti coverage got you wondering what’s really up – and if things are slowly getting better or not? We all know Haiti is a complex, evolving situation. The mega-earthquake, a once-in-a-250-year-occurrence, was one of the world’s largest urban implosions, in an area already chronically deprived – but located only a large-rowboat’s-ride from Florida. What should be done? What IS being done?
Do you want a birds’-eye view into the relief work that people are still doing on the ground there – the challenges and rewards and struggles?
Are you wishing, just once, that you could ask people working in Haiti a question yourself?
Now’s your chance! Friday, July 23rd, at noon (lunch anyone?), I’ll be interviewing LIVE, by phone, people who are working in Haiti right now. Join us for this unique Webinar and you can listen to the discussion and even ask a question of your own.
How do you join us? Here are the steps, below. Spread the word! Get your family and friends signed up. Attendance is limited to the first 100 people. But if you don’t, or can’t make it Friday – don’t worry. The event will be recorded for viewing later, at your leisure.
Haiti Webinar
Join us for a live interview with two people who’ve been consistently involved in Haiti (and one who’s actually there now) to find out what’s actually happening on the ground.
Register for a session now by clicking a date below:
Fri, Jul 23, 2010 12:00 PM – 1:00 PM PDT https://www1.gotomeeting.com/register/765871857
Once registered you will receive an email confirming your registration
with information you need to join the Webinar.
System Requirements
PC-based attendees
Required: Windows® 7, Vista, XP, 2003 Server or 2000
Macintosh®-based attendees
Required: Mac OS® X 10.4.11 (Tiger®) or newer
What do you think? Should it matter that Haiti is so close to Florida? Do you wonder what happened to your donation? Do you want to send Doc Gurley back to Haiti? Join us with your burning questions. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
As the six-month mark has arrived, there’s suddenly been more about Haiti in the news, tales of paralysis and corruption and despair. But almost all of these reports are from people who’ve flown in for a quick visit – one Esquire reporter even starts his story describing how he didn’t step outside his hotel during his one-week visit, and only went on drives with his “facilitator.” So what IS actually happening? To find out, I went to people who’ve been consistently involved with Haiti since the earthquake. So who are these people?
Enoch Choi is an amazing individual – a Palo Alto Medical Foundation physician who has, in his free time, organized teams of healthcare providers to go each month to Haiti. Enoch’s approach is different from the usual large relief or non-profit organization – his groups are lean, mean, guerrilla teams with healthcare providers who each pay his/her own way and take a 7-10 days of vacation time to work like dogs. There’s low/no overhead, and these teams can move in and out of areas of greatest need with their own supplies. More importantly, Enoch’s groups are still going to Haiti, long after most agencies and volunteers have pulled out. One team is heading to Haiti now, with more teams scheduled for August and October. By September, over 100 healthcare providers (doctors, nurses, therapists and pharmacists) will have gone to donate a chunk of their own time to those still struggling to survive, and suffering from, the aftermath of the earthquake.
The backbone of this incredible, sustained effort is Jesse Mendoza, the on-the-ground organizer for these teams. Jesse is the point man for security, provisions, lodging, and facilitating where the team should see patients each day. Just imagine trying to do his job – catapulting yourself, without a speck of knowledge, into the worst disaster situation known, and then getting to know everyone and making the impossible happen. Since the earthquake, Jesse’s spent way more of his life in Haiti than he has been home in Gilroy with his lovely wife and toddlers. Jesse is affiliated with Jordan Aid International, a non-profit that stepped up to partner with Enoch (who is now on their board) to be a fiscal agent, to make it possible for people to make a charitable donation, and to help make this important work happen.
I interviewed these two people, who have lived and breathed Haiti for the last six months, and whose own personal lives have been devoted to this effort. These two are not celebrities who have swooped in from time to time and blown out again. These are people who have traveled the worst parts of the city, serving the suffering and talking to individual Haitian. They have stayed with it long after the cameras have left. I asked them what they thought about the situation in Haiti and where things stood six months after The Day The Earth Trembled.
1) How Haiti has changed, or how has the approach you/your teams use has changed? [Enoch] Back in February, the camps were a month old and fluid, with areas set up nightly as shelter, in a way tolerated by government and owners. But now, I hear that as those locations have become unliveable, or have tried to get back to their initial intended purpose (e.g the pool hall), the evacuees are sent to desert-like locations in the boondocks, like Camp Corail, where there is no way for anyone to earn a living. For some of the camps who are less well-supported, people have to resort to stealing from other camps for sustenance. It sickens me to hear that these folks are tempted to move from Port-Au-Prince with the hopes of “owning” their tents in these arid wastelands, in an unsustainable location. In February, I took hope in the UN convoy that we tried to sneak into to get through the border at night, because it was a visual symbol that aid was getting through. Now, I’m so upset to see news reports of a pileup of heavy equipment and supplies stuck in Dominican Republic at the border, unable to be imported due to Haiti’s government-blockade.
[Jesse] I would have to say what has made the most impression on me over this time is the thought that these people have lost and suffered so much and are still standing holding on to HOPE. I have seen so much of what the earthquake’s aftermath caused – in terms of debris, the dead and the injured, an entire city literally collapsed and was left in ruins, yet the Haitian people have not allowed all of that to stop them from living and pursuing their hopes and dreams. Having traveled there 5 days after the earthquake I witnessed a city that was literally paralyzed. Everything was just so recent, people walked the streets with a look on their face of disbelief at what had just happened, without direction as to where to go or what to do. I recall seeing people carrying their loved one’s found body parts in bags, and others just sitting on the sidewalk with their frail frowning faces of sadness. It was a hopeless scene over all. Every month thereafter, the Haitian people have encouraged me to know that you can have hope in the midst of misery. I was uplifted to see on my ongoing trips that the people just started to get back to what they knew to do. To live. They started to sell things on the side of the roads, cooking and opening their shops and marketplaces. It’s a small thing, but I was also moved one day when I saw a group of young men playing basketball.
 2) You have stayed with Haiti over the long haul. How are people trying to survive and adapt during these months? It seems that there is still so much need and the change of weather is now complicating the relief efforts. We have had to change our approach in many aspects because the Haitian Government is now placing lots of restrictions on how and what you can do. For example, in May we heard of a tent city just outside of Port au Prince where there are currently over 5 thousand people without any running water, food or resources. These are folks that have moved to higher ground near a UN camp called Corail. We were specifically told that we could not go and help these people medically without Government authorization. I’m sorry but I had to make the call of going with or without authorization. These people are in so much need and need help urgently! Our team treated over 2 hundred people that day. And it’s not just people in tent cities. There is a young policeman whom we hire continually for our security. I didn’t realize until May that he literally lost all he had. His home, his wife and his only daughter. He has survived only by the work that we give him while we’re there. He is a very responsible young man, always there and always on time.
3) What can you tell us about the children – about the present or future of Haiti? [Enoch] The children who touched me the most were a young girl and her younger brother, who were my own children’s chronological age but appeared 1-2 years younger due to malnutrition. When I asked them who was taking care of them, they said “aunties” but when I asked who they were so I could explain to them how to administer their medicine, none were to be found. Apparently, their parents were in Jimani trying to buy items to sell in Haiti. Even these middle class children were at risk, with parents who were affluent enough to be in business but with no one to carefully watch their kids as they tried to recover. I wondered where the grandparents or other relatives were, and I realized they were likely dead. It was heartbreaking to have these children come and cling to my arms as we packed up at the pool hall, with me not knowing when their parents would return, and how these precious children would be provided for, as they asked me for food and water. I worried that if these children of some means were at risk, how could orphaned children and more neglected children have hope for their future?
[Jesse]I would add, though, that in spite of all that’s happened, the children of Haiti are playful and still have a smile when they see you. I was impacted back in April when our team delivered 4-5 babies on that trip. One night I was in the JPHRO make-shift field hospital and saw a woman who delivered her baby at about 8pm and then left the hospital that night with her newborn baby in the rain. She lived just down the hill in the Petionville Club refugee camp. I was haunted by the thought that the home in which this baby was to live is made of plastic tarp walls and plastic sheet-roof over mud floors. My eyes get teary every time I think about this. But this is the reality of the homeless people of Haiti.
4) The massive piles of rubble have become a visual image of Haiti’s destruction and paralysis. Is the rubble as big a barrier to progress as it seems to be? [Jesse] This has been one of the biggest things that has impressed me. I saw firsthand the initial aftermath, debris everywhere. I remember seeing large amounts of debris on the streets, so much that you would have to find alternate routes to get anywhere. For the most part there hasn’t been much large machinery moving the collapsed buildings. Rather, it has been lots of manual labor. To this day it’s not uncommon to see large groups of men and youth clearing up debris with picks and shovels. Groups of youth can be seen sweeping the streets and keeping Port au Prince clean as much as they can. Much of what I initially saw has been cleared up to this point. But there are still large buildings left in ruins to this day. If they were to continue to clear up by hand as they have I estimate that it would take them several years to achieve clearing it all up. I have to say though – the Haitian people [emphasis is Jesse's] are hard working people.
[Enoch] JPHRO started moving rubble 2 days ago, but are one of very few organizations doing so. It is a huge barrier. The government is blocking progress. Much more could be done if they allowed the heavy machinery in to work.
5) Finally, is there something about Haiti, or Haitians, that you think people are not hearing in all the gloomy coverage about how things have not really changed? [Jesse] I see that the media is no longer covering what is still happening, or the effects that the rains are having on the 1.5 million people who still find themselves homeless. Not to mention the sicknesses and diseases that are being seen as a result of a broken infrastructure.
[Enoch] It surprised me to hear from KQED’s 6 month anniversary broadcast that a journalist who’d been there before and after the quake said that many of those in tent cities were better off than before. I found that comment insensitive to the suffering, both physical from injuries, and emotional from losing loved ones – but it surprised me and made me think. I realized that for some of the survivors, having regular food and water, as well as free medical care, that this was an improvement, since most went without medical care since they couldn’t afford the fee-for-service system. It makes me glad to think there’s some improvement, but I wonder for how long, as volunteers leave Haiti and are unwilling to continue caring for survivors.
Reading about Haiti from this country, it’s easy to get overwhelmed and cynical about how to help. If people like what you’re doing and want to contribute, how can they? [obligatory conflict-of-interest notice - Although she went to Haiti as a member of Enoch's February team, Doc Gurley is not paid, is not affiliated, and does not receive any gifts/support, nor funds of any kind, from JAI or Enoch Choi]. [Jesse] Please help us in our efforts to continue to help the people of Haiti. They need you! You can read more about what we’re doing and give toward our efforts by going to our website: www.jordaninternationalaid.org There is a PayPal link, and if you specifically want to sponsor or offset the cost of sending a healthcare provider to Haiti, you can write their name on your donation.
What do you think? Is there hope for Haiti? Should we be enabling their government? What happened to your donation? Do you want to send Doc Gurley back? Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist.
You may be wondering why Stanford Medical School’s new genetic interpretation class – the one that offers medical students the opportunity to study their own genes – has made the news here. After all, what better genes are there to study than your own? And if you were a medical student, wouldn’t you want to have your medical school subsidize 80% of an $800 test as part of your curriculum – isn’t that kind of like a “free” healthcare kickback?
But people whose work includes genetic counseling, or people who themselves have undergone genetic testing for a serious disorder, will likely beg to differ. And usually in very strong terms. The fact is, looking at your own genes is not at all like that Bio 101 lab we all remember where we got to look at our own cellular spit under a microscope. Do-it-yourself genetic analysis – especially the kind that methodically sifts through the dusty archeology of all known hideous human disorders – is a whole world of hurt, just waiting to happen.
Genes have become our modern day molecular gods and goddesses. Uncoil the wrong one of these tiny strands of nucleosides and you can inadvertently unleash enough tragedy and omnipotence to be worthy of a Greek myth.
A lot of genetic-counseling experts will tell you that sure, it can be done safely. But only with the proper understanding and respect for what you may awaken. And you have to keep in mind that it’s vitally important to have the tools to deal with the fallout when the unexpected is unleashed. Especially if what you find is a nasty gene, slumbering amid all the mummified others in your airless chromosomal Pantheon.
Here’s one example of the kind of fallout I’m talking about. Say a member of a family needs a transplant. Maybe it’s a close-knit family with kids in their twenties and parents who’ve stuck by each other as lives have changed and careers have risen and fallen and now, when life should be a source of teasing and holidays in crowded kitchens snorted laughs in response to old jokes. But, instead, tragedy has struck and life has become one endless series of hospital rooms and misery and wasting. Everyone wants to help, to be a donor. Siblings, parents, even cousins, aunts and uncles will all show up to get tested for a genetic match. It is not that uncommon for the testing to reveal that one of the men who volunteers as a potential donor is not, after all, the biologic father of one of his (often adult) children. But that’s not what was asked, and instead of delving into what is called “ancillary” findings, the family is only told there “isn’t a match.”
Now, since the Stanford Medical School class isn’t looking at family-member gene comparisons (yet), no one is likely to step on that particular landmine. But minefields await, some of them even more self-destructive. Because here’s the sneaky thing about genes: Even if you know, intellectually, that genes don’t determine everything, there’s still some part of your brain that does believe that they do decide everything. Filtering flawed information through the bias of self-interest has always been know to be bad medicine (“the doctor who doctors himself has a fool for a physician”). Much of the predictive value of genetic testing still falls into the category of (at best) bad science, or (at worst) profiteering snake oil.
But what makes the situation even worse is the fact that hidden within this murky labyrinth of cracked pots are some omnipotent nasties you wouldn’t ever want to unleash on the unsuspecting. Some genes are, clinically, as all-powerful as our subconscious fears.
At least one of the genes for early dementia, for example, is “dominant with 100% penetrance.” That’s dry medico-jargon for the fact that if you have this gene, you will indeed be stricken with severe dementia – usually in your forties. It remains a disease for which there is no treatment. As scientists dryly report “such knowledge has been reported by patients to significantly alter life decisions and relationships.” Reasonable people might argue that knowing such a fate in advance could be worse than living the experience later.
The number of genetic diseases that manage to hit the sweet spot of being altogether a) reliably detectable, plus b) reliably predictive of disease, and c) very treatable, are almost non-existent in the adult clinical world. The story is different for children, where the classic example of effective genetic testing is that of newborn-testing for phenylketonuria (PKU) – a disease whose potentially tragic outcome can be completely avoided by knowing you have the gene and changing your diet. But in adult medicine, genome mapping has unearthed, as of yet, almost no PKU treasures.
Yet.
With few exceptions, we are still, for the most part, a wonderfully messy combination of what we are born with, and what we make of it. And, for almost all medical conditions, how good our care is.
For years I resisted getting genetic testing for breast cancer – my primary fear being that I would become a healthcare pariah. If a positive test was in my record, I’d be one of those people whose lives and careers are determined by the coverage they can get (or keep). As a doctor, I knew that a decent physician would know my risks purely by taking a good history – and that the test itself shouldn’t change things that much. I chose to get the genetic tests when I had a biopsy done, reasoning that the biopsy alone raised so many red flags that the difference in getting tested would be relatively trivial. The fact was, I realized I wanted to know for my daughters – that I didn’t want to have genetic testing on their medical records if it could now be on mine. And, frankly, if my test showed that I was positive for one of the more nasty genes, I’d be at peace with making evidence-based decisions about all the risk-reducing options, including the more drastic surgical ones. I had one priority – I wanted to survive for my kids.
It all seemed so clinically logical. So financially prudent. So cleanly prioritized.
So I was woefully unprepared for the emotions that testing churned up. I went through the counseling, mentally ticking through the checklist of data to see if my counselor covered it all (she did), while my emotions veered and scrambled and careened. I sleep badly and called my mother to ask who died of what (“hard to say, ‘female troubles,’ that’s all we were told”). I put my family into boxes and X-d out the dead. I’d thought we were healthy, farm-folk who were tough and persevered. Apparently we died like flies. I balked at asking for my family’s medical records, merely shaking my head at my counselor’s lack of understanding about the South, and the natural modesty and privacy of people. Besides, I knew the request, veiled as a normal part of the process, was purely for research purposes and would not benefit my personal medical care at all – not unless we, as a family, wanted to become the subject of someone’s doctoral project.
I didn’t sleep the night before my appointment time. I tossed and turned and had fevered discussions with my long-ago passed away, wasted-of-pancreatic-cancer grandmother as she suffered and moaned despite getting enough morphine to kill a horse.
I arrived early at UCSF, and, being a medical insider, I knew when my counselor called my cell to tell me she was running late for our appointment, what my result test would be. No one runs late to give bad news.
So I had a negative test result, but I was told, earnestly, that I mustn’t let my guard down – that I’m now labeled as being part of a “cancer cluster.”
Probably they just don’t have a genetic test yet for what my family has.
Genetic testing stirs up all the silt in your life, even when the result is good, even when there’s something you can do about the result. A wry, insightful physician-colleague of mine (another internist), after extensive heart problems, got genetic testing done and found that he had the kind of gene that can make people drop dead. From his Castro home, he felt compelled to pack his bags and head to Memphis, driving down two-lane roads to find far-flung family that he hadn’t spoken to in decades, and had sometimes only heard out in that way we Southerners drape our family trees to orient a conversation (“you remember Ethyl’s kid – the one with the limp? – his youngest, the one that married Myrtie’s second littlest after they met at the Revival? – well, his third cousin, Rayford’s buddy, got a job down at the plant…”).
He told me about his days of standing in blistering Tennessee heat as he explained to virtual strangers genetic details about the very fabric of their cells, and how they should be tested, and that if they had the gene a resuscitation box could be stuck under the skin of their chest – here, like this, see, it’s only as big as a pack of cigarettes – and that this box could shock a heart back to life if a person tried to suddenly die (“swoon, you mean? My great aunt did that all the time, and we don’t have health insurance…and besides, how is it I’m supposed to explain this to a doc?”).
To me, the frustrations, and explosive emotions, and changing life-paths all provoked by this one genetic test represent what many would call, ironically, a best-case scenario outcome. After all, testing for a sudden death gene is not exactly like testing for aggressive, early dementia – having a defibrillator implanted, while not at all trivial, is a one-off treatment option.
And if the task is to filter through your body’s entire genome, surprising discoveries can happen to anyone. People whose family histories do not seem full of health problems can find unexpected genetic results – after all, recent studies reveal that we’re all, basically, mutants. So how is a relatively young, inexperienced, probably ill-informed and un-counseled medical student going to deal with an explosive genetic result? Stanford has taken steps, but is it enough? Even for my experienced, well-informed physician colleague, who thoughtfully requested his own specific testing, the experience was intense.
One day during his trip to Tennessee, feeling demoralized, overwhelmed, his life derailed completely, he found himself stuck on a two-lane road in his rental car, traffic rapidly backing up behind him. The way forward was blocked by a mutt, an unwashed ribs-showing dog that had suddenly wandered onto the center line. The dog was two-headed – literally. My physician friend said it was the kind of thing you only seem to see on very rural roads. There the two-headed dog stood, swaying, and the poor thing appeared stuck, unable to decide, it seemed, which way to go next.
It was, he said, symbolic of the whole experience.
What’s your experience? Do you have a genetic testing story you’d be willing to share? Do you think genetic testing ought to be a mail-order or do-it-yourself test? Remember – general medical information is NOT a replacement for medical care – if you have questions, concern or confusion about diet or exercise, see your doctor.
Are you tired of discovering that your McNuggets and Silly Putty have more in common than just garish packaging? Are you starting to wonder about how you’ll ever get that jiggly pad of lamprey-fat to detach itself from your formerly shark-sleek sides? Or maybe you’re feeling Lombard-Street short-of-breath…when you stroll along the Marina.
 Fireworks! So how can you use the sun-soaked energy boost of summer to kick start some healthier habits? Here is a July 4th checklist of simple, easy steps you can take – steps that studies have shown will have a BIG positive impact on your health. Pin this list on your frig. Share it with friends, family and co-workers to create a healthier territory for you to live (hey – maybe it will become a permanent State!). Make these tasks part of your daily to-dos on Tada. Write them on your heart (FOR your heart) as your personal Constitution to improve your daily constitutional. Hey, a three-month commitment is all you need to make – a shorter goal is easier to keep, and, besides, when fall rolls around you can decide if you want to convene again to assess your state of health. Maybe by that time you’ll be feeling nationalistically proud of your united front to achieve a more perfect union of behaviors. You might ratify a few into personal laws.
#1) Declare your soda independence: The data are clear – the tyranny of sugary drinks is taking a tremendous toll on all of us. Have you committed to a soda-free summer yet? Local departments of public health are gathering the troops, ready to march in the streets to let you know that it’s time to throw off the yoke of calories-that-don’t-slake your hunger (or thirst). Sweet drinks, whether they’re sweetened with sugar substitutes, or fructose, or cane sugar, or are just plain old juice, have been shown in numerous studies to be associated with a large increase in excess calories, an increased risk of diabetes (even for people with the same weight/BMI, and EVEN when you drink sugar substitutes). Excess sugar in your diet has also been shown to increase your risk of heart disease. The sugar you drink can be one simple thing to eliminate for you and your family that will have a huge impact on your health. If you declare your allegiance to a soda-free summer, check out the websites for some great recipes for thirst-quenchers (pitcher of ice-cold water with floating slices of tangerine, anyone?), and for motivational boosts to keep going soda-free all summer long.
#2) Declare your support for the little guy: Tired of the queasy-making images and descriptions from the factory-farm front? Are you frustrated and grossed-out, but wondering how to make your food more nurturing while still having it be FAST? One simple and fun step is to commit to a Farmer’s market summer. The Bay Area is rich in agri-resources. Check out these great listings of farmer’s markets in your area. Make a weekly visit to a farmer’s market your summer-long commitment. Try to arrange your schedule so that you go to the chain or bodega grocery stores to shop only AFTER you’re hit the farmer’s market. That step alone will shift your eating habits into less-Silly-Putty ingredients territory. And hey, knowing you’re taking a step to do something about the factory-farming images that haunt you may mean you get to rest easier at night (with less ruminating on the fate of cows). Speaking of resting…
#3) Declare your bedtime: No longer the domain of toddlers and school-children, bedtime needs to be reclaimed as a vital national resource for all Americans. It’s time for a land-grab of mattresses nationwide. The data on the health-hit your body takes when it’s chronically sleep-deprived are impressive. Insufficient sleep can lead to weight gain (11 pounds for women!), diabetes, heart disease, depression and more. You may think you’re functioning fine on your six hours a night – and in the short run, that’s probably true. But the cumulative impact is like constantly having your rights chipped away by a monarchy – little bit here, little bit there and before you know it, it’s taken a tremendous toll. So how do you reclaim your rest? Commit to a fixed bedtime, one that will give you (brace yourself) a solid eight hours a night. If you think that’s not do-able, that fact alone may be a sign that your health is suffering from the combo of stress and too little sleep. Have a bedtime all summer. Make it your passionate stand for freedom from feeling crummy. Tell yourself it’s a shame you have but one bedtime to give to for your health. Stick with it and you may be surprised to find how much better you feel.
#4) Declare your fast food independence. With your trips to the farmer’s markets, you may be staring in the frig, wondering what you’re going to do now with all this colorful stuff. Summer is a great time to expand your quick-to-the-table skills and prioritize homemade meals. Check out the amazing Mark Bittman’s 101 20-Minute Dishes for Inspired Picnics. Then read Mark Bittman’s 101 Fast Recipes for Grilling. Yum. And can I just say again, yum. You may want to print these up and keep them on your kitchen counter. You’ll find yourself eating fast and WELL all summer long.
#5) Declare your energy independence. Summer is a fantastic time to deal with an energy imbalance – when it comes to exercise, do you have a personal energy deficit? Make a plan to use those extra hours of sun to walk or bike each day. While the drier months of summer are upon us, consider making exercise a core part of your life. If you make a plan and commit to speed-walking or biking to work and back, for example, you may be more likely to succeed in making exercise a built-in part of your day, every day. More so than if you try to add exercise on as another activity at the end of a long and stressful day. Sure, it may take you some extra time to get to and from your work – but that will be time you WON’T be spending going to a gym. Whatever type of exercise plan you choose, be sure and include that last, crucial step that most of us neglect – being accountable. That means writing down each time you go, setting a weekly goal and checking each week to see how you did, where you succeeded, and when you can improve on your commitment to your personal wellth.
There we have it: cut the soda, cruise farmer’s markets, stick to bedtime, dish up at home, and move each day. Five simple summer steps that can, together, make a huge impact on your summer health. Spread the word, encourage others to join you, and then, as fall approaches, take a moment to assess the results of your efforts. You may decide you want to continue.
What’s your vote? Do you have any tips, encouragement or experiences you’d be willing to share on how to stage a personal health revolution this summer? Remember – general medical information is NOT a replacement for medical care – if you have questions, concern or confusion about diet or exercise, see your doctor. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.
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About The Author  Doc Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing. Find out more.Doc Gurley Library of Medeos
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