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Archive for the ‘Medicine’ Category

I’ve read several articles and posts recently featuring the same conceit: that COVID–19 and police violence are the “twin plagues” or “parallel plagues” of black America.  …

What we need here, if we’re going to continue to speak the language of plague, that is, the language of disease, is the distinction between acute and chronic affliction. I’m speaking metaphorically here, in terms of how whole populations are affected by some invasive, destructive force, whether it’s a literal biological disease or not. I’m thinking of the black population of America as a single body. And in relation to that body COVID–19 is an acute disorder. It has sprung up quickly, out of nowhere, and afflicted people intensely. It just might go away. (From my keyboard to God’s ears.)

Police violence, by contrast, is a chronic disorder. It goes on year after year after year, decade after decade after decade. …

If you think of the black population of this country as a body, then COVID–19 is indeed a terrible plague ravaging it. The fear, the expectation, of police violence isn’t like that: it’s instead a misery that the body (the whole body of black Americans) must suffer and suffer and suffer, with no end in sight. People who have chronic diseases know that what’s attacking them probably won’t kill them — but even if it doesn’t, it might make them wish they were dead. It frays their nerves. It disrupts their sleep. It damages their relationships and weakens their judgment. It makes them vulnerable to other afflictions that really could kill them.

If you’re a black person in America, walking down the streets of a city, the cops probably won’t stop you. But they might. If a cop stops you, he probably won’t kill you. But he might. It’s a non-trivial possibility. The constant awareness of that possibility is itself an affliction. …

We shouldn’t conflate the sudden onset of COVID–19 and the endless tension that arises from walking, or doing anything else, while black. But keeping them conceptually distinct, we can still see them as have this essential thing in common: they attack the bodies of black Americans, they attack the social body that is Black America.

Those of us who are white don’t know much, firsthand, about that chronic affliction. But you know, while the coronavirus itself might be acute, For all of us concern about it has become chronic. Buying groceries probably won’t make us ill. But it might. And if we get ill, we probably won’t die. But we might. It’s a non-trivial possibility. We’re learning how to live at tiptoe stance. Our nerves are fraying after just a few months. Imagine what it would be like to live this way all our lives long.

Alan Jacobs

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Patient HJ needs an emergency caesarean section for failure to progress in labour. This has not come as a a surprise. When I met her on admission, she presented me with her nine-page birth plan, in full colour and laminated. The whale song that would be playing on her laptop (I don’t recall the exact age and breed of the whale, but I’m pretty sure it was documented to that level of detail), the aromatherapy oils that would be used, an introduction to the hypnotherapy techniques she would be employing, a request for the midwife to say ‘surges’ rather than ‘contractions’. The whole thing was doomed from the start — having a birth plan‘ always strikes me as akin to having a ‘what I want the weather to be’ plan or a ‘winning the lottery’ plan. Two centuries of obstetricians have found no way of predicting the course of a labour, but a certain denomination of floaty-dressed mother seems to think she can manage it easily.

Needless to say, HJ’s birth plan has gone right up the @!$*. Hypnotherapy has given way to gas and air has given way to an epidural. The midwife tells me the patient snapped at her husband to “turn that bullsh*t off” when he was fiddling with the volume on the whale grunts. She’s been stuck at 5 cm dilatation for the best part of six hours despite Syntocinon.

We’ve ‘given it a couple more hours’ twice now, so I explain baby isn’t going to come out vaginally and I’m not prepared to wait until it inevitably becomes distressed and there’s a huge emergency. We’re going to need to perform a caesarean section. As expected, this doesn’t go down ‘ particularly well. ‘Come on!’ she says. ‘There must be a third way!’
I’m loath to court a PALST complaint from a patient who wants their birth to be blogpost-perfect and has somehow been let down by nature. I’ve had a complaint in the past from a patient who I refused to allow to have ‘candles burning while she laboured. ‘I don’t think it’s such an unreasonable request,’ she wrote. About having naked flames right next to oxygen tanks.

This patient’s got ‘strongly worded email’ written all over her, so I cover myself by asking the consultant to pop by and have a quick chat with her. Luckily, Mr Cadogan is on duty — he’s fatherly, charming and soothing, and he smells expensive, which has posh women flocking to the private ward he’d much rather be on. He soon, has HJ consented for theatre. He even offers to do the section himself, to quiet mutterings of derision and amazement from the other staff. No one here can remember the last time he delivered a baby for free. Perhaps golf’s been rained off? He suggests to the patient that he performs something called a ‘natural caesarean’ — it’s the first time PVC heard of such a thing. The theatre lights are dimmed, classical music plays and baby is allowed to slowly emerge from the tummy while both parents watch. It’s, a gimmick, and no doubt attracts a huge premium as part of his Platinum Package or whatever, but HJ laps it up. It’s the first time she’s looked remotely happy all day.

— Adam Kay, This Is Going to Hurt

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An inpatient’s blood results show her clotting is all over the shop for no good reason. Hugo eventually cracks it. She has been taking St John’s Wort capsules from a health food shop for anxiety. Hugo points out to her (and, in fairness, me) that it interacts with the metabolism of warfarin, and her clotting will probably settle down if she stops taking it. She is astonished. ‘I thought it was just herbal — how can it be that bad for you?’ .

At the sound of the words ‘just herbal’, the temperature in the room seems to drop a few degrees and Hugo barely holds in a weary sigh. It’s clearly not his first time at this particular rodeo.

‘Apricot stones contain cyanide,’ he replies drily. ‘The death cap mushroom has a fifty per cent fatality rate. Natural does not equal safe. There’s a plant in my garden where if you simply sat under it for ten minutes” then you’d be dead.’ Job done: she bins the tablets.

I ask him about that plant over a colonoscopy later.

‘Water lily.’

— Adam Kay, This Is Going to Hurt

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It is vital that people who have survived violence become habituated to ordinary cues and reminders woven into the fabric of daily life. Avoiding triggers is a symptom of PTSD, not a treatment for it. According to Richard McNally, the director of clinical training in Harvard’s Department of Psychology:

Trigger warnings are counter-therapeutic because they encourage avoidance of reminders of trauma, and avoidance maintains PTSD. Severe emotional reactions triggered by course material are a signal that students need to prioritize their mental health and obtain evidence-based, cognitive-behavioral therapies that will help them overcome PTSD. These therapies involve gradual, systematic exposure to traumatic memories until their capacity to trigger distress diminishes.

Cognitive behavioral therapists treat trauma patients by exposing them to the things they find upsetting (at first in small ways, such as imagining them or looking at pictures), activating their fear, and helping them habituate (grow accustomed) to the stimuli. In fact, the reactivation of anxiety is so important to recovery that some therapists advise their patients to avoid using antianxiety medication while undertaking exposure therapy.

For a student who truly suffers from PTSD, appropriate treatment is necessary. But well-meaning friends and professors who work together to hide potential reminders of painful experiences, or who repeatedly warn the student about the possible reminders he or she might encounter, could be impeding the person’s recovery. A culture that allows the concept of “safety” to creep so far that it equates emotional discomfort with physical danger is a culture that encourages people to systematically protect one another from the very experiences embedded in daily life that they need in order to become strong and healthy.

— Greg Lukianoff and Jonathan Haidt, The Coddling of the American Mind

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To understand how an Oberlin administrator could have used the word “safety,” we turn to an article published in 2016 by the Australian psychologist Nick Haslam, titled “Concept Creep: Psychology’s Expanding Concepts of Harm and Pathology.” Haslam examined a variety of key concepts in clinical and social psychology—including abuse, bullying, trauma, and prejudice—to determine how their usage had changed since the 1980s. He found that their scope had expanded in two directions: the concepts had crept “downward,” to apply to less severe situations, and “outward,” to encompass new but conceptually related phenomena.

Take the word “trauma.” In the early versions of the primary manual of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatrists used the word “trauma” only to describe a physical agent causing physical damage, as in the case of what we now call traumatic brain injury. In the 1980 revision, however, the manual (DSM III) recognized “post-traumatic stress disorder” as a mental disorder—the first type of traumatic injury that isn’t physical. PTSD is caused by an extraordinary and terrifying experience, and the criteria for a traumatic event that warrants a diagnosis of PTSD were (and are) strict: to qualify, an event would have to “evoke significant symptoms of distress in almost everyone” and be “outside the range of usual human experience.” The DSM III emphasized that the event was not based on a subjective standard. It had to be something that would cause most people to have a severe reaction. War, rape, and torture were included in this category. Divorce and simple bereavement (as in the death of a spouse due to natural causes), on the other hand, were not, because they are normal parts of life, even if unexpected. These experiences are sad and painful, but pain is not the same thing as trauma. People in these situations that don’t fall into the “trauma” category might benefit from counseling, but they generally recover from such losses without any therapeutic interventions. In fact, even most people who do have traumatic experiences recover completely without intervention.

By the early 2000s, however, the concept of “trauma” within parts of the therapeutic community had crept down so far that it included anything “experienced by an individual as physically or emotionally harmful . . . with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well—being.” The subjective experience of “harm” became definitional in assessing trauma. As a result, the word “trauma” became much more widely used, not just by mental health professionals but by their clients and patients—including an increasing number of college students.

As with trauma, a key change for most of the concepts Haslam examined was the shift to a subjective standard. It was not for anyone else to decide what counted as trauma, bullying, or abuse; if it felt like that to you, trust your feelings. If a person reported that an event was traumatic (or bullying or abusive), his or her subjective assessment was increasingly taken as sufficient evidence.

— Greg Lukianoff and Jonathan Haidt, The Coddling of the American Mind

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Writing in Foreign Affairs, the Princeton economist Alan Blinder considers the question of job security and falling wages for U.S. workers in light of global competition:

“Many people blithely assume that the critical labor-market distinction is, and will remain, between highly educated (or highly skilled) people and less-educated (or less-skilled) people–doctors versus call-center operators, for example. The supposed remedy for the rich countries, accordingly, is more education and a general “upskilling” of the work force. But this view may be mistaken. . . . The critical divide in the future may instead be between those types of work that are easily deliverable through a wire (or via wireless connections) with little or no diminution in quality and those that are not. And this unconventional divide dose not correspond well to traditional distinctions between jobs that require high levels of education and those that do not.”

Blinder suggests the crucial distinction in the labor market will be between what he calls “personal services” and “impersonal services.” The former either require face-to-face contact or are inherently tied to a specific site. Physicians who treat patients don’t need to worry that their jobs will be sent offshore, but radiologists who examine images have already seen this happen, just as accountants and computer programmers have. He goes on to point out that “you can’t hammer a nail over the Internet.”

The MIT economist Frank Levy makes a complementary argument. He puts the issue not in terms of whether a service can be delivered electronically or not, but rather whether the service is itself rules-based or not. Until recently, he writes, you could make a decent living doing a job that required you to carefully follow instructions, such as preparing tax returns. But such work is subject to attack on two fronts—some of it goes to offshore accountants and some of it is done by tax preparation software, such as TurboTax. The result is downward pressure on wages for jobs based on rules.

These economic developments command our attention. The intrusion of computers, and distant foreigners whose work is conceived in a computer-like, rule-bound way, into what was previously the domain of professionals may be alarming, but it also compels us to consider afresh the human dimension of work. In what circumstances does the human element remain indispensable, and why? Levy gestures toward an answer when he writes that “viewed from this rules-based perspective, creativity [sic] is knowing what to do when the rules run out or there are no rules in the first place. It is what a good auto mechanic does after his computerized test equipment says the car’s transmission is fine but the transmission continues to shift at the wrong engine speed.”

— Matthew Crawford, Shopclass as Soulcraft

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It is an odd thing about us. We expend huge efforts exhorting ourselves to “Say No to Drugs,” then go to the drugstore and buy them by the armloads. Almost $75 billion is spent each year in the United States on medicines of all types, and pharmaceutical products are marketed with a vehemence and forthrightness that can take a little getting used to.

In one commercial running on television at the moment, a pleasant-looking middle-aged lady turns to the camera and says in a candid tone: “When I get diarrhea I like a little comfort” (to which I always say: “Why wait for diarrhea?”).

In another, a man at a bowling alley (men are pretty generally at bowling alleys in these things) grimaces after a poor shot and mutters to his partner, “It’s these hemorrhoids again.” And here’s the thing. The buddy has some hemorrhoid cream in his pocket! Not in his gym bag, you understand, not in the glove compartment of his car, but in his shirt pocket, where he can whip it out at a moment’s notice and call the gang around. Extraordinary.

But the really amazing change that occurred while I was away is that now even prescription drugs are advertised. I have before me a popular magazine called Health that is chock full of ads with bold headlines saying things like “Why take two tablets when you can take one? Prempro is the only prescription tablet that combines Premarin and a progestin in one tablet.”

Another more intriguingly asks, “Have you ever treated a vaginal yeast infection in the middle of nowhere?” (Not knowingly!) A third goes straight to the economic heart of the matter and declares, “The doctor told me I’d probably be taking blood pressure pills for the rest of my life. The good news is how much I might save since he switched me to Adalat CC (nifedipine) from Procardia XL (nifedipine).”

The idea is that you read the advertisement, then badger your “healthcare professional” to prescribe it for you. It seems a curious concept to me, the idea of magazine readers deciding what medications are best for them, but then Americans appear to know a great deal about drugs. Nearly all the advertisements assume an impressively high level of biochemical familiarity. The vaginal yeast ad confidently assures the reader that Diflucan is “comparable to seven days of Monistat. 7, Gyne-Lotrimin, or Mycelex-7,” while the ad for Prempro promises that it is “as effective as taking Premarin and a progestin separately.”

When you realize that these are meaningful statements for thousands and thousands of people, the idea of your bowling buddy carrying a tube of hemorrhoid unguent in his shirt pocket perhaps doesn’t seem quite so ridiculous.

— Bill Bryson, I’m a Stranger Here Myself

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