Lift Up Your Hearts!

Pressure is increasing on schools to remove that nutritional disaster called soda from their vending machines and replace it with healthy fare like water, juice, and milk. In response, the soft drink manufacturers, not to be caught with their profits down, have succeeded in spinning milk into soda. Take a delicious bottle of milk, add sugar, artificial flavor, and sometimes even carbonation, give it a name like Milky Way, Starburst, or Bubble Blast, and voila! — a drink no calf would recognize.

Schools are happy; they can continue to expect income from their highly profitable vending machines. Soft drink companies are happy; they've found a way around the threat to evict them from campus. Apparently even mothers are happy, as they are finding this an easier way to get some of the benefits of milk to children who whine for breakfast soda. So why am I such a grumpy old lady about this new trend? After all, I do love hot cocoa, an early form of sugared, flavored milk, and I'll admit a cup of steaming Milky Way flavored milk on a cold night sounds delightful. Two things, I suppose: There's a difference between an occasional cup of cocoa and having fat-laden, artificially flavored sugared drinks several times a day; moreover, I am saddened at the realization that so many of the next generation are growing up with no knowledge of the delights in drinking plain, cold, smooth, perfect-with-a-plate-of-Grandma's-cookies milk.

In England, Darren and Debbie Wyatt are fighting in court to save the life of their 22-month old daughter, Charlotte, who is severely handicapped. Charlotte is no Terri Schiavo, with her parents and her legal husband in disagreement over her medical care. The Wyatts' battle is with England's medical and legal system, with doctors who insist Charolotte has no "quality of life," and a court ruling giving the doctors authority, against her parents' wishes, to refuse to resuscitate Charlotte if she stops breathing.

Bottom line, though no one is admitting it: The United Kingdom's socialized health care system is financially strained, and it costs too much to keep Charlotte alive.

Unquestionable reality: Some types of medical care are expensive, and resources are not limitless.

Critical Question: Who should make medical decisions for you and your loved ones? Some would say the ultimate authority should rest with some form of government, whether legislative, judicial, or a medical review board, because otherwise the limited resources will end up going to those with the most money rather than those who are most deserving. I would argue that someone who doesn't have enough money for medical care has room for appeal: insurance, friends and family, charities, other governmental programs, fundraisers, pleas to the general public. It may not be easy, but there is room for hope. Where can you turn when an institution, under the influence of philosophies that may differ vastly from your own, decides that you—or your child, or your parent, or your spouse—no longer deserve to live?

Focusing on Charlotte's quality of life, or on what decisions you would make were she your own child, only distracts from the vitally important issue: Who has the authority to make life and death decisions for you and your family?

If you believe that we can trust governmental and institutional authorities to make the wisest decisions, I have a public school system and a war in Iraq to sell you.

I've noted before some of the problems with epidural pain relief during childbirth, and my latest reading, Lise Eliot's What's Going on in There: How the Brain and Mind Develop in the First Five Years of Life confirms my worries. Here are a few of her concerns:

• Every drug used for epidural anesthesia can diffuse out of the epidural space and enter the baby’s circulation. The good news…is that the total amount of drug reaching the baby is considerably lower than in systemic administration. Nonetheless, whatever dose does enter the mother’s bloodstream crosses quite efficiently to the baby’s circulation.


• Although many studies report no effect…on Apgar scores or cursory neurological exams, few of them have used wholly unmedicated mothers as a control group. Using more sensitive indices of infant behavior, some studies have found that newborns…are less alert, less able to orient toward stimuli, and less mature in their motor abilities than babies of unmedicated mothers. Greater exposure…makes babies jumpy and more irritable. The effects are most pronounced on the first day after birth, but some have been found to persist up to six weeks of life.


• The most common side effect of epidural administration is…a reduction in the mother’s blood pressure. Maternal hypotension is at least partially responsible for the fact that the baby’s heart rate often slows down for a while shortly after an epidural anesthetic is injected. If the mother’s blood pressure falls too low for too long, it can seriously compromise blood flow to the placenta, reducing the fetus’s supply of oxygen. These serious side effects are prevented by giving the woman fluids through an IV….If this countermeasure doesn’t work, another drug may be needed to prevent her blood pressure from falling too low and compromising the baby.


• Many studies have now shown that women who receive epidurals have longer labors, on average, than women receiving systemic analgesia. This is especially the case during the pushing phase…. Women receiving epidurals are more frequently diagnosed with dystocia, the failure of labor to progress, four times likelier to require forceps, and two or three times likelier to end up having a C-section, than women receiving systemic analgesia or no pain relief.


• Although most babies are not significantly affected, epidural anesthesia may compromise the health of the small subset of babies already at risk due to illness, prematurity, or a difficult delivery. Encouraging more women to have unmedicated deliveries would be better for babies, and for the women themselves, who would be exposed to fewer side effects, have shorter labors, and might be in better shape to begin breast-feeding and bonding with their babies right after delivery.

None of these concerns surprised me. What I did find astonishing was her report of the difficulty in getting reliable data on the adverse effects of epidural anesthesia relative to no anesthesia at all, instead of relative to other forms of pain relief: “There are simply too few ‘natural’ deliveries to enroll in a clinical study!” Upon reflection, I believe there are more mothers who chose unmedicated delivery than she implies, though I’m also certain the numbers are far lower than they would be if the public were better educated about the joys of natural childbirth and the dangers of anesthesia. Two additional reasons come to mind for the lower numbers available for study: Those who chose natural childbirth often do so for reasons that would also make them reluctant to have their newborns’ lives disrupted by clinical study. And, sadly, the hostile atmosphere frequently encountered by those seeking to avoid unnecessary medical interventions in the births of their babies often drives them underground, where they avoid observation for good as well as ill.

I've heard it said that the male human body has enough blood to power the brain or the sexual organs, but not both at the same time. I'm not convinced women are any smarter, but this news report about the Third International AIDS Society Conference on HIV Pathogenesis and Treatment goes far in proving the adage for men.

Anti-circumcision activists will be dismayed by the results of a study of more than 3000 South African men, which suggests that female-to-male HIV transmission may be significantly reduced for circumcised men. There's also plenty in the report to dismay anyone:

For the study, about half of the subjects were circumcised by medical professionals, and the rest remained uncircumcised.

[A]fter 21 months, 51 members of the uncircumcised group had contracted HIV, the AIDS virus, while only 18 members of the circumcised group had gotten the disease.

The scientists conducting the study can't be so stupid as to ignore the obvious: adult circumcision, performed shortly before the study, might have a dampening effect on the subject's sexual activity, thus contributing to the lower disease rates. I find the report meaningless, however, without an explanation of how this factor was taken into consideration.

All of the men received counseling on AIDS prevention.

Since most of "counseling on AIDS prevention" relies heavily on the mantra, "use a condom, use a condom, use a condom," this casually-stated fact should terrify all those who belive condom use to be the best approach to combating AIDS.

[Dr. Charles Gilks, of the World Health Organization] worried that [the results of the study] would lead many men to rush to get circumcised, and said the World Health Organization was racing to set guidelines for safe and hygienic circumcision.

I'm prepared to believe that some men would rather undergo a painful and risky procedure rather than restrict their sexual appetites to a faithful, monogamous relationship. (See above comment about blood and brains.) That they would willingly choose mutilation over condom use is beyond my comprehension, if not beyond that of the WHO.

Women who want to get pregnant are now being advised to avoid tofu and other soy products, at least around the peak times for conception. New studies have shown that even small amounts of genistein, which mimics the hormone estrogen and is found in soy products, cause sperm to lose their fertility.

Well, I guess that explains why 20% of the world's population is Chinese!

Who wouldn't want to be smarter, think more clearly, and be able to concentrate better? New Scientist has compiled a list of brain-building suggestions for everyone from students to senior citizens.  Some were new to me, some old hat, some intriguing, and some frightening:

• Drugs  This is a scary one.  Modafinil, officially prescribed to treat narcolepsy, keeps healthy people awake and alert on little sleep.  Students wanting an extra edge on exams are taking Ritalin for its concentration-enhancing effects.  No matter how much it's claimed that the drugs are not harmful, I'm extremely skeptical.  But if athletes will sacrifice their future for a little present glory, taking metabolic steroids despite the known risk, can performance-enhanced SAT scores be far behind?
• Food  We've heard most of this before:  Eat a protein-rich breakfast; they suggest beans or Marmite on whole grain toast, but perhaps we could get away with peanut butter.  Throughout the day emphsize fiber (improved cognition), B-vitamins (brain-boosters), eggs and yogurt (for building neurotransmitters),  colorful fruits and vegetables (antioxidants), and fish (brain-enhancing omega-3 fatty acids).  Avoid brain-fouling trans fats.
• Music  The jury is still out on the Mozart Effect, but the brain-boosting benefits of music lessons are clear.
• Mental Workouts  Exercises for improving memory help other parts of the brain as well.
• Physical Workouts  Regular exercise promotes brain growth and reduces brain-damaging stress homones.  Aerobic exercise, sedate walking, and yoga have all shown significant benefit.
  
• Sleep  Just what Mom always said:  If you don't get enough sleep, that extra studying is a waste of time.  Not only does sleep improve attention and concentration, but it gives the brain a chance to work in ways it can't when you're awake.  Sometimes a problem really can be solved by "sleeping on it."
  
• Not for Children Only  Contrary to what we were all told, even adults can grow new brain cells.
• Strange but True?  You might have more brain power than you think.  Volunteers in one study increased the strength of their biceps by 13% after 12 weeks of spending 15 minutes a day just thinking about exercising.  And neurofeedback, related to biofeedback, has enabled some people to use their brains in surprising ways, from improving musical technique, to reducing pain, to treating ADHD.
• Attitude A healthy brain is only one of the benefits of a positive, happy outlook on life.
  

Research has shown, once again, that the human body works best when used according to its original design. A study of more than 2000 nine to fifteen year olds indicates that exclusive breastfeeding significantly lowers systolic blood pressure, with the strength of the benefit directly proportional to the duration of the breastfeeding. This positive effect is comparable to that of exercise and of restricted salt diets in adults.

When God created the sun, He called it good. In recent years we have been told that God was wrong. Doctors—and hence parents, especially mothers—have been insisting that we dare not venture out into the sunshine without the protection of clothing and/or lavishly applied sunscreen. Living in Florida, I have a highly-developed sense of respect for the power of the sun's rays, and certainly do my share in supporting the sunscreen industry. But I also remember my mother's insistence on the importance of sunshine on skin for making much-needed vitamin D. Thus it was heartening to read that evidence is mounting in favor of my mother (not to mention God).

Not that anyone is recommending we go back to the days of frying ourselves on the beaches. Our overuse of sunscreen, however, may actually be causing more cancer than it prevents. Vitamin D, it turns out, plays an important role in preventing and fighting certain cancers, particularly colon cancer—and even skin cancer itself. Not only are we not getting enough vitamin D in our diets, as a rule, but the supplemental vitamin D we do receive (in milk and vitamin supplements) is not as good as the vitamin D made through the collaboration of skin and sun.

So—heed my mother's warning: Respect the sun, limit your exposure, but never forget that fresh air, exercise, and sunshine provide some of life's best medicine. (Turn off the TV and go play outside!)

While the United States is busy wrestling with the so-called right to die, in the United Kingdom it's the right to life that is in question. Leslie Burke, who has a degenerative brain disease, has won a court judgement forbidding doctors to withdraw nutrition and hydration should the time come when he needs them and is incapable of expressing his wishes. The government is challenging the decision, claiming that doctors, not patients, should be the final arbiters of treatment decisions. Nor do they make any attempt to disguise their financial concerns, for under socialized medicine, leaving the power to "pull the plug" in the hands of those who wish to continue to live can get very expensive for the government.

Consider these statements:

• The health department claimed that if a right to artificial nutrition or hydration (ANH) treatment was established, patients would be able to demand other life-prolonging treatments
• [The government argued that the ruling] may be interpreted as giving patients the right to demand certain treatments, contrary to the considered judgment of their medical team, that would lead to patients obtaining access to treatment that is not appropriate for them, and to inefficient (and unfairly skewed) use of resources within the NHS
• [and also that the ruling] had led to a confusion between the roles of doctor and patient—the decision over treatment [is] for the doctor, not the patient

In the words of Mr. Burke's lawyer, "The key issue could be summarised in two words: who decides?" It's not an easy issue, and it won't go away. I remember a conversation with an anesthesiologist friend 25 years ago, in which he warned that health care resources are not infinite and like it or not we will have to make decisions as to how they are allocated. A capitalist system, in which money provides access to health care, seems at first to be monstrously unfair, but I'll take its flexibility any day over socialized medicine, in which life and death decisions—still made on an economic basis; that's unavoidable—are in the hands of an inhuman, faceless bureaucracy. When decisions are left up to individuals and smaller institutions, creativity and compassion have room to flourish. People can cut back in other areas of their budgets to provide for medical care; families and communities can unite to raise funds; deals can be worked out. A friend of ours who never had medical insurance needed a quadruple heart bypass operation. The hospital asked him to pay his $150,000 bill of at a rate of $100/month. He won't live long enough to pay it off, but this solution pleased both him and the hospital. The more decisions are left at a local level, the more flexibility we have.

One thing I know: I agree with Mr. Burke that I don't want a doctor, a lawyer, a judge, or anyone else who doesn't know me extremely well deciding that my "quality of life" isn't worth living.

Parents in Rochester, New York no longer have to stay home with sick children, nor be inconvenienced by having to take them to the doctor, thanks to a program that connects schools and day care centers with doctors via the Internet. Little Johnny wakes up feeling miserable? No need to fret; just pack him off to school or day care anyway. There, a staff member with a whole week's worth of training will examine his ears, swab his throat, and otherwise check him out using equipment that sends the results over the Internet to a physician. The diagnosis is made, medication begun, and you pick your child up at the end of the day as usual, no fuss, no bother.

The good news is that if a day care worker can wield the equipment after a week of training, so can a parent. When our children were young we were blessed with a doctor who respected our powers of observation and judgment; he spared us many unnecessary trips to his office by dealing with minor problems over the telephone. Although few doctors these days are so accommodating, perhaps this new equipment will make them feel more comfortable with trusting their patients.

For the most part, however, I don't think this development is worthy of the enthusiasm with which it is being received.

• 92 percent of parents said the hassle-free option allowed them to stay at work when they otherwise would have taken their children to a family doctor or an emergency room

This may look like good news for parents, but the only clear winners are their employers. What begins as a new option for parents will soon translate into pressure from the boss: You don't need to take your child to the doctor; let the school handle it.

• doctors have diagnosed mostly everyday illnesses like colds, rashes, asthma, ringworm and pink eye that account for almost three-quarters of all pediatric office visits

The doctors can't really be happy about this. At the moment it's a physician at the University of Rochester who is giving the diagnosis, but you can be sure someone has already realized the job can be done less expensively by "offshoring" the work. If the diagnostic information can be sent across town, it can be sent anywhere in the world.

• any patient with a fever or a contagious disease is sent home

Except for severe cases, you know that isn't going to happen. Do schools and day care centers really want to become infirmaries? I doubt the (temporarily) healthy teachers, children, and their families will be happy with the idea.

• ...available where children spend the majority of their time, such as schools and child-care centers

This is the saddest line of all. Who really loses with this new technology? The children. Now even illness can't guarantee them time in their own homes, with their own families.

I'm am really tired of reading about procedures that were once known to be right now being shown to be useless or even harmful. Actually, I'm not tired of learning the truth, just frustrated with those (especially doctors, teachers, and governmental authorities) who are absolutely certain they know best and thus justiify runing roughshod over other people. I think of the Canadian judge who will force an unwanted medical procedure on a child, in violation of her own conscience and the desires of her family, because he and some doctors think it's the best thing for her; of those who would insist, with the force of law, that a hospital is the only acceptable place to be born, and a school the only acceptable place to be educated, despite mounting evidence to the contrary; of bloodletting, and hormone replacement therapy, and routine circumcision, all procedures once pushed by the medical profession and since retracted. Here's the latest: episiotomies, once considered essential to prevent serious problems during and after childbirth, have now been shown to be useless.

I know we must make decisions based on the knowledge we have at the time, and have no problem with honest errors. My quarrel is with those—I include myself—who in the certainty of their own convictions would use the force of law or their position to shut down contrary beliefs.

"First, do no harm."

Regular breast self exams, pap smears, mammograms, colonoscopies, prostate exams, full excision and pathological examination of moles that once were just shaved off at skin level, even routine full body scans—our understandable fear of cancer is reflected in the many procedures available and often recommended in hopes of besting this scourge.

However, there is a downside to all this screening that is now beginning to be recognized.

In an article questioning the wisdom of celebrity endorsements of cancer screening, I came upon these astonishing statements:

• Counterintuitive as it may sound, it's sometimes better not to find out about cancer
• Some cancers are likely to resolve themselves without treatment
• Some patients may be likely to die of another ailment before cancer becomes an issue
• The risk of false positives seems to increase with more screenings
• Overdiagnosis…is an increasing problem

The U.S. Preventive Services Task Force has a collection of current recommendations for cancer screening, plus a lot more. I don't know anything about this organization, and in any case it is no ultimate authority, but it's a place to start.

Having known people whose lives were probably saved by cancer screening, and people whose lives were probably shortened by cancer screening, I can only conclude that life is never as simple as we want it to be.

If this story doesn't scare you, you need to read it again. (Here's another version.) A 14-year-old Canadian girl has gone into hiding to avoid being forced to have a blood transfusion that some doctors in British Columbia believe she needs because of her cancer chemotherapy. The girl does not want the transfusion, and her parents agree with her. Whether you believe private medical decisions belong in the hands of individuals of any age, or of parents in the case of under-age children, this is a gross violation of individual and family rights by the Canadian government. Of course it's all done with the best of motives and "for her own good," but somehow that makes it even more frightening.

"The girl has gone into hiding with her family in Ontario to avoid blood transfusions that a [British Columbia] court ordered should be given."

"B.C. courts ruled the girl is capable of making a decision, but B.C. law requires that a person be 19 years or older before they are allowed to refuse lifesaving medical treatment."

"April 11 B.C. Supreme Court ruling said she couldn't refuse treatment despite her religious beliefs."

"The B.C. Ministry of Children and Family Development was granted custody of the girl last week."

"All children are entitled to be protected from abuse and harm . . . the ultimate threat of harm would be death. . . her religious beliefs don't override her right to life and death."

"[An] order of apprehension issued in B.C. remains on police computers."

"We are using all of the resources available to us to make sure that we know where she is."

"An air ambulance to return her to B.C. is on standby."

Think about it.

Watching our grandson grow, seeing his parents making choices for his care that I wish we had made with our children, knowing much more now than I did 30 years ago, I sometimes wish I were having children now rather than before the turn of the century.

And sometimes not. Steve, our obstetrician and friend, allowed me to labor 20 hours with our firstborn, with four hours of pushing. This baby was a "left occiput posterior presentation," coming into the world head down, but facing the wrong way. The work was hard, and painful, made more so because somewhere along the line obstetricians lost the knowledge midwives had of the important role labor position plays in baby position. But his patience (and ours) paid off with the birth of a beautiful, healthy girl.

Blame it on doctors, hospitals, insurance companies, lawyers, or all of the above, that scenario would be unlikely today. Long labor and posterior presentation are each indicators for Caesarean section. I'm glad Steve had faith in the natural process.

Back then we had unmedicated deliveries, too, which I still believe is better for both babies and mothers. Recent findings (originally reported in Obstetrics and Gynecology, May 2005) show that epidural anesthesia, widely practiced and proclaimed as harmless, significantly increases the risk of posterior presentation and consequent Caesarean section.

Janet needed a chest x-ray as part of a pre-employment physical. Having been advised that insurance would not cover the procedure, she attempted to find out what it would cost. That was much easier said than done, and more than once in her quest she received the following encouragement:

You don't have to pay anything now, you'll get a bill later.

As if that had any effect on the cost! Have we become so inured to debt—home mortages, car financing, credit cards, college loans—that the only price tag we care about is what we must pay right now, the copay, the down payment, the minimum monthly charge?

And what are we to think of a health care system that buries the price of its procedures under so many layers of bureaucracy that no one knows the true cost?