Category Archives: Health Care

MS “liberation” therapy – not in Canada (eh)

The story so far:  An unpredictable disease in both course and symptoms, multiple sclerosis (MS) is a terrible diagnosis (and is more common in Canada than anywhere else – perhaps because we’re so far north and lack sun and Vitamin D half the year).  Some people can live for decades with only minor symptoms; others deteriorate with alarming speed. And nobody really knows why; our best hypothesis is that MS is an inflammatory autoimmune disease, one where the immune system turns on itself and destroys the myelin “sheaths” surrounding the various nerves in the body.

Although it was identified in the mid 19th century by the French physician and thinker Charcot, MS is a recent disease, probably because it is devilishly difficult to identify – essentially the diagnosis is made by ruling out everything else.  An MRI, that shows up the lesions that the myelin loss causes, is the ostensible gold standard of MS diagnosis but even that’s tricky because several other conditions cause similar lesions, e.g., Lyme Disease.

Unusually, for an autoimmune disease (which rarely get the same kind of air play as cancer and heart disease even though they’re terribly common), MS has been much in the news lately.

Apparently, a certain Dr. Zamboni, an Italian physician whose wife had MS, has hypothesized that a lack of blood flow to the brain could cause many MS symptoms (known by the unwieldy moniker ‘chronic cerebro-spinal venous insufficiency’ or CCSVI) and that clearing aforesaid blood via angioplasty (a common procedure in cardiac disease) could relieve many of the onerous symptoms. MS could even be said to be “cured” according to some proponents.

Well! The experts and researchers are miffed. This so-called “liberation” procedure has been roundly criticized and a panel of Canadian experts has refused to countenance a clinical trial, insisting something so untried is probably untrue.

Maybe it is. But a great many MS patients have not paid attention to the experts and are flying to various places like Costa Rica to have the procedure done, paying out-of-pocket because they so desperately want to feel better.

What I find fascinating is that the argument seems fixated on the notion of “cause”.If MS is caused by the destruction of the myelin, or so the narrative runs, then this venous insufficiency notion is incidental and getting rid of it, useless.

But what if these blocked veins are simply a side effect, as it were, of the inflammatory condition (if indeed that is what it is) we call MS? What if clearing such blockages relieves symptoms for patients for six months or a year or longer? Why shouldn’t it be offered as an option, at least for those MS patients whose veins are blocked?

We give dying cancer patients ridiculously expensive medications in the hope that they will live a few months more. We transplant multiple organs into small children knowing full well that the vast majority of them will not live very long. We provide heroic measures for people whose life expectancy is pretty damn short. So why can’t we at least consider providing a procedure for those MS patients who might benefit – closer to home and without bankrupting them, which was, after all, how Medicare was originally envisioned: a program to prevent Canadians from losing their all in the case of catastrophic illness.

It’s true that for now there’s only anecdotal evidence to support this procedure. But, umpteen clinical trials have shown the connection between high cholesterol and dying of heart disease is tenuous at best if not invisible, but we still insist people lower their lipids. Doubly so if they’ve already had a heart attack. There is little evidence that in people over 60 most cardiac surgeries have any benefit (pharmacotherapy works just as well), but we do them anyway.

But no, now with this treatment we’re gone all cautious and conservative and gosh-we-couldn’t. Venous insufficiency isn’t the cause of MS, trumpeted the expert panel, so the bottom line is that we shouldn’t do it. Heck, we shouldn’t even undertake a test of it.

So why get so fixated on cause – when the myelin hypothesis is still only that, a hypothesis. One that most people agree on, true, but simply because a lot of people think something is true doesn’t make it so.

Many patients insist the procedure has helped. So, are they all nuts? Deluded? Is it placebo? (Bearing in mind that ‘placebo’ means ‘to please’.) The placebo effect is, after all, a wondrous thing and people who have just spent a whole bunch of money flying to Costa Rica for surgery are predisposed to believing they haven’t wasted their time and money. Maybe they just needed a few weeks of rest in a nice hospital in an even nicer tropical paradise.

But the only way to know with a modicum of accuracy is to do a clinical trial: find about 100 MS patients who do have this blocked vein thing, give half of them the real surgery, the other half a sham surgery and see what happens.

In the interim, why not offer it as an option for symptom relief. That’s all most drugs are.

What’s the point of turning it into a battle of wills, an argument about who’s right about the cause of MS? Dr. Zamboni, as nearly as I can make out, is not claiming that his treatment is magic or truth, merely that it seems to help some people.

More later on classification systems and their essential role in medicine in a later post – for now, perhaps medicine and the medical establishment needs to remember that its role is not just about cure but care. Which is what MS MS patients need right now.

Medical myths, cholesterol and more

“If only I’d known … ”  I’ve heard it a lot, that phrase, when people talk to me about their various medical misadventures. ” If only” someone had realized the potential consequences of that surgery or those drugs or that ostensibly innocuous test – before they’d done it. Maybe they’d have asked for a second opinion or talked to a few people who had done the same thing. Waited. Not assumed that it was safe and easy, like the brochures promise. Except of course most of us don’t know – so we go ahead. It’s only later that we realize that everything carries a risk; all drugs have side effects; all medical interventions are ambiguous.

The popular narrative is self-assured, authoritative and leads us to believe that medicine Knows. Knows why we get sick, how we get sick. The problem is, most of the time it does not. Particularly when it comes to prevention.

Acute illness – well, as a rule it does OK but the model is different. Let’s face it, if you’ve just fallen off a ladder and heard an ugly “crunch”; you have a temperature of 42C and a stiff neck and are delirious; if you are doubled over in agony with abdominal pain – the risk of what could happen without medical intervention is probably far worse than the alternative. So you rightfully race to the ER and get help – do whatever it takes.  Hey, I’m with you; when  I’m deathly ill I’m not stopping to look at statistics or evidence or googling “abdominal pain”, I want Dr. House.

The problem is when we extend this model to prevention. That’s when we’re walking along, singing a merry song – having a good day thank you very much – when our glance idly falls on some seemingly innocuous headline or pamphlet or poster warning that You Are At Risk. A ticking bomb, in fact, unless you do something immediately. You need that blood pressure checked, those glucose levels looked (diabetes on the rise you know), your cholesterol measured. You need to head over to that mammography clinic post haste. Or if you’re a guy, you need to have that PSA looked at. Or a bone density test. In other words, you need to engage in “pro-active” health care. Most people naively believe that this is good advice – and that’s when they can get into trouble (and many realize medicine is nowhere near as blindingly accurate in this as most of us think).

On television, on web sites, on the radio – whatever it is, whether it’s drama or news, it’s all presented with authority. Implication: we know what causes heart disease, we know how breast tumours evolve into cancer, we know how normal physiology morphs into pathology.

The trouble is we don’t.

And unlike those doctors on House or Mercy or whatever the medical show du jour happens to be, the outcome in real life is rarely neat and often not pretty. Contrary to what the news items tell us, it’s not all overwhelmingly positive and very little is “miraculous” or a true “breakthrough”.

Here’s where the risk/benefit thing kicks in. If you’re in pain, sick and feeling like hell, you don’t care what the risks are. It has to be better than whatever’s going on right now. Plus, that high temperature and stiff neck could be meningitis – which could kill you in less than 48 hours if you don’t get antibiotics. That crunch in your spine could mean paralysis. That abdominal pain could be appendicitis. Whatever the down side of the surgery, the side effects of the drugs, well, they probably aren’t worse than death.

But when we merrily head over to the clinic to have our blood checked for lipids, we are assuming that those panels of experts who’ve decided that anything above or below X is bad and wrong and abnormal know what they’re talking about. We assume that “they” know what ideal blood pressure is for a person of our age and weight and size; a person who eats the way we do and has the family we have; is, in other words, us. When we docilely head over to have mammograms and PSA testing as we’re bid, well, that’s where it gets tricky.

Take cholesterol. True, in a fairly smallish subset of people, hyperlipidemia or the tendency to create more cholesterol than the body needs, will create problems. Often, these are the folks who have had one or more close relatives drop dead of a massive coronary at a young age, say 50. Interestingly, often there is a geographical connection – people from northern countries such as Scotland seem to have this tendency.

What evidence there is (and virtually all of it comes from drug companies) does tell us that after a person has had a heart attack, lowering cholesterol with medication does seem to reduce their risk of a second one. But in people who’ve never had a heart attack, what is called  primary prevention? Not so much.

Not that you’d know it from the television ads for statins and other cholesterol lowering meds on TV that here in Canada we get from across the border. (Direct-to-consumer ads are only allowed in the U.S. and New Zealand – all other countries ban them.) They make it sound as though it’s a moral imperative to take drugs if your numbers aren’t right. In fact, cholesterol is needed for normal physiologic functioning. It protects against infection and not having enough, as Finnish researcher Ravnov has shown, can be dangerous.

(For more see his site: http://www.ravnskov.nu/cholesterol.htm and also the Cholesterol Skeptics site: http://www.thincs.org/ which includes hundreds of names of physicians, researchers and other bit ‘names’.  Also see “Should we lower cholesterol as much as possible?” in the BMJ (3 June 2006; Vol 332, pp 1330-32)

What they don’t tell you is how many of those expert panels the makers of these drugs have funded. Or that the whole idea behind cholesterol as a risk factor came from the Framingham study, a longitudinal study begun in the late 1940’s in Framingham (Massechusetts), in a report where a researcher hesitantly noted that it seemed as though cholesterol might be a factor in heart disease. (That was what the Framingham study initially was looking at, cardiac disease and why its incidence seemed to be on the rise at that time. And, they wanted to test out some cool new technologies that were being developed like the electrocardiogram.)

Science deals in probabilities, in maybe’s; it is a dynamic process. Individuals are not statistics and what works for one may very well not work another. Plus, medicine is just as prone to fads and fashions as anything else. Unfortunately, too often in the culture we have it descends into dogma.

And that isn’t healthy.

ObamaCare – damning with faint praise all one can do

Two weeks ago President Obama signed what is being called an “historic” health care bill, and belated the United States is to have a sort-of-almost-maybe national health care system. Except that much like the Holy Roman Empire, which was neither Roman, holy nor an empire, US health care will not be universal (some fifteen million people are still left out in the cold), national (people still have to buy health insurance) or particularly historic, since everybody else in the western world got health care 40+ years ago. So, er, hurray.

comme-ci, comme-ca health care*

Of course everybody hates it.

The left because they maintain, not unreasonably, that Obama gave up the public option (early on he seemed to be harbouring the vain hope that it would lead to some bipartisan support) and as such Medicare, the existing system for seniors, was not expanded – which would have at least provided a kind of national health care without starting from scratch. Pity. That would have been the logical route. But nooo. Not in America. So, the basic, dysfunctional structure of American health care remains – and insurance continues to stand firmly between the patient and the health care provider.

The right hates it more and for a lot more reasons – although there’s some serious irony here since the genesis of this bill was the Republican proposal to counter what was dubbed HillaryCare back in the 90’s.

First and foremost, the right is cranky because a lot of them listen to Glenn Beck and Fox News and hang out at those tea parties where there aren’t any sandwiches, and they simply hate anything Obama does. More rationally, however, they object to the form of the bill, which forces individuals to purchase health insurance (which, if they can’t afford, the government will subsidize). Here they have a point, since you have to admit it does seem a touch undemocratic to make people buy something whether they want to or not.

Republicans add that the the bill makes no attempt to cut costs or deal with the ludicrous consequences of  litigation; this argument is true albeit disingenuous since if they had actually got involved, as Obama had asked, they could have added that in.

Business is not too keen on this bill either, probably because health insurance is currently provided, for the people who have it, through their employer, and business has no idea what this bill implies for them, and they loathe uncertainty.

(The bill would tie health insurance to the person, so even if they lose their job they keep their insurance. There is also talk of creating some kind of risk ‘pooling’ for people who are not employees but self employed or what-have-you. Plus, in theory at least, insurance companies will no longer be allowed to turn away people with pre-existing conditions – though I’m sure some clever lawyers are already figuring out other ways to reject people they think will cost too much. Too tall, perhaps or too freckled.)

My problem with this bill is its fundamental premise, namely that health care has to be administered by insurance companies. It’s a nincompoop idea and only one that a country besotted with business could endorse.

Insurance companies, boys and girls, are what are known as bu-si-nesses. This means that they exist to  make money: their raison d’etre is profit. If it were otherwise we’d call them, oh, NGO’s. Not-for-profits. (That’s what we used to call charities before we opted for the more unwieldy name.) Except that health care, medicine, is not and cannot be (ever!) a business. Economists long ago realized that it simply does not fit the market model.

Health care is not a commodity. You cannot make money on health care. Never mind that you shouldn’t. Why? Well, for those of you who missed Econ 101, I’ll explain. Please pay attention, there’ll be a quiz later.

The free market is at heart transactional: I make hand-embroidered doilies; you, for reasons that elude everyone else, like and want hand-embroidered doilies. So, I make them and you buy them from me. And we’re all happy. I, in turn, use the money I make to buy things I want/need, like food and shelter and some really cool stilettos. Supply and demand.

But (and here’s where it gets tricky), if a villager in China can make aforesaid doilies that are just as nice for a lot less, then you will get them from her so I will be out of business, unless I move my manufacturing to an even cheaper place, Bangladesh, say. This, in a nutshell, is the free market, which, in Adam Smith’s immortal baker metaphor, does not rely on the goodness of anyone’s heart but is inherently rational. As are consumers.

Now you and I both know that this is patent nonsense. Not only are most people not rational consumers, most of the time they  are crazy. Or, as a psychiatrist would say, stark raving bonkers. Why else would tens of thousands of people line up on Boxing Day to get a gizmo they don’t need? Or pay good money to buy a piece of bacon wrapped in a pancake with a list of ingredients too long to read? (I could go on but you get the picture.)

Even if consumers aren’t nuts their actions are often dictated by a lot of things other than reason, price and need. Otherwise nobody would ever buy a Kelly bag or have eighteen pairs of virtually identical black trousers. But for the sake of argument, let’s stick to the model – this is 101, remember, and we don’t have time to veer into behaviorial economics and all that complicated stuff like status and advertising and whatnot.

So homo economicus operates on simple efficiency and if he or she can afford it, they will get the best darn doily or car or house they can get. So, people with money get the nice stuff, the cashmere sweaters and the Prada belts, while everybody else makes do with Joe Fresh and H&M. That’s life according to economics.

Health care doesn’t work that way. Nobody gives up a trip to the Bahamas to check themselves into the hospital for a quadruple bypass for fun. That’s because, in economics-speak, health care is not a direct “purchase” but is subject to agency issues. In other words, there is a person or a group between the person and whatever is being bought, whether it’s a bypass or a prescription. When I feel sick, no matter how many internet sites I surf or friends I text, I really don’t know the reason; I need a doctor. Or a nurse. Or a faith healer if that’s what I happen to believe in. Even if I did figure it out the diagnosis, I can’t write myself a prescription or do surgery on myself. I need someone else, an “agent”, to confirm my choice. (In terms of that quadruple bypass I should really go back to the internet and do some serious research because there’s no evidence it is in any way preventive if I’m feeling all right, but that’s another post.)

Medicine, unlike cars and refrigerators and new tiles for the bathroom, is about a patient, a person who is sick and vulnerable and scared and in no position to make rational choices about anything. This is also why there are medical ethics and professional organizations and the Hippocratic Oath (though that’s just a metaphor, the actual Oath hasn’t been used for nearly a century no matter what TV shows would have you think.)

“Enough”, when it comes to cars and refrigerators and trips to sunny Spain is only limited by your budget and, presumably, greed and appetite: if you really want thirty six SUV’s, or feel the need to stuff your kitchen with 97 Sub-Zero fridges full of chocolate ice cream and would like to give Imelda Marcos a run for her money when it comes to shoes – well, if you can afford it, it’s your choice. Medicine is not like that.

Too much medicine – too many medical interventions – can kill you.

It’s called iatrogenesis. A term from the Greek, meaning harm caused by medical treatment. One aspirin can take away your headache; popping the whole bottle is a suicide attempt. One operation could save your life (if it goes well) but if you have an appendectomy and for whatever reason things screw up and you end up in ICU with sepsis and need four more operations, well, you could easily end up maimed or dead. In fact the more you get done medically, the lower your chances.

As Peter Davis writes in the Canadian Medical Association Journal (“Health Care as a Risk Factor”, http://www.cmaj.ca/cgi/content/full/170/11/1688), close to 70,000 preventable adverse effects occur each year, some 20% of which result in the person’s death. This, writes Davis, is not because hospitals are inherently dangerous places but because the “unchallenged therapeutic imperative” tends to move people to ever-higher (and more complex) levels of care, levels that they are unable to sustain.

When people proudly proclaim that American health is “the best in the world” therefore, as they are wont to do, what they mean is that they have access to more MRI’s and operating theatres and doctors than anyone else. The model they’re using is that of the market. Except they’re dead wrong (so to speak). By any objective measure American health care is the worst in the developed world. Life expectancy is lower, infant mortality is higher and your odds of surviving healthily after a heart attack are considerably lower than they are anywhere else in the west. Why? Iatrogenesis. Americans do too much. Too many tests, too many surgeries; too many drugs. In short, overtreatment. Because medicine in the US is treated like a commodity, like cars and refrigerators and Prada bags, which it is not.

That’s what Obama’s bill didn’t even begin to address. True, some of the currently uninsured might, if  all goes well, not end up bankrupt if they get sick. More people will have access to health care. The notion that health care might be a basic mark of a civilized society has at least come up and might even be discussed further. It will continue to cost too much (16% of GDP at last count versus an average of 10% in Canada and France and everywhere else); doctors will continue to practice “defensive” medicine and Americans will continue to get sub-standard care. But at least it is a start.

Too bad it was so fitful.

* photo c/o creative commons and newsrealblog.com

There is a thin line between genius and insanity

“There is a thin line between genius and insanity,” said the curmudgeonly Oscar Levant, “and I have erased this line.” We have too – unfortunately, we went straight to crazy without so much as a pause at intelligent, never mind genius.

It seems like only yesterday when a modicum of civil discourse was possible – and one could engage in the odd conversation or commentary on the environment or the economy or health care without people going all apoplectic (or reducing the argument down to infantile levels: t’is too, t’is NOT). Then again, it seems like only yesterday when taking a bottle of water on a plane didn’t set off alarm bells and only crazy people walked down the street waving their arms about and talking to air.

Ah, the good old days, circa 2002  …

So what happened? How did we descend into babbling incoherence without so much as a telethon or ribbon to commemorate the day when sense, like the whales in Hitchhiker’s Guide Guide to the Galaxy, just up and left (without so much as a note saying “good-bye and thanks for all the fish”)?

Maybe it’s just information overload: our 24/7 ability to stay connected, in touch, on line and on top of every gloomy  bit of news as it happens – all in High-Def in all its ugly, excruciating, migraine-inducing hues and garish detail. Or those minor but constant irritants, like having to press 2 and 6 every time we call some company (and end up talking to a nice man in the Philippines who can’t help). Maybe it’s all those cameras everywhere (according to The Economist the number of surveillance cameras in the UK averages out to one per 14 people) or that horrible fluorescent light we’re now suppose to embrace (even though they make everyone look diseased and their flicker gives the rest of us headaches). And don’t get me started on those ghastly SUV’s in the city and those horrid, ugly little cars with great mileage and mean little headlights. Or my favorite: reality shows. Thousands of years of story arcs tossed aside in favour of watching nasty people snipe at each other in contrived situations on desert islands. (Where’s Dr. Moreau when you need him?)

Most of all I object to the sheer, unrelenting dreariness of it all, especially that 24-hour news cycle. All presented with such gravitas that Brangelina’s possible breakup becomes as much of a tragedy as Darfur or Haiti. Sure, the spotlight occasionally goes to some natural disaster that brings tears to our eyes but the resultant overkill is almost as bad. Once we’ve made the donation to Medecins sans Frontieres we can feel better and go watch Avatar.  (I must confess to a modicum of cynical glee when I read the MSF and other charities had asked that Haiti donations be halted as they were unable to use them.)

Not that we ever get the followup. Anyone know what happened with that tsunami thing? Because I sure don’t.

Moreover, we don’t protest or argue, just take it all at face value; rarely if ever questioning the perspective or veracity of those authorative sound bites. So we end up shallow and flat and two-dimensional, just like our technologies.

We forget there’s a world of history and culture out there, the backdrop to those uncontextualized blobs of information we’re fed. The economy or even the markets aren’t just rows of video ticker-tape symbols at the bottom of the screen. Borders did not magically appear on the map – they were the result of years of conflict, colonialism and hardship (not to mention warring interests and powers). Real life is messy, complex and oftentimes boring, containing, as Walt Whitman said in a different context, “multitudes”. It’s not neatly reduceable to a 90-second segment.

And when it’s s not ‘out there’ it’s us: our genes, our aging bodies, our addictions, our telomeres or whatever those stupid things are called (the ones that shorten as our cells regenerate and end up making us old and dead). Not to mention our blood pressure and lipids and body fat index and bones that – any minute now – will fall in on themselves and make us disappear altogether (perhaps a not-so-hidden metaphor for how we tend to disappear in this culture as we age).

This last while it’s been epidemics. Of obesity, of type 2 diabetes, of cancer – and of course the epidemic-epidemics. The ones where viruses are described in metaphors that liken these little chunks of protein to an invading army, lurking, like Stephen King’s Chucky, waiting to pounce on the unwary.

Frankly, I’m surprised more of us aren’t standing on street corners holding placards reading “Abandon All Hope” or “The End is Nigh”.  (Or “night”, given how badly everyone seems to spell.)

So for now I plan to skulk here, in my curmudgeonly corner, making the odd attempt to bring some sense and sanity here and there when things particularly irk me – maybe debunk a bit of  nonsense or two from the mounds of information all over the place: information that’s largely shrill, reductionist, sensationalist, biased and just plain wrong. Not that that ever stops it from streaming out, all assured and authoritative.

Progress, said Paul Fussell, is one damn thing after another.  Well, someone has to say something.

Spanish Flu – not

If I hear one more smug, well-dressed public health expert threaten us with the Next Great Pandemic, be it swine flu, avian flu or H1N1, with its inevitable comparison to the 1918 Spanish flu that “killed millions and millions”, the top of my head will blow off.

Presented in the metaphor of war, the virus is no longer a miniscule chunk of protein that requires a living, breathing body to reproduce but a rampaging army, mowing down everything in its path. Conveniently forgotten is that just as important as the “strength” of the virus is the health and immuno-competence of the host. Which brings me to the Spanish flu.

First off, it wasn’t “Spanish” – viruses not being good with national borders (plus most of them don’t have passports). The flu began somewhere in Europe at the end of a long and bloody war which you might recall: World War I.

The Allies, however (us, I mean, aka the Good Guys fighting the “Hun” and keeping the world safe for capitalism and democracy and whatnot) heavily censored news of the flu, thinking it would cause panic and pandemonium. (As if the war hadn’t already done that.)  So news of the flu trickled in from Spain, neutral during the war, which did not censor its news. Hence, people assumed the flu came from Spain.

Generally speaking, 1918 was not a good year, coming as it did after four years marked by new weapons and a war machine the likes of which the world had not seen before  – which is why WWI was also known as “the war to end all wars”. Millions of of young men died: cannon fodder for tactics devised by generals schooled in the gentlemanly art of 19th century war in what became known as the start of the 20th century in all its technological splendour.

Faded sepia photographs are all we have left of the many who died; dressed in those ugly boiled wool uniforms that make you itch just looking at them. Boys, really, living and dying in muddy trenches: damp, mouldy underground passages where micro-organisms proliferated as did gangrene and fungus and rot. And if anyone objected they were shot as a traitor.

I don’t tend to get sentimental about war but I confess that I wept when I saw the monument at Vimy. (“Every day they die among us,” said Auden, “those who were doing us some good.”) An entire generation lost to trench warfare.

That was the context for the Spanish flu: war, rationing, weakened immune systems, shell shock, malnutrition; the constant noise of cannons, stress, and injuries too horrible to contemplate; amputees in the hundreds of thousands. As ugly a situation as it gets. And no social programs, remember – those came much later, after the next great war. Everyone suffered, not just the military.

Medicine had little to offer: no antibiotics, no ventilators, no ICU’s, no potentially life-saving surgeries. Had there been, fewer people might have died (since it is the immune reaction that kills, not the virus), though we have no way of knowing – any more than we know how many people actually died of the “Spanish” flu.

(I suspect a fair amount of  hyperbole has crept into the numbers – particularly given the sheer number of agencies, drug companies and individuals that currently stand to gain in power and prestige from the scare tactics, not to mention funding and/or profit.)

Certainly in 1918 there was no way of testing for the virus, and even today, when we can (if we do), easily half the people diagnosed with the flu turn out not to have it. Experts call it “flu like” illness because they have no idea what it is. People just get sick when the weather gets cold, some worse than others.

So you’ll forgive me if I don’t get into a lather every time this pandemic business comes up with its inevitable reference  to 1918. Today, conditions for the majority of us in the developed world are so different as to make such comparisons  meaningless. Epidemiology shows us that the risk of getting any disease is higher if one is poor, malnourished, stressed, immune compromised; if one does not have ready access to clean water and air, nutritious food and decent  living conditions, jobs and hope. This means some Aboriginal reserves  in Canada and various pockets of poverty  throughout the United States, Europe and Japan, as well as most of the developing world.

Not the rest of us for whom hardship means our internet is down.

It wasn’t really a vaccine and a multi-million dollar PR campaign we needed last fall. Particularly since the massive expense will no doubt mean future cuts in less glamorous public health programs like suicide prevention for at- risk youth and the like. What we really needed were clear-eyed, long-term initiatives to fundamentally ameliorate the conditions of those communities on our own doorstep where people live impoverished, hopeless lives, in circumstances somewhat more similar to those of 1918.

There’s a public health program I would support. But, I doubt anybody would be interested. It wouldn’t make good TV.