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Looking Back to 2004

If you believe the doctors, nothing is wholesome:
If you believe the theologians, nothing is innocent:
If you believe the soldiers, nothing is safe.
Lord Salisbury – (1830-1903).

It is time to look back to 2004.

Most of us are worried about our health. What did 2004 do for us? Did we make any significant gains to achieve good health? Did medical science make any progress in that direction?

Viox has gone off the shelves after initially being promoted as the magic drug. Looks like Celebrex and other painkillers will go the same way. These events remind us once again that medicine is an imperfect science, clouded with uncertainties

We have experts in all kinds of fields. But experience of life teaches us that we should be careful of what the experts have to say. An article in the British Medical Journal (BMJ) says, “Despite the exponential growth of medical information, the effects of healthcare interventions are often uncertain or controversial.”

I cannot recollect any major scientific breakthrough this year that changed medical practice in a positive way. Most headlines related to medical practice were of negative nature – withdrawal of Viox, outbreak of diarrhea in Calgary and Montreal, shortage of flu vaccine in US etc.

We continue to fight the old battles against obesity (including trans-fatty acids), smoking, cancer, heart disease and trauma. These are the big five causes of most diseases and disabilities in our society. This has not changed in 2004.

The editors of the journal Science have put out a list of top 10 scientific achievements of 2004. But the list does not contain any medical breakthrough to improve our health in the immediate future. For example, here are the top three scientific achievements of 2004:

The most important scientific achievement was the landing and discovery of water on Mars by NASA’s two rovers, Opportunity and Spirit.
The second was the discovery on the Indonesian island of Flores of fossils from a species of tiny humans. These humans were one meter tall with a brain less than one-third the size of modern humans. They lived about 18,000 years ago.

Third most important scientific achievement was the cloning of human embryos by South Korean researcher Woo San-hwang and his colleagues.

Why progress in medicine is so slow?

According to the BMJ article the major hidden barriers to better health care:

-uncertainty as a result of lack of convincing evidence because of delayed or obsolete data from clinical studies;

-uncertainty about applicability of evidence from research to the patient’s bedside;

-and uncertainty about interpretation of data.

Because of these uncertainties, there is overuse, misuse and sometimes underuse of medical technology with associated errors. Patients undergo excessive investigations and sometimes inappropriate treatment.

The BMJ article asks, “Can the fog that enshrouds the medical practice be lifted?”

Yes, the article says, if we can find evidence that is judged to be important for practicing doctors. Unfortunately, most existing evidence is irrelevant or unreliable.

Yes, if we can train doctors to make decisions under uncertainty.

Yes, if our leaders and the public understand the inherent limitations of medical knowledge and the role of research in reducing uncertainty.

Unfortunately, uncertainty influences virtually all of medical decision making. And this has not changed in 2004. So, we just have to keep fighting the old battles!

Thought for the week:
To like and dislike the same things, that is indeed true friendship.
-Sallust 86-34 BC

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Christmas, Religion, and Health

“Religion is a way of walking, not a way of talking.”

William R. Inge (1868-1957)

Christmas is almost here and that gives me a chance to talk about religion.

I have lived in four continents and I have spent most of my adult life amongst people of different religions. I agree with Robert Burton (1577-1640), who said, “One religion is as true as another.” All religions teach the same virtues – forgiveness, kindness and generosity.

If one religion is as true as another then why do we need so many labels? Benjamin Disraeli (1804-1881) said that sensible men are all of the same religion. And what religion is that? Sensible men never tell!

But the current world atmosphere makes it difficult not to talk about one’s religion. Look at the politicians in this country and the USA. Religious beliefs come up for discussion all the time. Elections are fought and won on what is religiously right. It seems our values and politics are judged on the basis of our religion. There is no end to stereotyping.

What I don’t understand is why it is necessary for a sensible man to talk about his religion in public? Here, I agree with Sean O’Casey (1880-1964), who said “I think we ought to have as great a regard for religion as we can, so as to keep it out of as many things as possible.” To this I would add, let common sense prevail so that society can be just and kind.

Every religion has its share of bigots, zealots and fanatics. This is not something new. It’s been there for centuries. These people promote their brand of religious beliefs which promote divisions and hatred rather than forgiveness, kindness and generosity.

But I believe the vast majority of people (whatever their religion) use religion and spiritualism to promote good health, happiness and brotherhood of man. It is used to achieve peace and tranquility in life.

Sigmund Freud (1856-1939) said, “Life as we find it is too hard for us; it entails too much pain, too many disappointments, and impossible tasks. We cannot do without palliative remedies.” Unfortunately, religion is not what he had in mind when he suggested palliative remedies. In fact, he said that when a man is freed of religion, he has a better chance to live a normal and wholesome life.

Now, some people would agree with that. Since every religion imposes on its followers certain type of discipline. Some religions are more rigid than others. But many people find common sense flexibility more attractive than dogmatic rigidity.

Most sensible people carry on life the way they feel is best for them and their families, in a quite way, without making waves or hurting anybody’s feelings. After all one’s religion should be something very personal. Many people find happiness and comfort in religious activities in a quite way. And that is good. The happier you are, the healthier you feel.

Remember what George Bernard Shaw (1856-1950) said, “There is only one religion, though there are a hundred versions of it.” Let us respect them all so we can do unto others what we like done to us.

Merry Christmas and a safe holiday season.


Thought for Christmas:


At Christmas play and make good cheer,
For Christmas comes but once a year.
Thomas Tusser (1524-1580)

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Staying Healthy

Dear Dr. B: How do I know I am healthy? And how can I stay healthy?

This is a good question for the month of December. This is a month when most people are not worried about their health. It’s a month to shop, eat, drink and be merry. After all Christmas and New Year come only once a year.

But many people use December as a time to reflect on the year gone by and plan for the year to come by. It may be about health or about other matters. It is a good month to remind oneself to get a yearly physical examination and blood tests. And pay a visit to your doctor and ask, “Doc, am I healthy?”

“Yes,” he will say, “you are healthy if you are maintaining a healthy weight, eating right, staying physically active, not smoking, controlling your blood pressure and cholesterol levels, and if you are a diabetic then you should be controlling your blood sugar level.”

This is a bit simplistic answer but you get the point. Many factors determine good health. Maintaining good weight is important. We know that being overweight increases the risk of heart disease, diabetes, high blood pressure and cancer.

But how does one know if a person is of normal weight?

Recently the Canadian Medical Association Journal (CMAJ), published the 2003 Canadian Guidelines for Body Weight Classification in Adults which updates the weight classification system that had been in use since 1988.

The authors of the article say that although the guidelines are helpful, the absence of concrete answers to relevant clinical scenarios weakens their practical application, and they should be applied with caution. After all they are only guidelines. These guidelines should be used in conjunction with clinical findings.

The body weight classification depends on the body mass index (BMI) – kg/m2 . There are many sites on the internet were you can enter your height and weight and your BMI will be calculated for you.

You are considered underweight if your BMI is lower than 18.5 kg/m2 . This could be a marker of malnutrition or may identify people with eating disorders.

If your BMI is between 18.5 and 24.9 kg/m2 then this is considered normal and good weight for most people.

Overweight is defined as a BMI between 25 and 30 kg/m2. This is associated with increased health risks and may lead to health problems in some people. The authors say that many factors beyond BMI influence health risk, such as body fat distribution, physical activity, diet and genetic background.

Obesity is defined as an excessive accumulation of body fat. The BMI of over 30 is considered to be obese. These individuals have increased risk of health problems.

Waist circumference is also important. Healthy waist circumference in a male should be less than 102 cm and for females less than 88 cm.

World Health Organization says that in the most industrialized countries at least one-third of all disease burden is caused by tobacco, alcohol, blood pressure, cholesterol and obesity. So, if we want to stay healthy then we need to tackle these problems.

Healthy eating and maintaining a healthy body weight are the first steps in that direction!

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Heartburn, Barrett’s Esophagus, and Cancer

Dear Dr. B: I have chronic heartburn. I have been told I have Barrett’s esophagus. I believe this is a pre-malignant condition. Should I be having scope tests every year as a method for surveillance and early detection of cancer of the esophagus?

Dear reader: Answer to this question depends on the type of changes seen in the esophagus. There are many unresolved controversies regarding the surveillance and management of this condition. Let us briefly look at the whole subject of Barrett’s esophagus and the current recommendations.

All experts agree that Barrett’s esophagus is a complication of long lasting and usually severe gastro-esophageal reflux disease (GERD) – commonly known as heartburn. This may or may not be associated with a hiatus hernia.

The condition was first described in 1950 by Sir Norman Barrett. His original description has been revised few times. Currently, Barrett’s esophagus implies change in the lining of the esophagus (of any length) from a squamous type to columnar type. This change is only recognized at the time of endoscopy and confirmed by biopsy.

Barrett’s esophagus affects mainly white men, with an average age of 55 years. It occurs in only a small percentage of people with GERD – approximately five to15 percent of patients with inflamed esophagus due to reflux. There is a small but definite increased risk of cancer of the esophagus in people with Barrett’s esophagus.

About 10 percent of patients with Barrett’s esophagus at the time of the initial endoscopic examination have coexistent esophageal cancer. Unfortunately, the 5 year survival rate for patients with esophageal cancer is only 11 percent.

Is it possible to do something to prevent Barrett’s esophagus from turning into esophageal cancer?

Regular endoscopic surveillance and biopsy is recommended for patients with Barrett’s esophagus despite the high cost and inconvenience and the lack of proof that it prolongs survival. Biopsies are done to look for dysplasia.

Dysplasia is a cellular process that occurs in the lining of the Barrett’s esophagus. Presence of dysplasia indicates increased risk of cancer. It is not a foregone conclusion that patients with dysplasia will develop cancer but dysplasia remains the best indicator of cancer risk.

How often one should have scope tests and biopsies? It depends on the presence of dysplasia in the Barrett’s esophagus:
–If the patient has no dysplasia: The frequency for endoscopic biopsy surveillance is annually twice, and then, if no dysplasia is found, every 3 to 5 years. Risk of subsequently developing cancer is quite low.
–If the patient has low grade dysplasia: A surveillance endoscopy with biopsies at six months, one year, and then yearly is recommended.
–If the patient has high grade dysplasia: The management of high grade dysplasia involves repeating the biopsies right after the high grade is discovered to rule out an accompanying cancer. Esophagectomy (surgical removal of the esophagus) is the gold standard of therapy for high grade dysplasia and cancer, but experimental procedures are available.

The treatment for Barrett’s esophagus is, in general, essentially the same as for GERD and heartburn. It is either medical (acid-suppression drugs) or surgical (fundoplication). There is no guarantee that either treatment will result in the disappearance of Barrett’s esophagus or in a reduced cancer risk.

Thought for the week:
“Nothing can be created out of nothing.”
-Lucretius 99-95 BC

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!