Alcoholism among Native Americans

In the May 5 column, the Times Nicholas Kristof cites Anheuser-Busch, the company that makes the Budweiser and the bestselling beer in the US, Bud Light, for perpetuating alcohol dependence and addition among Native Americans and as an example of corporate greed and predatory practices. He calls for the boycott of Anheuser-Busch's products.

A small liquor shop in the town of Whiteclay, Nebraska (population 10; yes 10) sells about 13,000 cans of beer and malt liquor a day. Whiskey Tango Foxtrot? Most of this alcohol ends up at the Pine Ridge reservation that is located just a stone-throw away over the state line in South Dakota, and which bans alcohol on its territory. With the a closest major city more than two hours away, Whiteclay is where residents of Pine Ridge go to get alcohol. The most of it ends up on the reservation.

Pine Ridge is home to approximately 45000 Oglala-Sioux Native Indians living on the swath of land roughly the size of Connecticut. Last year tribal police made more than 20000  alcohol-related arrests that made up more than 90% of all arrests. But tribal police has no jurisdiction over Whiteclay since it is in Nebraska. The drink of choice at Whiteclay is Hurricane High Gravity Lager, a malt liquor brewed by Anheuser-Busch. The tribe alleges that the whole purpose of Whiteclay is to sell to Natives since there is no one else around to sell alcohol to. The tribe sues A-B and other brewers for $500M arguing that they sell alcohol knowingly of its illegal import and consumption on the reservation.
 The effects of alcohol on the reservation residents are visible and severe. Kristof gives the following statistics: "As many as two-thirds of adults there may be alcoholics, and one-quarter of children are born suffering from fetal alcohol spectrum disorders." Alcohol feeds crime, domestic violence,  suicide, risky behaviors that lead to significant health problems such as injuries and sexually transmitted infections including HIV, unintended pregnancies, etc.

Beyond a boycott or a variation thereof, solutions suggested in readers' comments included shutting down the liquor store hoping those without cars won't be able to go very far to the next liquor outlet (you can see how those with cars will make all the profit), eliminating the demand (no word on how), closing down the reservation (!), expanding the reservation to include the White Clay store and thus making it illegal (you can see how this is an especially doomed solution),  taxing sales and using proceeds to fund education and alcohol detox and rehab programs. The blame is invariably poured on reservation residents for the lack of personal responsibility, on A-B and the likes for corporate greed, and tribal leaders for inadequate and incapable governing, incompetence and corruption. There is no

Several readers suggested decriminalizing drinking and possession of alcohol on the reservation. This might seem as a sure recipe for worsening the situation, but studies and experience in countries like Netherlands showed that legalization of (some) drugs (and certainly alcohol) moves the issues from the criminal system into the realm of public health, where it belongs.  Several more countries like Belgium and Portugal have decriminalized drugs. In the case of Portugal, which abolish all criminal penalties for personal drug possession including cocaine and heroin, illegal drug use by teenagers had declined, the rate of HIV infections among drug users had dropped, deaths related to heroin and similar drugs had been cut by more than half, and the number of people seeking treatment for drug addiction had doubled. None of the nightmare scenarios such as increases in drug usage among the young and the transformation of Lisbon into a haven for “drug tourists” have occurred. (http://www.cato.org/pubs/wtpapers/greenwald_whitepaper.pdf). It is worth noting that decriminalization does not mean legalization. In Portugal, drug possession for personal use and drug usage itself are still legally prohibited, but violations of those prohibitions are deemed to be exclusively administrative violations and are removed completely from the criminal realm. Instead of prison sentences, drug users and alcoholics are targeted with therapy and harm reduction.

Alcoholism is a severe problem on many reservations across the country; there are a number of causes that feed it, and no single solution is going to be sufficient. But whatever approach is used, it must be non-penalizing. Instead it should be protective of harms of alcohol and drug use.

Health disparities and IHS

Indian Health Services (IHS), an agency within the Department of Health and Human Services, was created in 1955 to broader effort to reform health care on the reservations. In its initial survey IHS found that total mortality was 20% higher, infant mortality was 3 times higher, life expectancy was 10 years lower, and infectious diseases and accidents were more prevalent; however, heart disease and cancer were less common. In 1970s life expectancy was two thirds the national average, and the incidence of infant mortality (1.5 times), diabetes (2 times), suicide (3 times), accidents (4 times), tuberculosis (14 times), gastrointestinal infections (27 times), dysentery (40 times), and rheumatic fever (60 times) also were above the national average. Although still above the national level, by 1990 incidence of  tuberculosis was reduced by 96%, infant mortality by 92%, pulmonary infections by 92%, and gastrointestinal infections by 93%. However, disparities persisted. American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). Life expectancy at birth is five years less than that of the U.S. All Races population (72.5 vs. 77.5  years).

Congress passed several bills aimed at improving conditions on reservations. In 1975 Congress enacted Indian Self-Determination and Indian Assistance Act followed by 1976 Indian Health Care Improvement Act. These acts gave tribes more control over their health services. For the fiscal year 2012, the budget of IHS is $4.6B (for comparison, Veteran Administration total budget was $127B).

Despite a significant progress, disparities remain. Many causes were proposed and debated throughout several centuries, from invocations of providence in environmental factors such as diet, living conditions, and climate to more deterministic causes such as behavioral, genetic, and socioeconomic. Some blamed personal choices, others argued that roots of disparities lie in disrupted social conditions following colonization and continues to this day due to exploitative policies of the federal government (e.g. uranium mines, water rights). That disparities cut across a number of diseases challenges the belief the disparities are the product of inherent susceptibilities of American Indians. Instead, and rather much more likely, the health disparities arose from the disparities in wealth and power that have endured since colonization.

Going West

For the next four or five weeks I am working at Gallup Indian Medical Center (GIMC) in Gallup NM, on the border of the Navajo Reservation. Located about half way between Albuquerque, New Mexico, and Flagstaff, Arizona, Gallup was settled in 1881 as a coal mining town and became a stop for the railroad and the Interstate Highway of Route 66 in the past and the present I-40. Route 66 still goes through Gallup, and much of local sites bear history of that era. In the 1930s, 40s, and 50s Gallup has seen a lot of motion picture crews with a long list of movie stars and even two presidents, President Reagan and President Eisenhower. GIMC is a 100-bed Indian Health Services hospital that serves American Native patients, primarily Navajo. While here I will do inpatient medicine, HIV, ID, and general medicine clinics, and do home visits to Navajo patients. And of course hope to do a lot of traveling and site seeing. 

Praying with Patients

In a cramped curriculum of medical education, there is hardly enough room for anything not directly related to learning how the human body works and fails. Yet on occasion, I find us students, exasperated from discussions of arcana and enigma of diseases and dodging academic curve balls ceaselessly thrown at us by well-wishing faculty, pleasantly distracted and wondering in and through the matters of spiritual province.

One of the dilemmas crisscrossing the canvas of patient-doctor relationship is that of praying with patients. Should a physician fend off the patient's request and choose to distance with references to own precepts that do not allow him or her to join in with a plea that may be as meaningful as a medicine. Would professional boundaries of an encounter be overstepped? Is praying a private personal matter, or private to a relationship, just like the matters of sexuality, psychiatric, or legal concerns?

While the modern medicine segregates theology and science on the basis that the latter affords practical packages of knowledge that at hands of its practitioners often translate into objective improvement of organic health, Hippocrates, Maimonides, and Rene Laennec (inventor of stethoscope and a devout Catholic) practiced at God's behest and will, as messengers and deputies of God. Certainly, the environment these forebears lived and practiced was less secular than ours, but practitioners of medicine of the past and religious figures of the community -- rabbi, imams, and priests, have frequently embodied the same person

So what should a modern physician do? Does the white coat confer an obligation to evaluate every action from the perspective of the benefit to the patient? Or, citing atheistic viewpoint, refuse? Or launch into a discussion whether praying actually confers any health benefit. The conflict arises for physicians when the role of a sensitive human being conflicts with the boundaries of a medical persona. Sometimes these boundaries are too rigid and a physician should enact the role of the caring human even if it may feel uncomfortable or embarrassing not to maintain the professional veneer. On the other hand, the boundaries could protect both patients and physicians. May be we are asking a wrong question? Rather than to look at a prayer as a treatment of material afflictions, perhaps a better question would be whether a prayer can positively affect emotional state of mind. And if you don’t like the word prayer, substitute it with meditation.

Perhaps, there is no good single answer for everybody. But I will pray to have wisdom to find one for myself.

Being in the center of medical education, in fact its object – a medical student – affords a unique freedom that often does not survive as we progress towards seniority – the freedom to choose one's path in medicine and to form one's opinion about tenets upon which medicine rests.  And its gray zones. While meanings of some principles, such as primum non nocere, transcend inclinations and interpretation, a great majority of others are debatable inconclusive minefields of uncertainty. One of such areas currently attracting a lot of attention is the research involving embryonic stem cells.

While it is widely believed, by supporters and opponents of the ESC research, that stem cells indeed hold an enormous regenerative potential, how to unleash such a potential is a matter of gritty debate. The central place in this debate is taken by ethical concerns.  Such concerns drove the former president George W. Bush to limit federal funding to ESC research, only allowing such spending for investigations with ESC lines existing prior to the ban. This was claimed as an approach that would preserve the balance between ethics and scientific progress, and was hoped to satisfy sensibilities of those who oppose the ESC work on the one hand and on the other, thirst for development of new therapies by those who believe that such research is the holy grain for the preservation of human health. Furthermore, it was argued that the ESC ban would itself serve as a catalyst-in-disguise, prompting the development of new technologies, in a fashion not dissimilar to a clever work-around for a problem that cannot be solved head on. Indeed, clever ideas were put forward, and the field of stem cells was advanced by the development of so called induced pluripotent stem cells (iPSCs). These are the cells that were coaxed into ESC-like cells by clever molecular trickery. The key word here is ESC-like, for it is not yet known for sure whether these iPSCs are indeed identical to ESCs in every way, or simply appear indistinguishable at the level of detail we are currently capable to look. While some studies showed that iPSCs and ESCs are indeed quite similar in many ways, differences are also beginning to be identified. For this reason among others, the use of iPSCs in therapeutic trials lies in a foreseeable but indeed remote future. In meantime only ESCs can serve as a gold standard to further characterize the fidelity, potential, and safety of iPSCs.

Another argument often stated by opponents of embryonic stem cells research aims to question the very need for such science. They argue that instead of focusing on emotionally-loaded ESC research, we should escalate support for adult stem cells, which are considered ethically-safe. These are the cells that already found in human body, and are also capable of maturing into several types of cells, albeit with a potential restricted to fewer types of cells. If an ESC cell can become any mature cell in the body, the fate of an adult stem cells is restricted to a certain lineage or organ tissue. For instance, a hematopoietic stem cell can give rise to all cells found in blood, but it cannot mature into, say, a brain cell, at least based on the current knowledge. Proponents of adult stem cell research claim that adult stem cell research would not only leave embryos alone and alive, but also have been shown to have generated therapeutic strategies in treating and even curing many diseases. The ESCs have not been used to treat any disease, not to mention cure one.

At the first glance, this is a true statement. Indeed, the most well-known example of using adult stem cells in treatment is bone marrow transplant, which has been used for decades in treatment and even cure of cancers of blood. The argument, however, has two significant flaws. The adult stem cell research has been going on for more than five decades, during which the field had time to evolve, and research led to production of super-efficient drugs and treatment regimens. The ESC research is much younger, with the first human embryonic stem cell (hESC) line created from a fertilized egg in 1998; iPS cells were first created in 2006. To expect the ESC research to generate viable treatments in such a short period of time is unrealistic, and to suggest that that such research is less profound because of lack of therapeutic solutions is ignorant. It is ever more ignorant to argue that one avenue of research should not be pursued because a similar research has borne out viable treatment options. One who professes this point of view point of view should be asked if they would agree to be satisfied with penicillin as an only option to fight infection diseases rather than developing vaccines and other anti-microbial agents.

Scientific intricacies, however, are not the part of the ethical debate for the most part. Instead, in the epicenter lies the conflict of dogmas. The opponents of the ESC research state that in their view life begins at conception, and by destroying an embryo one destroys an individual. The activists and proponents of the ESC research follow a line of thought summarized by Harvard paleontologist and evolutionary biologist Stephen Jay Gould, "I do not grant the status of a human life to a clump of cells in a dish, produced by fertilization in vitro and explicitly destined for discard by the free decision of the man and woman who contributed the components."

An individual vs a clump of cells in a dish.

It is wishful thinking to suggests that this conundrum can be resolved based on definitions and clever logical sequences, for no dogma can be altered. Yet, there are examples when long-held believes and thinking yielded to innovations without quite leaving the scene and often without even having been invoked. In most of such examples, the benefit of action and innovation is usually recognized in hindsight. Consider the related concept of in-vitro fertilization. Roman Catholic Church (RCC) opposes the IVF on the grounds that it violates the rights of the child, and deprives conjugal fruitfulness of its unity and integrity. Yet, a number of Catholic women and families have undergone such a procedure and have been given an opportunity to have children, something that the RCC cherishes. A similarly divisive ethical issue of gay marriages has been under constant push-pull court battle; while only six states (CT, IA, MA, NH, NY, VT) and the District of Columbia have now recognized it, people aren't waiting -- they live and enjoy each other’s company. What seems to have happened is that the decision on where to draw the line has shifted from the government and other institutions to individuals. It might happen to the ESC research debacle. People for whom ethical concerns about the wholesomeness (and holiness) of an embryo is an unalienable principle might in the future consider the regenerative fruits of the ESC research, and perhaps even take advantage of them. When they do, we, physicians, must leave the dogmas behind, accept the wholesomeness of a patient and his or her decision, and help enable them to live meaningful lives.

Coversation is Interruption

"There are qualities that have been ascribed to the stereotype of Jews that are also ascribed to the stereotype of women who step out of line and it's about being loud, it's about being strident, it's about wearing bright colors. It boils down, I think, to making yourself obvious in a place where you're not supposed to be and if you are, you should at least have the decency to shut up and wear beige."-Judith Arcana, Interviewee, Conversation Is Interruption by Graham Street Productions

Would you notice frameless art?

The Washington Post published this sweet article Monday, April 9th (which I got via Arts and Letters Daily's RSS, an aggregator of great articles across the Web). It's kind of long, but so deliciously poignant. Also there is a transcript of the online chat between the article's author, Gene Weingarten, and the readers.

Would you stop?

Nuts and Bolts of CCLCM I

They call it Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Mouthful of proper nouns and eponyms. Well, the name doesn't tell you a whole lot what CCLCM is and what it isn't. Of course, there is the web site with the brochure de rigueur, and student blurbs about the program. There are also a lot of the "unpublished." If you dig a bit deeper into the mantle of the Internet (or shall we say, Google), you'd find lots of interesting bits and pieces publicly available. For instance, the first mention of CCLCM I was able to find is here, made by Dr. Fishleder, the executive dean of CCLCM. By the way, CME minutes is by itself a very interesting resource. Even though it is Case's CME, College's Curriculum Steering Committee is reporting to the CME, and thus minutes include discussions relevant to both programs. I sure will be coming back to check what the curriculum committee is thinking, and what dynamics to expect, given they keep posting them.

Then, there is Dr. Fishleder's presentation, which I found on the AAMC website. It gives you a very thorough overview of the program's philosophy, organization, rationale, and financial arrangements. I have to tell you that a lot of questions that prospective students asked faculty during the Second Look weekend would have been answered by this presentation. The penultimate slide of the presentation shows the increasing number of applications (604 in 2004, 728 in 2005, and 1071 in 2006). The most current numbers I found for the 2007 admission cycle were posted in the CME minutes (almost at the end). As of December 13, 2006, the number of applications received by the College Program was 1,239, a 15% increase since 2006. And there are only 32 of us in the class. Pretty competitive, if you follow that sort of rankings. I think it is so competitive that I'm not sure whether I would have gotten in had I applied a year later.

If you seriously considering applying to this school, there is an absolutely must-read blog, which I regard as the spokesblog of the program. It will tell you more than you ever wanted to know and then some.

Revisit of the Revisit

Back from Cleveland where I went for the second look weekend. To second-look what? When was the first? you may ask. The first one was during med school interviews in March of 2006. I was accepted to matriculate in 2006 to Cleveland Clinic Lerner College of Medicine (CCLCM), but chose to defer a year. Why and what happened in between is a long story for another post sometime when its retelling would earn me a sizable offer from a major publishing house.

Meanwhile, don't trust anyone saying that Cleveland is the poorest city in America two years in a row. Well, technically they are correct, but between us, they are just naysayers, someone, when invited to visit Cleveland Botanical Gardens, would hear Cleveland rather than Botanical Gardens. And so their tushes freeze in well warmed-up chairs. For those with portable tushes, Cleveland Botanical Gardens are worth seeing. And those with macro lenses and patience, it's an El Dorado of nature photography.

The Cleveland Clinic campus, which is about a mile away from that of Case U. is being actively developed. A new Heart Institute is taking shape, and a big pit is dug for some other building, which looks grand on pictures plastered on the construction vehicles. Unfortunately nobody I asked knew what it was going to be.

Downtown Cleveland is also being developed and growing like crazy mostly because all warehouses are being converted to condos. They are converted so fast that one of the buildings was mostly finished before some genius noticed that it didn't have an elevator for three ground floors. So they ended up attaching one on the outside of the building. How do I know this? From the trusty driver of the Lolly-the-Trolley that the school has arranged for us to tour Cleveland. The driver, a woman in her early sixties animated with dark energy (what would be a good GRE word for it?), praised parking lots as life-savers ("There are way too many cars on the roads, we need places to park them.") I expected her to be pro-public transportation since she's a bus driver. At another interactive occasion she asked if anyone was from Canada. As it turned out, there were none on board, but two people admitted to visiting the septentrional neighbor. But it didn't matter whether you were a native or a tourist, she had a line, "See those Canada geese? Take them back home _with you_, they don't have Green Cards." So now you know, dear Canadians, come prepared with Green Cards. If geese become subjects for the immigration debate, so will you.

In fact this line made me a tad defensive on the inside. As any foreigner will tell you, if you don't start thinking about getting a Green Card from day one, you need a sanity check. And to get one isn't easy. Before you get one, you're pretty much a nobody with no rights whatsoever. We foreigners have to prove to INS (now DHS) people sitting literally in caves (there are a number of caves under St. Louis, MO left over from old-time breweries now used by the National Record Center for storage and sorting of all immigrational paperwork) that we are worthy people. Not easy even when you have a Ph.D. and several publications to your name.

I've been in this country only six years before I decided to apply to med school. I took MCAT twice because the first time I missed the bubble in Bio/Orgo answer sheet. So if I managed to get into med school (and I got into several), you can too. Good luck.

Next time more about the Cleveland Clinic College of Medicine.

Preparedness

"[Dr. Virginia Apgar] even carried a scalpel and a length of tubing in her purse, in case a passerby needed an emergency airway -- and, apparently, employed them successfully more than a dozen times. "

From "The Score" by Atul Gawande. The New Yorker, Oct.9, 2006