Up@dawn 2.0

Monday, October 2, 2017

"Can I Spread the Word About an Unvaccinated Child?"

The Ethicist (nyt)
I’m pregnant with my first child, and concern for my unborn baby has prompted me to ask my friends if their children are vaccinated. One close friend, Y, has two young (vaccinated) children, and lives near another friend, X. Both Y and I have suspected for some time that X chose not to vaccinate her child, and we have been trying to work up the courage to ask her. With the new pregnancy as an excuse, the task fell to me.
It turns out that X has indeed chosen not to vaccinate. When telling me this, she also asked me to keep her answer private. While her choice is not one I would make, I am perhaps even more upset by her request that I conceal the information.
Y and X’s children play together, and we have regular gatherings with many young children present. I feel that parents have a right to know whether they are exposing their children to unvaccinated children, especially with anti-vaxxers on the rise and herd immunity declining. My frustration is compounded by the fact that X’s child attends a public school and as far as I know has no valid grounds (for instance, an immuno-compromised child) for exemption.
I respect the privacy of others; however I don’t like being asked to be complicit in placing others at risk. I feel a responsibility to other parents of young children, especially parents of new babies who are not yet vaccinated. Do I respect X’s request to keep the information secret? Name Withheld
Having children can be scary. Parental love, like all love, makes you vulnerable, because you can be profoundly threatened by harm to someone else. Unlike most other loves, however, parental love also involves overwhelming responsibility. Your young children are enormously dependent on you. In light of these intersecting conditions, it’s not surprising that parents can be panicked by the possibility that they will fail as caretakers. Such panic has been promoted by activists who spread untruths about the dangers of vaccines, especially the vaccine that protects against measles. (The anti-vaccination movement was fueled by a discredited study from 1998 that linked the measles vaccine to autism.) I refer to untruths and not lies, because the anti-vaccination movement is no doubt largely sincere. Sincerity, though, doesn’t make them true.
As you make clear, two benefits come from vaccination. First, a vaccinated child is less likely to suffer serious harm from exposure to the relevant pathogen. Second, if enough children are inoculated, everyone’s risk is reduced by the “herd immunity” you mention. That means that you can help protect all the kids in your community, including those who (because they are immune-compromised or allergic to the vaccine) can’t be vaccinated.
When vaccination rates are high enough, the disease disappears from the population until it’s reintroduced from outside. The level where this happens is called the “herd-immunity threshold”; and it varies depending on the efficacy of the vaccine and the contagiousness of the pathogen. Unfortunately the immunity threshold for measles is very high, around 92 to 94 percent. Fortunately, in most of the United States, we’re at that level. In 2000, the disease had effectively been eliminated here. But there are 10 million cases a year outside the United States, and travelers (especially unvaccinated ones) bring it back. The anti-vaccination movement, meanwhile, appears to have depressed vaccination rates in certain communities, as happened recently in Minnesota. So the virus reappears, and outbreaks can happen.
Given the combination of vulnerability and responsibility I mentioned, one reason parents avoid vaccinations is some version of this thought: “If I decide to vaccinate my child and something bad happens, my child will have suffered at my hands.” But if that’s a sensible thought, so should this one be: “If I decide not to vaccinate my child and something bad happens, my child will have suffered at my hands.” What’s important is whether the likely results of vaccination are better than the alternative. And the answer, once exposure to measles is a possibility, is yes. Even if that weren’t true, there would be a second reason for being vaccinated: If we all did it, we would get herd immunity.
At that point, someone who thought that there were even small risks associated with vaccination might say, “Hey, I’m going to avoid the risks of vaccination for my kids, because the disease is very unlikely to reach them.” But that’s true only because other people are vaccinating. So someone who thinks this way is a free rider, like the person who figures she doesn’t need to pay the bus fare because everybody else does. One of the anti-vaxxers’ offenses is refusing to undertake their fair share of the burdens for something from which they benefit.
And just to be clear about how great those benefits are: In a typical year before the measles vaccine was available in the United States, the virus infected millions, sent tens of thousands to the hospital, gave encephalitis to at least a thousand and killed hundreds. Given that measles is a highly contagious disease that can be fatal and that the risks of vaccination are minuscule, not vaccinating your children is wrong. X has done wrong, too, if she’s lying to her kid’s school — public schools require vaccination unless there’s a recognized medical reason not to or the parents have a sincere religious objection. (Can’t imagine a religious objection? Many Christian Scientists believe that health problems should be dealt with by prayer, not medicine, and so some reject vaccination, even though the founder, Mary Baker Eddy, said that a Christian Scientist should be vaccinated “if the law demand” and then “appeal to gospel to save him from bad physical results.”)
To be sure, the direct risk of infection remains very small, and the main harm done by avoiding vaccination would occur only if more people did it. But it isn’t crazy to worry about the danger of contact with unvaccinated children; parents are entitled to know the status of the kids that their kids play with. Something like 3 percent of vaccinated people can still get measles (though it’s very likely to be less serious than in the unvaccinated). And children aren’t normally vaccinated until they are 1, so older children with infant siblings need to be kept away from the virus, too.
What about respecting X’s request that you keep her answer private? There’s an important norm here, but it doesn’t necessarily apply to information that other people are entitled to know. Besides, you and Y have conferred in your effort to find out the truth; how are you supposed to respond when Y asks you what you learned?
Tell X that she ought to inform Y about the situation and also tell the school the truth. Letting her do it shows that you acknowledge her request not to pass the information on yourself. Give her a few days. If she continues to leave Y in the dark, though, you can tell Y what you’ve learned. As far as the school goes, there may be no easy alternative to informing its officials directly. Why not tell X that you’ll be checking on her? Because that would turn a request to tell the truth into a threat.
But some vigilance is warranted, especially now that anti-vaccination “science” has a proponent in the White House. A recent study found that even a small increase in what’s diplomatically called vaccine hesitancy would have large public-health consequences. Talk about scary.
I volunteer at a used-book store whose proceeds benefit the local public library. Our books are donations and library discards, which we sell at very low prices. Occasionally an old or rare book comes in. We then check the internet to see who else is selling that book and price it at the lower end of what others ask. Recently I came across a book that was priced by another volunteer at a normal low price. However, the book seemed to be an old and rare book that should have been checked. I bought the book at the low price. Do I have an obligation to check the going internet price myself, and if it is high, pay the difference or return the book? Name Withheld
You can tell yourself that you just did what anyone interested in the book would have done. After all, your store is no worse off than if a random customer had bought it. But people who work for charitable businesses have an obligation to look after their interests. If you thought the book was underpriced, you should probably have brought it up with the other staff members and, if you still wanted it, paid the price that was set once its value was known.

Tuesday, September 19, 2017

The Best Health Care System in the World

Friday, July 28, 2017

Dying: A Memoir

Years ago, a palliative care doctor told me that what he knew of a patient’s personality often had little to do with how he or she coped with dying. Generous people could become ungenerous, and brave people could become frightened. Angry people could become gentle, and controlling people could become Zen. Dying, in other words — like combat, like becoming a parent, like any transformative life event — doesn’t always reveal or intensify aspects of our character. It sometimes coaxes out new ones.

For a long time, the writer Cory Taylor took, by her own admission, “a fairly leisurely approach to life.” That changed in 2005, just before her 50th birthday, when doctors removed a mole on the back of her leg. Melanoma, Stage 4. She wrote the novel she’d always meant to write, then another. Then she wrote “Dying: A Memoir.”

The book rings louder in my imagination the more time I spend apart from it, a kind of reverse Doppler effect. “Dying” is bracing and beautiful, possessed of an extraordinary intellectual and moral rigor. Every medical student should read it. Every human should read it. My own copy is so aggressively underlined it looks like a composition notebook.

“Dying” is short, but as dense as dark matter. There is an electrifying matter-of-factness to it, one that normalizes death, which is part of Taylor’s goal. She deplores the “monstrous silence” surrounding the subject of mortality. “If cancer teaches you one thing,” she writes, “it is that we are dying in our droves, all the time. Just go into the oncology department of any major hospital and sit in the packed waiting room...” (nyt, continues)

Cory Taylor, a fine Australian writer, has died within weeks of the rush-publication of her last book, Dying: A Memoir.
Taylor, who had just turned 61, died peacefully on Tuesday in a Queensland hospice with her family at her side... Sydney Morning Herald

Debunking "What the Health"

There’s a sensational new documentary out on Netflix that seems to have a lot of people talking about going vegan.

In the spirit of so many food documentaries and diet books that have come before, What the Health promises us there is one healthy way to eat. And it involves cutting all animal products from our diet.

Meat, fish, poultry, and dairy are fattening us up, giving us cancer and diabetes, and poisoning us with toxins, Kip Andersen, the film’s co-director and star, tells us.

Reflecting on a youth spent inhaling hot dogs and cold cuts, he asks, “Was this like I had essentially been smoking my whole childhood?”

No, Kip, not really... (continues)
Q. It seems that many people who are not elite athletes are now hyper-focused on protein consumption. How much protein does the average adult need to consume daily?

A. The recommended intake for a healthy adult is 46 grams of protein a day for women and 56 grams for men. And while protein malnutrition is a problem for millions of people around the globe, for the average adult in developed countries, we are eating far more protein than we actually need.

Most American adults eat about 100 grams of protein per day, or roughly twice the recommended amount. Even on a vegan diet people can easily get 60 to 80 grams of protein throughout the day from foods like beans, legumes, nuts, broccoli and whole grains.

The Hartman Group, a consumer research firm that has been conducting a study of American food culture over the past 25 years and counting, has found that nearly 60 percent of Americans are now actively trying to increase their protein intake. Many are avoiding sugar and simple carbohydrates and turning to protein-rich foods, snacks and supplements. The firm calls protein “the new low-fat” or “the new low-carb,” even “the new everything when it comes to diet and energy.”

“Soccer moms feel they can’t be anywhere without protein,” says Melissa Abbott, the firm’s vice president for culinary insights. “Really it’s that we’ve been eating so many highly processed carbs for so long. Now it’s like you try nuts, or you try an egg again, or fat even” to feel full and help you “get through the day.”

In her research, Ms. Abbott said she always seems to be finding beef jerky in gym bags and purses, and protein bars in laptop bags or glove compartments. Many consumers, she notes, say they are afraid that without enough protein they will “crash,” similar to the fear of crashing, or “bonking,” among those who are elite athletes.

But most of us are getting more than enough protein. And few seem to be aware that there may be long-term risks of consuming too much protein, including a potential increased risk of kidney damage. To learn more, read “Can You Get Too Much Protein?”

Saturday, July 22, 2017

Gene editing, techno-optimists

Gene editing threatens to homogenize society, says Atul Gawande. Aberrant yet valuable characteristics are under threat. Think of George Church's narcolepsy... more »

Biology and its discontents. Techno-optimists come in all stripes — scientists, seekers, grifters, con artists. They share a zeal for augmenting their bodies... more »

The Gene Machine: How Genetic Technologies Are Changing the Way We Have Kids—and the Kids We Have
by Bonnie Rochman
Scientific American/Farrar, Straus and Giroux, 272 pp., $26.00
DNA Is Not Destiny: The Remarkable, Completely Misunderstood Relationship Between You and Your Genes
by Steven J. Heine
Norton, 344 pp., $26.95
A Crack in Creation: Gene Editing and the Unthinkable Power to Control Evolution
by Jennifer A. Doudna and Samuel H. Sternberg
Houghton Mifflin Harcourt, 281 pp., $28.00Graeme Mitchell/Redux

In recent years, two new genetic technologies have started a scientific and medical revolution. One, relatively well known, is the ability to easily decode the information in our genes. The other, which is only dimly understood by the general public, is our newfound capacity to modify genes at will. These innovations give us the power to predict certain risks to our health, eliminate deadly diseases, and ultimately transform ourselves and the whole of nature. This development raises complex and urgent questions about the kind of society we want and who we really are. A brave new world is just around the corner, and we had better be ready for it or things could go horribly wrong.

The revolution began in benign but spectacular fashion. In June 2000, President Bill Clinton and Prime Minister Tony Blair announced the completion of the first draft of the human genome. According to a White House press statement, this achievement would “lead to new ways to prevent, diagnose, treat, and cure disease.” Many scientists were skeptical, but the public (who footed much of the $3 billion bill) probably found this highly practical justification more acceptable than the mere desire to know, which was in fact a large part of the motivation of many of the scientists involved.

During the 2000s, Clinton’s vision was slowly put into practice, beginning with the development of tests for genetic diseases. As these tests have become widespread, ethical concerns have begun to surface. Bonnie Rochman’s The Gene Machine shows how genetic testing is changing the lives of prospective parents and explores the dilemmas many people now face when deciding whether to have a child who might have a particular disease. Some of these technologies are relatively straightforward, such as the new blood test for Down syndrome or the Dor Yeshorim genetic database for Jews, which enables people to avoid partners with whom they might have a child affected by the lethal Tay-Sachs disease (particularly prevalent in Ashkenazis). But both of these apparently anodyne processes turn out to raise important ethical issues... (nyrb, continues)

Monday, June 26, 2017

The Symptoms of Dying

You and I, one day we’ll die from the same thing. We’ll call it different names: cancer, diabetes, heart failure, stroke.

One organ will fail, then another. Or maybe all at once. We’ll become more similar to each other than to people who continue living with your original diagnosis or mine.

Dying has its own biology and symptoms. It’s a diagnosis in itself. While the weeks and days leading up to death can vary from person to person, the hours before death are similar across the vast majority of human afflictions.

Some symptoms, like the death rattle, air hunger and terminal agitation, appear agonizing, but aren’t usually uncomfortable for the dying person. They are well-treated with medications. With hospice availability increasing worldwide, it is rare to die in pain... (continues)

Tuesday, May 30, 2017

Web MD

“You can’t list your iPhone as your primary-care physician.”

“You can’t list your iPhone as your primary-care physician.”