Tag: medication

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Biased Results

The use of statistics in presenting results of research is common practice. Empirical studies are summarized using statistics and statistical methods based on samples of bigger populations are cost efficient. However, care needs to be exercised when interpreting results to guard against inappropriate conclusions derived from biased estimates. Since the topic has been highlighted and methods proposed to handle them, these methods were deemed worthy of a Nobel prize.  The basic problem of a bias due to a selective sample has been demonstrated by Stockwell et al. (2024). The authors investigate the old question, whether a little bit of alcohol consumption (per day) could be beneficial for our health. The statistical issue which needs careful examination is the construction of the control group against which the results are compared. Apparently many studies have biased control groups which included persons in the not drinking control group who had stopped drinking for bad health previously. Compared to those persons with other health conditions those drinking a little bit compared rather well. But of course such individuals should not be present in a control group. Of the control group is biased due to many persons with below average health the groups of interest consuming higher levels of alcohol do not perform so badly. Hence, interpretation of results from medical or social science studies has to consider carefully the actual or potential sources of bias. Not really a new results in statistics, but still not well known or understood by the public at large. Drug consumption as well as studies of this consumption could deserve the same sticker: handle with care. (Image: Extract from Tenier II David, Les fumeurs, also entitled Chanson à boire, 17th century, Paris Petit Palais).

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Guidelines Follow-up

The are many professional organisations which agree after thorough discussions on guidelines how to conduct professional services. As long as we have such guidelines, the adherence to the guidelines is an issue as well. This is part of a research program of organisational sociology, but there is a rather strange paradox in this field of compliance with guidelines. In the most highly educated professions like medical doctors, the rate of compliance to guidelines is below average. A study of 20+ years ago published in the JAMA Journal: Cabana et al. (1999) “Why Don’t Physicians Follow Clinical Practice Guidelines?” highlighted this paradox among medical doctors. The lack of awareness of existing or changed guidelines is one of the major reasons mentioned in this respect. Self-efficacy is also an issue, but mentioned less frequently for not following guidelines.
Besides a professional bias, related to the above average educational attainment of physicians, (believed) superior coping mechanisms compared to the average population might be at work. Mastering advanced technology might lead to a behavior that assumes to be able to handle higher risks as well.
For a profession that is used to confront issues of life and death on a regular basis some adherence to a very specific medical guideline might appear a negligible risk. However, maybe comparable to some cases among politicians or priests a logic: “rules or guidelines are for others to follow” rather than the physicians bear obvious risks to these persons themselves, but even to others in specific circumstances like the spreading of infectious diseases.
Drug or substance abuse has been evidenced before in relationship with specific professions or in historical time periods. We should take care to repeat similar studies (Cabana et al. (1999) every now and again.

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Law and Witches

Medical and chemical authorities have been questioned for many centuries. As far back as Friedrich Spee (1591-1635) in the early 17th century there were even among the clergy men with enlightened views on what might be helpful ways to assist people on their journey to better health or simply pain relief. This did include many unhelpful or detrimental methods as well. Scientific rigor was not well established at that time, which opened up many doors for alternative diagnosis and treatment. From a historical and sociological perspective the closing procedures of professional organizations are interesting as well as opposition to them. Early moderators between hardliner positions are rare at the times of forceful and fierce competition between opinions and doctrines that characterized medieval history. In the absence of an independent judiciary earlier moderation could be influential in specific instances. A testimony for can be found in a documentation of the biography of Friedrich Spee and the society that promotes the memory of such exemplary behavior.

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Law and Legality

Some persons consider themselves to stand above the law or push all interpretations of regulations beyond usual understanding of it. Even after a person has been dealing with pharmaceuticals or drugs used also for doping purposes, the conviction of such a person may take several years if not decades. In France, Mr Bernard Sainz seems to be a good example of such a relentless case of practicing para-medical consultations to assist mainly cyclists in endeavors to win championships or professional status. Le Monde  and Cash investigation have raised awareness of the public for such dubious practices. The “French Federation du cyclisme” and medical doctors association fight a continued legal battle against this persons exercising illegally such doping assistance. 

With apparently 56 legal procedures in connection with this person, the legal system has to bear the majority of costs of such illegal practices.

The reach of such dubious practices might be extended if the systems beyond doping, but for assisted euthanasia cannot be controlled effectively. Hence, the precursor cases of positive stimuli like doping pose similar challenges to the legal system as “negative stimuli” weakening persons as assistance to die. The end of a life course is not only a medical issue. Society-wide debates need to take place in order to organize a large consensus on the implications more liberal practices shall entail. 

(Image: Palais de Justice, Paris 2025)

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Synthetic opioids

Across the globe there are many tough lessons to be learned about synthetic opioids. These psychoactive substances fall under special legislation and can only be used with medical prescriptions. The strength of these substances is usually compared to heroin and the risk of addiction to these substances is very high.
A recent paper in International Review of the Armed Forces Medical Services (2024) has highlighted also “the abuse of the synthetic opioid U-47700” at times of military conflict. The power of these drugs to suppress the feeling of pain is helpful for medical operations. The abuse, however, may consist in the use of the drug to “keep fighting whilst pain is suppressed”. Such use of synthetic opioids increases the risk for addition and the fatal consequences of overdoses. The reporting of such occurrences in a specialized medical journal is an important warning against the conscious and willingness to abuse the drugs for war purposes.
The finding reminds us of the abuse that was already widely spread during the Nazi led 2nd World War (“Der totale Rausch“). The addictive potential was experiences even after the war time in terms of active combat was over. The costs to society of such abuse as well as use of supply chains of provision of opioids during peace times remain a problem for many years after the war. After a war, the war on drug abuse continues. Fighting addiction is a lengthy and painful process.

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Defence Spending

As in research there are many dual use products, which can be part of defence spending. Robotics in production or rockets to launch satellites for telecommunication are such examples. Much less known to the public is the amount of military spending that goes into medical developments that benefit both the military as well as the civil population. Countries build a whole ecosystem round the provision of medical services for defence purposes , which consists not only of a sufficient number of qualified persons, but also companies that provide specialised products. Most of them have civil applications as well after minor adaptations.
Oxygen provision was a prominent example of a product that has civil and military uses in treatment of respiratory infections or contaminations. A mobile transportable operation table is another element of daily rescue services as well as potential use in situations of conflict, just like anesthesia machines. An increase in spending on such infrastructure and the necessary long-term training of persons operating and maintaining these medical applications take time and considerable financial resources.
The current debate in Europe and NATO neglects the considerable time delays in production and provision of the equipment. Research on “Skill Needs in OECD countries” has shown the substantial delays between sudden skill needs and the time to train high-skilled persons.
The International Review of the Armed forces Medical Services is a journal dedicated to publish up-to-date information on needs of medical products and persons trained to use them in special emergencies. The need to safe lives in extreme and dangerous conditions needs preparation of thousands of specialists. Of course we hope that such an incidence will not happen. The persons and material have an obvious potential to serve the civilian population in more peaceful times as well. The unfortunate “hog cycle” in skill provision is not a problem for dual use products or services.
(Image: edited extract of a mobile operation table)

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Health Tech

Health technology assessment (HTA) is an interesting scientific field. The new digital opportunities allow people to participate in medical and medication trials in their homes or even in bed. Their health data and the administration of medication is also encouraged and sometimes supported through digital devices. The pharma and health industries have many devices ready to go. The differences to the traditional forms of medical trials, however, is an issue as we want to compare the results from both kinds of trials. Participants of trials, might prefer or struggle with these novel kinds of study designs. In any case the results will be impacted in several forms (Study Link). In the best of all worlds for the researcher the effects will cancel out each other, but is rather unlikely. Some participants will reach more positive effects with the use of digital tools, whereas others are challenged and might even abandon during the trial. Monitoring during the study (for example through digital inhalors) is another advantage of such distributed trials. Rather than taking adherence to a trial medication for granted, digital tools allow a more precise monitoring of subgroups as well. Data and effort invested in the trial is preserved through the easier access to person’s information, assuming continuous readiness to stay on in the trial.
Our own smartphones are still underexploited in terms of health monitoring and use in research designs. The possibilities to link data to other external data sources shall further advance the research potentials in many interesting ways. Data protection and data security become even more important with the ever smarter phones and connected devices.

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Health data

2025 will be a crucial year for health data across the EU. Germany introduced the electronic patient card, which can store basic information to then access data in the health insurance cloud for medical doctors, hospitals and other related health services. Potentially this is a great step ahead as some tests do not have to be repeated if they had been completed recently before already.

In pseudomised form, research may draw samples from such databases to enhance our science based understanding of disease. The evaluation of public health interventions becomes easier and medium and long term efficiency of measures can be assessed in many instances.
The Belgian research using health data has met to discuss the potential and limitations to link health data to other data sources to allow more complete and more complex analyses of health and disease processes. Another extensive data source sits on our smartphone. Collection of steps walked, sleep patterns or heart beats give valuable insights into a person’s own contribution and care about personal health. Although data are frequently incomplete, researchers are used to estimate missing data on the basis of existing or comparable person’s data. The basis for improving health for all are quite promising, data handling and linking them will be a challenge to the competence of all stakeholders and everyone involved in better health. It will be stressful before it becomes a routine.

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Shorter is better

Contrary to a lot of received previous recommendations, the shorter duration of antibiotics prescription and use (3-5) days is overall better than the prolonged use of durations between 7-14 days (JAMA Link).  A so-called narrative review of medical studies (Lee et al.2023) reports more precise results separate for medical indications (pneumonia, sinusitis etc.), which tend to go in the same direction for the majority of indications. In view of the serious issue of antimicrobial resistance, a consequence of overconsumption and too widespread use of antibiotics (also in animal health and food production), the slogan of shorter is better should receive serious attention.
It is not only a medical, pharmaceutical or public health issue. The topic has become an issue of nutrition as well. The food chain contains largely unknown amounts of antibiotics as well, especially if larger amounts of animal or fish products are part of it.
The knowledge from these sciences has still to filter through to the broader public. This means it has become a social science topic as well. The transmission of knowledge and patient expectations on prescriptions, which is also linked to regulations concerning sick leave, make it more difficult to shorten prescriptions of antibiotics. There is a steep challenge to change behaviour according to the new mantra “shorter is better” with respect to antibiotics, even if we know that it is better for all of us in the medium or long term.
(Image: Jan Harmensz. Muller, De keuze van de rechte levensweg 1571-1628, MRBAB, Brussels)

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On Dosage

  1. Dosage is key. We all know it from everyday expériences. Certainly from drinking alcohol we know the tricks that dosage can have on us. Consumption in small doses is fine and enjoyable, but larger amounts cause all sorts of trouble. In pharmacology the effect of dosage is applied with particular virtue. Small doses even of a poison can have beneficial effects. More of rhe same might well kill you. The same rationale applies to other fields as well. Physiological training effects depend a lot on the right amount of training and the timings or intervals between training sessions. In managerial, economic or social applications the question is not only about what is the right remedy, but also how much of it. The interest rate decisions of central bankers are mostly concerned with dosage rather than « whatever it takes ». A minimum wage increase is equally about dosage and we all have additional examples.
    Even in art, take painting or music, dose and pose, that is the question. It is quite surprising that such an overarching issue has received rather little attention, comparatively or only among specialists in each field.
    It appears strange, but it is possible to have only a little bit of war, as opposed to comprehensive conflict. The applications of dosage are manifold.
    Learning about dosage might prevent binge learning at first and binge viewing later on. In the age of tiktok and social media, dosage has become a key competence. (Image Extract of Gustave Courbet Die Welle 1870, Alte Nationalgalerie Berlin).
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Bi-directional Sleep

For most of us bi-directional sleep is a question of sleeping on the left or right side, or on our back or front, head left or right. In immunology bi-directionality of sleep has another meaning. The immune system is linked to sleep in a bi-directional manner. Good sleep enhances the immune response of cells (direction 1) and infected blood cells for example send a signal to the brain to extend sleep. The study by Huynh et al. (2024) in Nature has demonstrated this bi-directional mechanism. It allowed mice who slept well after an imposed heart attack to recover in a better way than those whose sleep got interrupted during the experiment. The most natural response to a heart attack or acute coronary syndrome is more sleep. This is induced by an inflammatory reaction in the brain, which « orders » your body to increase deep sleep. 😴 Sleep is more than just rest, it may be part of healing. ❤️‍🩹 (people looking at Caspar David Friedrich „Infinite Landscapes“, exhibition Alte Nationalgalerie Berlin 2024)

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Science Fraud

It is a big issue if publications in science in high reputation journals have managed to pass a rather lengthy and thorough peer review process and still contain evidence based on fraudulent data. The worst case scenario that based on this wrong evidence tests of useless drugs are performed on patients in hope of an honest concern for their health. In fact the financial rewards and even academic rewards have been achieved only through the successful publication of a bias introduced into the data and/or analyses of the data. The fraudulent researcher became subsequently Director of the institute of agingwhoch is part of the American National Institute of Health (NIH) and an academic reference in health sciences far beyond the USA. It is the merit of Charles Piller and his team to persist in challenging the treatment recommendations which were concerning Alzheimer and Parkinson diseases. The checks and balances in the academic research have failed and a serious reconsideration of the procedures should follow, not just business as usual. The reputation of scientific research is at stake beyond the natural sciences and medicine, although the normal way of proceeding is just to qualify such events as singularity and specific to a single discipline. Aging is also not just treated by one single discipline. Hence, there is a need to review the review process and publication practices. The Boeing airplane control failures were also indicating that reviews of technology are subject to high risks. Independent checks and control are hard to ensure in advanced subject matters, but sufficient time and resources have to be devoted to the process. (Image Repair Lab Deutsches Technikmuseum DTM2024).

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Own Insulin

People who suffer from type 1 diabetes do not produce enough insulin themselves. The World Health organization estimated that „in 2017 there were 9 million people with type 1 diabetes; the majority of them live in high-income countries“ (WHO 2023). The report on successful reprogramming of stem cells of a person to produce insulin again and subsequently transplanting these cells into the same person allowed to produce own insulin again for that same person (Mallapaty, 2024). The hope for millions of people with type 1 diabetes is high that eventually there will be a cure to the disease. Scientists caution that there are no data yet for how long the transplanted own stem cells will produce insulin. Hence, the hope is driving research forward on a promising way forward. The case of type 2 diabetes is very different as additionally the absorption of insulin in the body causes problems. We keep walking and building muscles to facilitate the insulin absorption in the body to guard against the onset of type 2 diabetes. Interaction of diabetes and aging is another topic that needs our attention as rapidly aging societies are at higher risks to face many more people with various forms of diabetes.

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Back pain

Most people know some form of back pain. This is understandable as an ever increasing share of people work in seated positions and spend additional leisure time in a similar position (gaming). Recurrent back pain is a frequent diagnosis. An Australien study has found a rather simple remedy for the widespread pain. The WalkBack experiment succeeded to significantly reduce recurrent lower back pain in study participants. Individualized and progressive walking accompanied by an education program did the trick. Keep on walking and try to extend the range of the exercise. It’s amazing to witness how the human body adapts to being challenged. Learning about the mechanics at work like the release of own personal “pain killers” hormones helps to trust in your body’s positive response to each dose of the challenge to pain. Do not walk too quickly too far. Stretching is a must and not an option. Go for it. Modern technology (in any smartphone) supports your efforts with counting your steps and measuring distances. Keeping track of a “pain diary” might give you guidance not to overdo the exercise and pause activities. Join a group of friends or people who are like-minded and get adequate shoes and clothes to feel comfortable while walking and afterwards as well.

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Patient Empowerment

The empowerment of patients is a well-established practice in the treatment of diabetes. Measuring your own blood sugar and adjusting your medication to the self-monitored data is common practice. For patients with high blood pressure this patient empowerment is less prevalent. A medical study carried out in Valencia (Spain) by Martínez-Ibáñez et al. (2024) has tested the effects of such a self-monitoring and self-medication experiment.
The results publishes in (JAMA) gave rise to considerable attention in the profession as the empowerment of patients is one way out of the likely increasing shortage of medical professionals in aging societies. Whereas other studies found that total costs to the medical system might increase, the study in Spain provides evidence of the cost-reduction effect of such an empowerment. 24 months after the beginning of the trial. After the establishment of a “medication based on an individualized prearranged plan used in primary care” the self-administering participants achieved a significant decrease in their blood pressure that lasted until the end of the study after 2 years. The drop-outs of the study seem to follow a random pattern.
The conclusion gives support to the potential of patient empowerment in the widespread treatment of higher blood pressure beyond the regular visits of medical doctors. The monitoring of changes in lifestyle add to this to keep the costs of health care under control in aging societies.

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Weight Stigma

The fashion industry has for a long time produced images of mostly women and men that did not correspond to the normal weight distribution of people. Skinny models were present across all media. The so-called social media of today amplify this trend further. The “Barbie hype” has reinforced the idea of low weight as a socially desirable norm. In scientific research the term coined for this phenomenon is “internalized weight stigma” (IWS). A study shows (Highes et al. 2024) it affects more women than men and more people who are described as socioeconomically disadvantaged adults. Pressure to lose weight originates from multiple sources and social media platforms have given rise to bullying. A major outcome of IWS is eating disorders as eating is often wrongly associated to be the only cause of higher weight. It is not. Many other factors contribute to the actual weight of a person. Even the overuse of the body mass index (BMI) as short hand version to define overweight or obesity is misleading for persons with strong muscles. Just fixing on one parameter of body shape or weight tends to reinforce weight stigma. “Keep walking” and a regular healthy diet, this avoids to internalize a weight stigma. Exercise is fun, the more you do it in a group, the easier it is to get going regularly. We ought to keep trying and eventually it will become a routine.

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Causal Benefit Model

In the field of medicine we move more and more towards precision medicine. Previously, the term of personalized medicine was used which suggested to a certain degree that a personalization might be feasible. The budget constraints have forced us to change the term to avoid unrealistic, untenable promises. In the field of cardiology scientific advances advocate to shift from a risk-based model of treatment to a causal benefit model. (Kohli-Lynch et al. 2024 Link). Long-term benefits of a treatment are more promising, if the treatment addresses the causal mechanisms at work. It is wide spread practice to deal with general risk profiles as guidelines as the precision medicine based on a causal benefit model is far more laborious since to search the causal mechanism at work requires additional testing of hypotheses. This becomes immediately clear if genetic causes enter into consideration. Nevertheless, medical research advances more and more in this direction. Genetic testing has been shown to be useful in analyzing and treating issues like sudden cardiac arrest (in survivors). We are somehow aware that genetics may play a role here, but we shall need a lot of additional studies to make the causal benefit model a feasible option for widespread applications. Targeting research in this field will offer new avenues for precision medicine in the 2020s.

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Personal Health

Most people would agree, health is a personal issue. From the onset of life, we have package of genes that predetermine a number of factors of our personal health. Epigenetics has taught us there are many factors to take into account additionally. Environmental factors have huge impacts as well. Improvements in the availability of medical devices in the hands of individuals as well as AI systems on portable devices like smartphones facilitate the monitoring of personal health. Several indicators of early-onset of illness can be retrieved from such devices. Dunn et al. (2024) show that prior to the onset of symptoms of Covid-19 or influenza portable devices can indicate the presence of infections through indicators of resting body temperature, heart rate/min, heart rate variability/millisecond or respiratory rate/min. Combined with the indicators of air quality, indoors as well as outdoors, the presence of allergens a much more personalized data set emerges which can easily be part of an AI-assisted diagnosis. More abundant personal health data and analytical power allows remote and digital health applications to inform patients, medical doctors and the public at large. Digital health technologies are only at the beginning to unfold their potential. Prevention becomes more feasible using such devices, medical professionals should be allowed to focus on interpretation of data and treatment rather than simple data gathering. Thinking about digital health technologies points in the direction of dealing with climate and environmental hazards as sickening causes more forcefully. Personal medicine and personal health are, after all, still heavily dependent on health and safety at work, commuting practices and all sorts of pollution. Personal health, however, is a good starting point to raise awareness of the potentials of digital health technologies to better our lives.
(Image: AI MS-Copilot: 2 robots run in a city. They sweat. The air is full of smog. 2 other robots rest near pool. All look at their wrist watch showing heart beats)

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Stroke

A stroke is a very serious medical incident. The NIH defines it in easy language as the the moment in which “blood flow to the brain is blocked or there is sudden bleeding in the brain“. Thanks to a European HORIZON project  forecasting models are produced to estimate the likely incidence until the year 2050 by age and gender within Europe. The good news is major regional imbalances of incidence and mortality have been reduced and will likely be reduced across Europe. The challenge remains the aging of societies which necessitates to address the issue of strokes in each single region of the European Union. We know that the shorter the time to treat a stroke immediately after its occurrence, the better the survival chances and the better the prognosis for (partial) recovery.
In the US the widespread use of blood thinners which tripled over 30 years has not lead to the reduction of intracerebral hemorrhage (Link to studies). High blood pressure and arhythmic heart beat are major causes of this often disabling medical event. The study by Wafa et al. (2024) uses age-pyramids to demonstrate the effect that as European societies are aging the incidence of intracerebral haemorrhage occurs with increasing age and even more so for women than men of 80 years and older.
Prevention of high blood pressure through walking or careful endurance exercise seems even more indicated for an aging society.
Image below from Wafa et al. (2024), The Lancet Regional Health, Europe.

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Drogen Rausch

Bereits in 2015 hat Norman Ohler die Ergebnisse seine Recherchen zu Drogen in der Zeit des Nationalsozialismus vorgelegt. Der Spiegel Bestseller liegt in 2023 in der 12. Auflage vor. Methamphetamin war demnach bereits vor dem 2. Weltkrieg eine Volksdroge. Die unter dem Namen Perventin gehandelte Droge war nicht nur unter Medizinstudenten wegen der aufputschenden, wachhaltenden Funktion bekannt. In den ersten beiden Kriegsjahren, oft wegen der schnell voranschreitenden Nazi-truppen, als Blitzkrieg bezeichnet, wurde die Droge gezielt eingesetzt. Abhängigkeiten waren im Anschluss häufig und bereits am 12.6.1941 wurde im Reichsopiumgesetz Perventin als Betäubungsmittel erklärt (Ohler, 2023 S. 137). Die Kontrolle und Verschreibungspflicht wurde demnach erheblich verschärft. Bis in die höchsten Ebenen bestand das Drogenproblem- und die Abhängigkeit von der bewusstseinsverändernden Wirkung. Selbst Hitler wurde damit von seinem Leibarzt versorgt. Um die sich abzeichnende Niederlage, aber dennoch die Motivation der Nazigefolgschaft aufrecht zu halten, kamen weiterhin Drogen zum Einsatz. Drogenkonsum stellt in keinster Weise eine Entschuldigung für die Verbrechen dar. Ohlers betont in seiner Schlussfolgerung (2023, S. 303) „die pervertierte Welt des Dritten Reiches, die so umfassend den Kontakt zu einer lebenswerten Realität verlor und derart viel Leid schaffte“. Wenn nur noch der Rausch durch Drogen als Ausweg dient, dann ist die Menschlichkeit, die in Empfindsamkeit besteht, bereits weitestgehend verloren. Auf viele traf die bekannte „Faustsche Formel“ zu:
„die ich rief, die Geister
Werd’ ich nun nicht los“.

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Helplessness

Learned helplessness is another which we have to be aware of as social scientists. It is far from surprising that for example giving birth has been transferred from the professional care and exercise of midwives to medical doctors and hospitals. This creates a kind of maximal security around the most natural of events that of child birth. Over the last few decades we have witnessed a pathologising of birth as high risk event. Additionally an emergencification has pushed costs upwards for social security systems as well. In numerous other domains like breast feeding industrial interests have pushed for replacement solutions which are worse than second best solutions.

In other domains like shopping we tend to believe that we need a car to assist us in the endeavor. It is mostly a choice of the least effort to use a personally owned vehicle to replace other solutions which demand more effort of organization like car or bike sharing options. The frequent result is “learned helplessness”. After years of getting used to the debilitating ease of use of navigation systems in cars and bikes we find it hard to put effort into a little self-organization. Learned helplessness will be a substantial burden on our health and social systems if we do not manage to reverse this trend. At times of increased skill shortages we shall no longer have the many helping hands needed to stem the powerful trend of learned helplessness.

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Pathology

The definition of disease, illness or disability are a matter of details of definitions. Mostly it is left entirely to medical professionals to define the limits of what shall be considered a disease or not. Pathology is the scientific discipline dealing with this difficult task. As in the scientific endeavor it is honorable to crown your research by finding or defining a new disease not necessarily finding a treatment for it, we have learned about new diseases at regular intervals. Attention deficit syndrome also known as hyperactivity is such an example. Many pupils have received treatments and some made splendid progress in their education due to early recognition of their condition as well as abilities. However, some children have received treatment with questionable diagnostic evidence or just to be able to fit into our modern ways of organizing our schools. We might frame this as a process of “to pathologise” persons or whole groups in society.

The American definition of what constitutes a higher than normal blood pressure or colesterol deviates from the one applied in many European countries so that sometimes the double amount of people should receive medical attention and treatment. From this it becomes more evident that even within the field of pathology there is a societal dimension to it. The “dry january” addresses the pathology of alcohol addiction. Smoking falls into a similar category but no smoke free month has been suggested yet. While it has become normal to overuse antibiotics we shouldn’t reproduce the same mistakes with other medications. We simply need a broader discourse about pathology and the societal origins and implications of it. From the Roman times we have amphitheaters and sacred buildings that we value today. Few sanatoria have survived but a few Roman baths as a preventative approach have survived in the British city of Bath or in the German city of Trier, both quite far from Rome. We should sometimes think more carefully before defining a disease. Not all are pathological. If it seems difficult to stem against the trend of “pathologising”. The ensuing overload of the medical system in consequence is a serious issue. The medical system will degenerate into a system to manage waiting queues with absurd, unequal and unnecessary adverse outcomes. Therefore, sociologists consider the pathologising of societies as just another kind of pathology.

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Teaching Ethics

Ethics is frequently taught by referring to reference cases, moral dilemmas and readings on the evolution of the discipline as some ethical issues arise due to technological innovations. Some fundamental ethical principles pertain to professional standards or so-called codes of conduct. This is also part of the sociology of professions which includes the societal and political role professions and professionals. The medical profession has been subject to ample research already. And yet it is important to notice that there is a renewed effort to include into the teaching of ethics “The hard truths about medicine and the Holocaust”. (AMA J Ethics. 2021;23(1): E59-63. doi: 10.1001/amajethics.2021.59). Eugenics were practices well before WWII. “Legal coercive sterilization, which progressed to the notorious “euthanasia” (medically sanctioned murder) program” (p.59) were the beginning. Medical doctors were not reluctant to implement the Nazi medical doctrines. “Most joined eagerly, earlier, and in much greater numbers than other professionals” (Chelouche, 2021; Kater MH, 1989). Physicians made the horrors of Nazi ethics efficient in its implementation. Nazi physicians had a strict ethical code which priorities obedience to the state rather than to the individual.
Research and experiments conducted by medical doctors during Nazi rule is analysed by Weindling (2015). In summary he states “Nazi experiments were accepted forms of science at the time, conducted not only in concentration camps but also in hospitals and clinics across Germany”.  This concise overview of recent research by Tessa Chelouche in this field is not only important to teaching ethics in the medical and care professions, but it is of high relevance to much broader audiences and many more professions like judges. Only the awareness and guarding against a renewed failure to respect human values and human rights of the individual allow us to advance humanity. Decentralisation of power, checks and balances, professions following widely accepted principles rather than authoritarian rules can avoid another failure. Teaching about this is a “conditio sine qua non” and not a nice to have part of the curriculum in schools as well as professional colleges.

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Overwork

In a country where most people subscribe to the “protestant work ethic” it is not easy to raise the issue of overwork. Yet, overwork needs to be become an issue of concern. In combination with overwork comes too little rest. Particularly the lack of rest and sleep is likely to cause serious medium and/or long-term effects. Burn-out is only one of the more obvious and drastic experience of exhaustion. The lifestyle of overwork has direct causal links to malnutrition and cardio-vascular risk factors. Once triggered these processes are even harder to control. The run on meditation exercises is only reiterating the huge difficulties to find a balance or antidote to overwork.
The Pew Research Center in Washington has published results from a survey in 2023 that shows that only about half of American people take the full vacation they are entitled to. The evidence of pervasive overwork in the U.S., not limited to the higher executive branches of employees, is hugely unhealthy. Physical and mental health is endangered and the cost to individuals and society are immense. Who cares? Well, we should care. (1) Documentation and monitoring this trend are the first elements of a strategy to counter these effects. Keep spreading the message that overwork is not without serious risks and mostly is followed by huge costs, someone will have to pay. (2) Start to analyse why we glorify overwork and keep doing so for centuries. The strive for higher pay, more money, higher profits, wealth or social prestige is a powerful driving force, of course. Legal measures or taxation to curb extra benefits of overtime have apparently had only marginal effects as they are circumvented, if people are too much focused on the immediate earnings effects. (3) Examine the question, why we glorify overwork? The Harvard Business Review published an article on this on 28th of August (just after the vacation period) to blame the culture of “workaholic” behaviour. In short, if your self-concept is defined exclusively through work, you will be doomed for overwork and its consequences. The next shot of overwork satisfies the urge for self-esteem and most likely also recognition from peers, colleagues and supervisors. This is an unbelievably heavy drug and addiction terribly hard to resist. (4) Who keeps pushing the agenda of overwork? We know for sure that it is not your children. If you have none, you will be at a higher risk to overwork and to push the overwork agenda compared to others, just because compared to families your time budget leaves more reserve capacity for time to rest. Employers set powerful incentives to reward any form of overtime and thereby overwork not only in pecuniary form, but also more rapid career advancement. Strongest and most addictive is your very own behaviour not to respect limits to working time. (5) Remedies to overwork are only partly in your own command. Of course, getting more sleep, doing more exercise, walk instead of drive to work are all fine. However, we need to address the danger of addiction, especially when we do not want to admit our dependency on overwork for self-esteem and recognition by others. Getting together with like-minded persons, for example, in trade unions, will make it easier to get collective solutions to isolated overwork. Higher wages should allow you to get more rest as you earn the same absolute amount with less input of hours. The danger of working even more, because the incentive to put in an extra hour of work has risen at the same time. Be aware of this “duality of higher pay”. Societies have lots of reasons to redistribute work. Between women and men, young and old as well as the “overworked” and “underworked”.

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Polypharmacy

Each specialist treats a person or patient in her/his field of competence to the best of current knowledge. Well, marketing of pharmaceutical products is also a field of special competence. Medical doctors and pharmacists are largely competent intermediaries between the world of medical and pharmaceutical research, commercial interests and patients. As persons age, so-called multimorbidity is creeping into the daily life of many persons. After a certain age (75+), depending on country of residence to some extent, we all become patients. Although the basic problem has been known since the phenomenal rise of the pharmaceutical industry, little research is devoted to patients receiving multiple treatments with medical prescriptions from several specialists. In addition, we know there is a rather severe issue with compliance to prescriptions, for example, taking antibiotics for the whole prescribed period, to name just one. The interactions between several prescriptions and molecules administered to patients are very difficult to monitor and scientific tests of those are expensive and no pharmaceutical company really has an interest in such studies that might further add to the already long list of potential side effects. However, the study published by Daunt et al. (2023) reiterates the warnings that treatment of multimorbidity can have unwanted side-effects we do not really know about. General practitioners will have to take on the role for medical stewardship for their patients. Monitoring a patient’s digestion of a combination of medications becomes a prime role as of the age of 75, the paper specifies. Whereas a common believe tells us, taking more, will help more, the “daunting” truth might be, less can be more. (Source: Daunt, R., Curtin, D., & O’Mahony, D. (2023). Polypharmacy stewardship: A novel approach to tackle a major public health crisis. The Lancet Healthy Longevity. https://doi.org/10.1016/S2666-7568(23)00036-3.

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Nächste Welle

Die Surfenden unter uns wissen, „nach der Welle ist vor der (nächsten) Welle“. Altes Surferlatein, etwas abgenutzt, zugegeben. Aber in Zeiten mit Coronavirus #Covid_19 und der δ-Variante ist das #nichtLustig. Wer bekommt wann die 3. Impfung, das ist die Frage, überlegte schon Hamlet. Aus Hamlet ist längst die „Hamlet Machine“ geworden. Eine Armada von Modellierenden versucht Prognosen von Wellen und deren Auswirkungen vorherzusagen, denn riesige Finanzströme folgen solchen Projektionen. Haben sie noch keine Biotechnologieaktien in ihrem Depot, die mRNA Impfstoffe produzieren? So als Absicherung gegen höhere Krankenversicherungsbeiträge oder pandemiebedingte Risiken. Lassen wir uns also einfach das dritte Mal jetzt impfen und wir kommen höchstwahrscheinlich relativ unbeschadet durch den Winter. Die Feier zum 8-ten März werden wir wohl wieder ausfallen lassen oder verschieben, aber das ist Teil des „new normal“.

FT 24.8.2021 on δ
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Pharma und Karma

Wieviel gutes Karma kann die Pharmaindustrie ansammeln. Das ist im Kern die Debatte rund um die Impfstoffe der verschiedenen Hersteller. Patentschutz hin oder her, schnelle Entwicklung hat kräftige Gewinne erzeugt, die sicher für die Erforschung anderer, neuerer Wirkstoffe benötigt werden. Das Unternehmen Johnson & Johnson hat jedoch ebenfalls Altlasten zu bewältigen. Asbest in Babyprodukten (s.u. ) das geht doch gar nicht, glauben wir immer noch. Achtung, nach jahrelangen Klagen, scheint sich ein hoher Preis für die Verwendung von Talk einzustellen, wie die FT am 2.6.2021 titelt. Industriepolitik, die das “Vorsorgeprinzip” verinnerlicht ist weitestgehend eine europäische Erfindung. In den USA gilt das nicht, da wird dann eben schneller produziert und dann die eventuellen Schäden kompensiert. Zumindest für die, die anschließend den Klageweg beschreiten kann dann eventuell eine hohe Entschädigung nach vielen Jahren und zusätzlichen Kosten erstritten werden. Gesundheit ist eben doch ein wenig Business oder viel Business. Das hat Boeing wohl so gesehen als die Boeing Jets 737 Max vom Himmel fielen. Europa mag es gerne langsamer und sicherer, aber das hat auch seinen Preis zumindest bei verspätet eintreffenden Impfstoffen für Risikogruppen.

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Asymptomatische Infektion

Es ist schon mehr als 1 Jahr her. Die Einzelfallprüfung zur asymptomatischen Infektion war uns bekannt. Alle Alarmglocken hätten klingeln müssen. Aber weit über München scheint die anschließende Veröffentlichung im New England Journal of Medicine nicht ernsthaft gewürdigt worden zu sein. Mit #Covid-19 Infizierte Personen sind ansteckend bevor sie selbst Symptome zeigen. Heute freundlich begrüßt, infiziert und einige Tage später selbst erst die typischen Symptome. Das SARS-CoV-2-Virus hat die kommunikativ weit überlegene Species Homo sapiens einfach ausgetrickstSARS-CoV-2-Virus hat die kommunikativ weit überlegene Species Homo sapiens einfach ausgetrickst, indem es kommunikatives Handeln (Bisous,Bisous, talk, talk) als Schwäche ausnutzt für eine rapide Übertragung. Wir müssen nicht gleich ins Schweigekloster umziehen, aber unsere Kommunikation auf digitale Medien temporär umleiten. Das sollte uns doch nicht schwer fallen, wir haben damit die Technik das Virus zu übertrumpfen. Nur wollen müssen wir es. Das Leid der 52.000 CoronaToten und deren Angehörigen wird es nicht mehr lindern können, aber weiteres Leiden und die Arroganz der Überlebenden bleibt uns hoffentlich erspart. Daher heißt es jetzt: Klaus ist allein zuhaus.

 

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Gott + Schirach

Am heutigen 23.11.2020 ist es soweit. Die Fernsehübertragung des Theaterstücks „Gott“ von Ferdinand von Schirach läuft im Ersten. Nach spannender Lektüre erwarten wir nun die Abstimmung der selbstbestimmenden Personen, nicht der meist über Listen aufgestellten gewählten RepräsentantInnen des Volkes. Alles andere als ein klares Votum für eine legale Sterbehilfe und Selbstbestimmung ein ganzes Leben lang wäre eine Überraschung. So wird endlich die breite Diskussion geführt, die diese schwere Entscheidung für alle Beteiligten benötigt. Toll, denn der Grundwert der Selbstbestimmung gilt  unbefristet. So ist es nie zu spät, auch eventuell erst am Ende eines Lebens Freiheit in einer letzten Entscheidung zu finden.

Finding Freedom

Abschließend ein Zitat aus dem Buch von Seite 177. “Ich bin kein Philosoph, aber, meine verehrten Damen und Herren, könnte nicht genau das es sein, was uns als europäische, als westliche Gesellschaft heute ausmachen sollte: nicht der zwanghafte Konsens, sondern, dass wir den friedlichen Dissens aushalten?”
Ein schönes Stilmittel – die rhetorische Frage, als Frage auf die wir keine Antwort erwarten, sondern beispielsweise, wie in diesem Falle, eine Zustimmung des Zuhörers einfordern.

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Transparent health care

In times of live or die questions, country comparisons are informative. It is the time to endorse, again and again, complete transparency to facilitate learning across borders (see recently The Guardian 13.5.2020). China has not been very transparent at the onset of the Covid-19 pandemia. Other countries should not follow this track in terms of lack transparency. This appies equally to transparency of hospital and care professionals doing amazing jobs in these critical times. No doubt about this. In order to learn about the need for qualified employees in this crisis, I recommend the full thread of the tweets from “Mary Poppins” on what it means to administer a respiratory machine to a patient.


The experience needed, the understanding of medical processes are only part of the story. Stress, mental overload, burn-out due to long-term shift-work and irregular working hours including frequent (unpaid?) overtime and lack of sufficient training may cause more fatalities than would otherwise be the case. Teamwork across shifts and weekends has to be effectively coordinated. Medication profiles need to updated and understood for adequate application from all team members not only the medical doctor or shift supervisor. In emergency situations panic control mechanism also are relevent features that have to be learned and experienced. In a previous analysis of data from 18.000 nurses in Canada we could provide evidence of the importance of some of these measures. Transparency is key. Cover-ups of past failures cost dearly in this global pandemia.  Full paper.
http://www.ccsenet.org/journal/index.php/gjhs/article/view/0/38574