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Medical science has now explained hot flashes — and help may be on the way

Posted on by Carolyn Brown

Menopause is hot … still … again … and always, as anyone who has experienced it knows (Menopause is having a moment, and many say it’s about time – YouTube). But there may be good news on the way for women who suffer from its most common symptom, hot flashes or flushes, if new drugs that tackle the problem in a completely new way pan out.

I complained in this space back in 2016 that hot flashes were a medical mystery (Why do hot flashes remain a medical mystery? | Carolyn Brown). Fortunately for me, my hot flashes were manageable and lasted only about seven years before dissipating. For some women, they can last up to 15 years and can cause difficulty with everyday life and severe effects such as insomnia.

But there has been a scientific breakthrough since then, and we now understand why hot flashes happen. I’m going to explain it, but you might want to take a deep breath, because it’s not simple. It’s neuroendocrinology.

The reproductive cycle

The following is heavily simplified for everyday readers.

In medical terms, hot flashes are “vasomotor symptoms” — meaning they involve the blood vessels constricting and dilating. It was clear that these symptoms were tied to the drop in estrogen that happens with menopause as the ovaries stop producing this important hormone. Women who have to have their ovaries removed at a younger age than normal menopause often experience very severe vasomotor symptoms after the abrupt cut-off of estrogen.

For the following, I’ve leaned heavily on a very good review article published in the journal Neuroendocrinology in 2019 (Neurokinin 3 Receptor Antagonism: A Novel Treatment for Menopausal Hot Flushes (karger.com)).

Before menopause, women’s reproductive systems go through their regular monthly phases thanks to a complex process involving nerves, peptides and hormones, all acting in a delicate choreography. It starts in the hypothalamus of the brain, where specific nerves release a hormone, gonadotropin-releasing hormone. This hormone reaches the pituitary, a gland involved in growth, metabolism and reproduction, where, in turn, it stimulates the release of two other hormones, follicle-stimulating hormone and luteinizing hormone. In the first phase of the monthly cycle, the follicle-stimulating hormone controls the ovary’s production of eggs. The luteinizing hormone triggers the release of the eggs from the ovary.

These hormones also lead to the release of two other hormones — estradiol (the most potent form of estrogen) from the ovaries and testosterone from the ovaries, adrenal glands and other tissues. These hormones signal the original nerve in the hypothalamus to cease production, and hormone levels drop throughout the chain. Then the cycle starts again. This process controls women’s monthly changes in an extraordinary way without which none of us would be here.

Why menopause causes hot flashes

The big discovery is about two neuropeptides in the hypothalamus that are really key to this process — kisspeptin and neurokinin B. They are the link between estrogen and the release of gonadotropin-releasing hormone. When estrogen levels are high, these two neuropeptides lower the levels of gonadotropin-releasing hormone.

The thing is, the nerves in the hypothalamus that produce (“express”) these two peptides are in an area of the hypothalamus responsible for regulating body temperature. One of the messages from this part of the hypothalamus reduces body heat through dilating blood vessels on the skin and sweating. In hot flashes, this message is sent from the hypothalamus when it shouldn’t be.

This is a side effect of the drop in estrogen when the ovaries stop functioning in menopause. Researchers believe that the loss of estrogen means that the other hormones are not controlled and therefore increase, changing the way that the two key neuropeptides work, leading the hypothalamus to send mistaken messages to reduce body heat.

During the process, neurokinin B binds to a receptor called the neurokinin 3 receptor. If this receptor could be blocked, the hot flashes would cease.

The search for new drugs

And that’s exactly what some new drugs in development do, quite successfully, according to initial tests in women with hot flashes. Two drugs have been tested. One reduced hot flashes by 73% (45% lower than placebo), and the other, by 93% (46% lower than placebo). Unfortunately, further studies of the first drug have been halted because of concerns about risks versus benefits. Studies of the other are proceeding.

The hope is that drugs targeting the neurokinin 3 receptor can reduce hot flashes substantially with few side effects. Currently, the best treatment for hot flashes is estrogen replacement, but estrogen — especially used over many years — can increase the risks of heart disease and certain types of cancer in menopausal women. The new drugs would not increase estrogen and would therefore avoid these risks.

If you’re suffering from hot flashes right now, don’t get excited. Years of testing are needed to ensure that new drugs are safe and effective. As we have seen, one potential drug has already been shelved. It will take time, but women in their reproductive years today may have better alternatives to ease their menopausal years.

A modest proposal: Chief Medical Officers of Health should report to their legislature

Posted on by Carolyn Brown

“The counsel of the CMOH [Chief Medical Officer of Health] is presented as unbiased medical advice, but it is almost inevitably tainted by politics,” said Dr. Jillian Horton in the Globe and Mail this week. Exactly. Here’s why.

Provincial and federal public health officers in Canada are public servants. Like deputy ministers in other, arguably less life-and-death roles, they express their views to the government of the day. The government makes its own decision, and the dutiful public servant must support that decision, even if they privately and professionally disagree. That’s how it works.

Several times I have shaken my head while hearing Dr. Deena Hinshaw, CMOH of Alberta, answer the media’s questions about whether she agrees with Jason Kenney’s latest decision. She doesn’t answer directly. Rather, she describes the process. She gives the government advice; they make decisions; she supports their decisions. Does she agree? Read between the lines.

Should public health decisions be political ones? Hint: the question is rhetorical.

Here’s my proposal to divorce public health from politics: make CMOHs answerable to the legislature rather than the government. They should be autonomous and free to provide evidence-based advice. They could release reports saying, essentially, “Here’s what our projections show if you take the most stringent public health measures, if you keep some measures and relax others, and if you drop all measures. We would recommend such-and-such a course of action.”

The government could say, “Thank you very much, but we’ve decided to go in a different direction from your recommendation and take the flak.” Everyone would know what the projections show and whether the government has followed the scientific advice. Citizens could hold their governments to account in full knowledge of the evidence.

CMOHs could be selected, evaluated and, if necessary, fired through a process similar to processes for other parliamentary officers or, for example, judges.

I would actually prefer it if CMOHs had some superpower to overrule governments, but my democratic ethics tell me final decisions have to be made by elected governments. So the report-to-legislature solution would at least allow them to speak freely and expose the discrepancies between scientific guidance and political decisions to the full light of day.

Can’t look away: in Don’t Look Up, science, media and power collide in a train wreck that you can’t unsee

Posted on by Carolyn Brown

The recently released film Don’t Look Up (director Adam McKay) has generated plenty of critical attention — positive and negative. Most of that attention has quickly moved from the film itself to the themes of existential threats, media, US power and so on. In a politically polarized world, whether you liked the film aligns you immediately with certain groups and views. Instead of seeing the film on its own terms, the media commentary on the film positions it as part of the media frenzy.

Such commentary is being called “meta-discourse.” The fact that the film itself is the subject of meta-discourse is ironic, since meta-discourse is one of the social trends it pillories.

Speaking of irony, Canadian critic Northrup Frye said that satire was “militant irony.” He divided myth and, hence, literature, into four modes: comedy, romance, tragedy and satire/irony. Satire (or irony) moves from tragedy to comedy. It has a foot in both. Some critiques of Don’t Look Up complain that it has these two tones — comic and tragic. But I think this double-edged nature is at the heart of satire.

If this were a scientific article — and scientific literature is also at the heart of Don’t Look Up — here I would write a review of the literature to date. Such a review is just as relevant for art reviews. Understanding the context for any art form is essential, because all art is about other art.

“I am still uncertain as to whether I should call it a comedy or a straight drama,” said Henrik Ibsen of his 1882 play An Enemy of the People. A doctor in charge of a spa that is the main employer in a Norwegian town discovers contamination of the spa’s water. What follows includes scenes that you would recognize from Don’t Look Up. The newspaper doesn’t want to publish the information because it will hurt the local economy. The doctor is pressured not to tell the townspeople at a town meeting, despite the risk to their health. Frustrated, he instead upbraids the stupidity of the town authorities and says the smug town elite should be exterminated. Townspeople attack his home and his former friends and colleagues want him to leave town. He decides to stand his ground, as the sole person in the town who speaks the truth.

Don’t Look Up is An Enemy of the People for our times and place. It’s about the resistance to an inconvenient truth.

The other obvious comparison is Dr. Strangelove (1964, Stanley Kubrick), where the tragedy is nuclear destruction and the comedy is, well, the rest of it. The rich parody of Cold War mutually assured destruction arguably contributed to the political and social discussion of the nuclear threat and eventually to disarmament. Don’t Look Up owes a stylistic debt to Dr. Strangelove and references the film in the character of military officer Benedict Drask (played by Ron Perlman), who pilots the rocket that is intended to blow up a comet, probably a suicide mission. Drask bears more than a little resemblance to Slim Picken’s character Air Force Maj. T. J. “King” Kong, who physically rides a bomb to its target in Dr. Strangelove. And both films trace catastrophe to decision-making by people who have taken leave of their senses, as an allegory for systems that no longer make sense.

Dr. Strangelove lacks the scientist characters who are the tragic heros of Don’t Look Up. Scientists, because today’s existential threats are not political and military, but from the natural world.

Director Adam McKay evidently said in an interview that Don’t Look Up was intended as an allegory of climate change. It’s unfortunate that he said so, as many works of art that have their genesis in one idea end up going in many other directions, as I believe this film did. Many critics have dismissed Don’t Look Up because the threat is much different from climate change. Absolutely true. For a film with the genre expectations of suspense and conclusion, the writers needed to invent a more immediate threat. But the satire of our society’s inability to act on existential threats stands. Just look at what is happening with COVID. As of this writing, 2288 people are dying of COVID in the US every day.

Regardless of the precise threat, the film parodies the current moral bankruptcy of the United States, which would cripple it in the face of any threat. The populist president (with elements of both Trump and Hillary Clinton) is obsessed with her popularity and re-election to the exclusion of real issues. The government’s only paradigm for response is secrecy and security. This echoes the scenario in The Day the Earth Stood Still (1951, Robert Wise). The government ignores an alien’s plea to speak with world leaders about disarmament and instead suppresses the alien’s message and detains him under tight security.

The United States’ self-view — and dubious ability — as world policeman was also parodied in Team America: World Police (2004, Trey Parker). If you want the comedy without the tragedy, see that one.

The United States’ moral bankruptcy also involves the media — both traditional media, such as network television, and social media. The film is one of the best depictions of the gross distortions that media creates I have ever seen. Critics to date have failed to mention the contender in this category, Network (1976, Sidney Lumet). Like the Randall Mindy character in Don’t Look Up, Network’s Howard Beale rides a roller coaster of popularity — from being nearly fired because of low ratings, he ascends to super-stardom by threatening to commit suicide on air, telling viewers to yell out their windows “I’m mad as hell and I’m not going to take it anymore,” and becoming the “mad prophet of the airwaves.” In both, the media has become about the media. It cares only about its own predominance. But it influences millions of people, who get their information from it — information that has less and less to do with reality.

Which brings us to techno-Utopianism. Has anyone else satirized the hollow promises of tech companies? The tech guru character, Peter Isherwell, a sinister autistic autocrat who has come to believe his own vapid happy talk, is Steve Jobs, Elon Musk and Jeff Bezos rolled into one. Because they once had a solid tech invention at the right place and time, they think they run the world and can find a tech solution to every problem. But they can’t.

From this rich ground of satire, I found there was a single shining insight from Don’t Look Up into the current morass for science, media and power.

As I write this, a small group of truckers, with hangers-on and infiltrators, are driving around my city saying they shouldn’t have to get a COVID vaccine to cross the Canada-US border, which both Canada and the US are requiring. They have been duped into believing a lot of misinformation about vaccines and the virus on social media.

We have all struggled to understand this phenomenon of the social media “echo chamber” that feeds back whatever people want to hear, and its chicken-and-egg relationship with the polarization of political views and the emergence of populist politics. But, when I saw Don’t Look Up, I suddenly realized…

It’s not just that the information is false. It’s not just that it’s lies.

It’s that it’s delusional.

It’s not even real.

And reality is right in front of you. All you have to do is look.

Why Ottawa can’t deliver

Posted on by Carolyn Brown

I am writing this six days before a federal election, one in which the current government is beleaguered. Civil society groups and other parties say the government isn’t delivering on its commitments, which is, to a certain extent, true. As I watched the leaders’ debate last week, I thought about the fact that any party that takes power will likewise be unable to deliver. Because there’s something wrong.

Science rally on Parliament Hill during the Harper era. Government scientists were muzzled, but the truth was that it wasn’t just scientists – it was the whole public service.

It’s difficult to put a finger on. Despite a lot of political will and good intentions, Canadian federal governments that really want to achieve something often fall short. It reminds me of T.S. Eliot’s lines in the poem “The Hollow Men”:

Between the idea
And the reality
Between the motion
And the act
Falls the Shadow

I worked in the federal government for almost 10 years, and many of my friends currently work there. While many have achieved important milestones, many have also encountered the Shadow – the soul-destroying Harry-Potter-esque Dementors that keep good people from doing good things.

To digress a moment from Canada, the place I saw this as an endemic problem was Mexico, where I taught workshops to scientists over many years. Satirized in the 1999 Mexican film Herod’s Law, the problem is essentially this: a leader asks his staff to accomplish a goal, and they say, yes sir (or ma’am), yes sir. But they have no idea how to accomplish the goal and are unable to make a plan and ask for resources, expertise, and other things they need to do so. So it never happens.

This problem is not unique to Mexico; that’s just where it became most blatant to me.

What would have to happen to accomplish goals?

Political staff and public servants would have to be able to admit that they don’t know how to get the puck into the net. The goal may be something normally done in the private sector; it may be a unique, new objective; it may be a thorny problem. Then they would have to create a roadmap right down to the fine details of how they will solve the problem. And they would have to get the expertise, money, people and time it will take to carry out the roadmap. And they would have to be able to correct the roadmap as they go. And learn. And fail. And start again.

This cannot happen in a bureaucratic, risk-averse culture. There are disincentives stopping public servants from asking for what they need and pointing out that plans are unfeasible. There are incentives to just continue with the status quo rather than take risks to meet objectives.

I saw this: I saw staff try to tell their Director-General that the organization was risk-averse. They were dissuaded from taking risks and their careers were negatively affected if a risky move did not succeed.

In Mexico, I saw another problem – there were incentives to meet the goals; there was just a lack of knowledge of how to meet those goals. And there were disincentives from admitting the lack of knowledge, which was considered “losing face.”

Public servants have to be able to admit that they need outside expertise. There need to be partnerships among government, business and civil society to meet many social goals. Such partnerships are stymied by funneling the relationships into categories that already exist, such as procurement and contracting. Those work great if you want basic goods and services, but not if you want change.

During the Dark Years, the public service became, in many places, dysfunctional. That was the intention: to discombobulate public servants with layoffs and cuts so that they could not carry out their functions – functions mandated in legislation – or spend their budgets.

I heard from colleagues about money unspent for programs, including programs for human health. The agency where I worked suddenly had a conference room full of auditors, and we were told we couldn’t take this measure or do that because it would be questioned by the auditors. At one point, I was told that I had to specifically sign a declaration on every contract that there were no security concerns, although I had already signed the contract on the same sheet of paper, about two inches away. Regular visitors could not just walk in the building, take the elevator or go to the bathroom (yes, seriously) unless they were accompanied by a staff member because (we were told) anyone could be a terrorist posing as a contractor. Every contract had to be assigned a security level, and whole swathes of staff suddenly needed security clearance. One day, without warning, the cafeteria closed down for a week because of an overnight edict that cafeteria staff had to be vetted for security.

When massive layoffs (amounting to half of the staff) were announced, all staff had to apply for the shrunken pool of jobs. They spent the next few months in a high-stakes game of musical chairs. In most cases, their daily work did not get done.

In a department where a friend of mine worked, there were three rounds of layoffs and complete paralysis as a result. In the same department, at one point, a preliminary policy plan was leaked to the media and, ostensibly as a preventive step, all staff were forbidden from speaking to each other about work – all communication about the most mundane daily activities had to be by email.

When I became a contractor to government, I was puzzled that some public servants met me in a coffee shop to discuss a potential contract, and others sent me emails from a personal email account. I learned from colleagues that this had become common. Public servants were not supposed to talk to potential contractors at all before issuing an request for proposals, but many did not have the expertise to know what they should be asking for, whether there were contractors available and in what fields, and what the likely range of costs were for the services they sought. The obvious thing to do was to ask some contractors in the area, but they weren’t allowed to. So they were doing what was arguably their job on the QT in order to get things done. Some had offices so secure that I couldn’t visit them; some had been told not to communicate anything beyond the most administrative questions by email for fear that other contractors would request emails via access to information.

Worst of all was a repeated mantra that the job of the public service was simply to carry out the will of the government of the day. That was not and has never been true: the public service must be objective and neutral, and it must point out to governments when policies are not constitutional, not advisable, or just not feasible.

After 2015, that dysfunction did not turn around immediately. Many public servants had drunk the Kool-Aid and were still following outdated rules. Others had joined the public service during that decade and had been inculcated in that system. There was a failure to root out and stamp out the dysfunction.

What is needed is a culture change. Public servants need to be able to speak truth to power. They need to be allowed to admit lack of knowledge and the need for resources. They have to be freed from security and auditing constraints the true purpose of which is to stymy progress. They cannot reach goals without the detailed plans and the tools to do so; they need to be able to ask for help with these plans and tools.

Then any government will be able to achieve its goals.

On vaccines, the Globe and Mail’s editorial is not giving it to us straight

Posted on by Carolyn Brown

A Globe and Mail editorial published Dec. 12, 2020, says that Canadians should be given the full picture on COVID-19 vaccines, including how they were approved, how they work, and how the risks are outweighed by the benefits. While I agree wholeheartedly with the conclusion of the editorial, the rest of it irresponsibly repeats misconceptions about vaccination and COVID-19 vaccines. By failing to communicate risk responsibly in the editorial itself, the Globe and Mail appears to support and condone inaccurate perceptions being spread in our society.

Its first argument is that “many Canadians are reluctant about vaccines” and “to some extent, they have reason to be” because of “government confusion, ignorance, inertia and mismanagement.” Reluctance about vaccines has a history as long as vaccination itself (as I have discussed in previous blog posts) and is not caused by the current Canadian federal and provincial government problems in managing COVID-19. Furthermore, vaccines are often part of public health strategy, but they are developed by private companies and heavily regulated through a science-based, objective process entirely autonomous and independent from the government of the day.

The editorial cites two recent polls of Canadians’ attitude. The Ipsos poll it mentioned said 70% of respondents felt nervous about getting a vaccine that was created and rolled out so quickly, but 57% said they felt confident that once a vaccine was approved by Health Canada, it would be completely safe (which the editorial failed to mention). The Angus Reid poll did find 36% of Canadians would prefer to wait for a vaccine, but that they would get vaccinated eventually (also not mentioned).

The editorial says this large group of vaccine-hesitant Canadians “are understandably reluctant” and “reasonable and rational,” when, in fact, the science shows that their concerns are misplaced.

In repeating that the vaccines were “developed at record speed” and received “rapid stamps of approval from the same governments that bungled so many other pandemic must-dos,” the editorial vaguely implies problems with the process, a view that is unfounded. Making baseless assertions has no place in responsible media.

Anticipating this reaction, the editorial justifies the view as one of “skepticism” rather than “cynicism” and says journalists need “evidence and proof.” There is no government cover-up or withholding of information. Globe and Mail journalists are covering the vaccine approvals; Health Canada would, I’m sure, respond to any questions the media have about the process. There is freely available evidence and proof. Here’s the US Food and Drug Administration data online.

Then the editorial accuses unnamed governments of “15-second web ads to tell taxpayers that everything is all right.” The advertising from federal and provincial governments in all media stresses the need for compliance with public health measures and the continuing nature of the emergency. In fact, I’m sure Canadians take “we will get through this” and “we’re in this together” as appeals to our strong collectivist feeling in order to improve compliance.

The editorial then gets into very murky territory by saying the risks of COVID-19 vaccines “appear to be low but are not non-existent for everyone,” whatever that Newspeak means. There is excellent evidence, published in many authoritative media, that the risks really are extremely low. The FDA, for instance, stated the vaccine had “low incidence of severe or serious events, and no clinically concerning safety concerns.” The editorial then mentions the two cases of severe allergic (anaphylactic) reactions in Britain, which were revealed immediately and transparently on Dec. 9, when approximately 100,000 people in the UK had already been vaccinated. So that’s a risk rate of about 0.002% — vanishingly low. Authorities in the UK are looking into the reasons for these severe reactions and have halted vaccination of people with a history of severe allergies of all kinds as a precaution.

The editorial calls for “a national conversation.” The media are part of such conversations and, in an era of misinformation, should lead in providing factual and accurate information, in their opinion pages as much as in their news pages.

Four misconceptions about COVID-19

Posted on by Carolyn Brown
Discarded mask on ground
It protects you too.
  • Your mask protects others but not you
  • Herd immunity can be achieved through natural infection
  • The second wave will be worse than the first
  • The pandemic may last for years

I have avoided writing about COVID-19, as there’s plenty of information out there, both good and bad. But I persistently hear a few misconceptions even from my well-informed, concerned friends and family. So I thought I’d address four of the most common here.

Your mask protects others but not you

I learned a lot about masks when I broke a story in the Canadian Medical Association Journal in 2009, during the H1N1 influenza epidemic. At that time, the Public Health Agency of Canada was recommending handwashing, but not masks, to protect citizens against the virus — a position that flew in the face of expert advice to wear masks.

During the current pandemic, well-meaning public health messages have stressed that wearing a mask protects the people you interact with. Here’s a typical one from the Public Health Agency of Canada:

  • DO wear a non-medical mask or face covering to protect others.

People are inferring from this that masks don’t protect the wearer. Not so! Masks aren’t a one-way filter. If you wear a mask, it is definitely protecting you too. Why aren’t public health authorities mentioning this? After all, a major slice of humanity cares more about themselves than others. I notice that public health agencies often simplify messages in a way that leaves out important information. Maybe they are worried that people will think a mask is a 100% guarantee that you won’t get infected.

For the record, there are no guarantees. But wearing a mask cuts the risk to the wearer as well as people around them.

Because it’s not foolproof, don’t rely on a mask alone to protect yourself. Keep distancing, hand sanitizing, and socializing outdoors, even when wearing a mask. And add a mask to these other practices. For a mask to work, you have to wear it.

Also, make sure the mask is tight-fitting. I wear an N95 mask (available at hardware stores, look for NIOSH N95 printed on each mask) because it keeps out even small particles, lasts a long time and is secured tightly to the face with straps around the head, not the ears. A medical or N95 mask can be pinched over the nose. If you’re wearing a non-medical mask, don’t let your mask fall below your nose. Don’t pull it down on your chin – any virus particles on the outside of the mask can fly up into your mouth or nose. When you take off your mask, remove it completely using the straps and immediately wash your hands.

Herd immunity can be achieved through natural infection

When I started hearing this from sources in the U.S. and Sweden, I was mystified. From my experience working on medical journals, I knew that “herd immunity” was usually discussed in the context of vaccination. The question is, what percentage of the population do you need to immunize to stop spread of a disease? For a highly contagious disease like measles, it has to be pretty high, around 85%.

COVID-19 is fairly contagious, although not as contagious as measles, so rates of combined immunization and infection to achieve herd immunity have been estimated at 50% to 60%. In reality, we won’t know for sure until we start immunizing people and see when the cases drop to zero. But compare even those estimates with the current COVID-19 infection rate in Canada, which is about 0.4%.

For most viruses, the kinds of rates needed for herd immunity are rarely achieved with natural infection. We do see some herd immunity through natural infection with colds and, before a vaccine was available, chickenpox. The disease spreads through a community, infecting a high proportion of susceptible people, then disappears once a high enough percentage of the population has had the illness currently or in the past.

For COVID-19, though, we cannot tolerate infection rates to achieve herd immunity through infection. This would mean an unacceptable burden of death, as well as other long-term effects on COVID’s victims that are coming to light: blood clots and organ damage. The health care system would be overloaded for years. But we can achieve herd immunity through immunization.

The second wave will be worse than the first

This is based on the Spanish influenza epidemic of 1918, which coincidentally followed a seasonal pattern similar to that of COVID-19. There was a first wave in the spring, then lower rates during the summer, then a second wave in the fall, much worse and deadlier than the first.

The second wave of Spanish flu was caused by people behaving badly. No law of nature made it inevitable; it was preventable. A lack of public health measures, massive public gatherings, as well as World War I troop movements and returns without quarantine, led to the highest death rate in human history.

The same goes for the second wave of COVID-19, which is already underway as of this writing. Humans caused it, and we can prevent it from worsening. The re-opening of the economy may have been, in hindsight, too quick and too unsafe. Some measures clearly led to clusters of infection that spread. We can get it under control, but we need to return to greater safety measures. A worse second wave is avoidable, not inevitable. It’s a question of political will and public co-operation.

The pandemic may last for years

Is it something in human nature that treats the moment as if it will never end? Maybe it’s evolutionary biology: to survive a crisis, we need to focus on it to the exclusion of all else, so we don’t have the brainpower left over to think that the future may be different.

Others use the crisis to ride their personal utopian hobby-horse: they say the future will need to be different, preferably in their own ideological mould.

Public health authorities warn that infections and safety measures may last several years, but what they don’t say is that the number of infections will decline, outbreaks will become sporadic, and the safety measures will be much less draconian.

It all depends on vaccination. The more effective the vaccines and the more people who get vaccinated, the faster we can get back to the things that matter most to us.

I foresee a scenario like this: vaccines are rolled out in the first half of 2021. As health care workers, the elderly, and vulnerable groups are vaccinated, infection rates start to fall. After everyone is vaccinated, cases drop significantly. If the vaccines are effective enough, the cases drop to zero. The authorities cautiously open up activities and sectors of the economy. They wait for cases to show up. There are still a few outbreaks, which are closely studied. Some vaccines are dropped because they aren’t effective enough, and others are preferred, in a vaccine shakeout. If any viral mutations make a vaccine less effective, they are incorporated into an updated vaccine.

The virus doesn’t go to zero worldwide, but becomes endemic in a few regions, with occasional flare-ups. Eventually the world gets to zero or near-zero cases. Scientists around the globe start tracking coronaviruses in animals, leading to occasional culls of infected animal populations. Coronaviruses are something we learn to live with, like influenza viruses.

We don’t think about how much our lives are affected by diseases past, but they are. We expect decent wages and low prices because the Black Death raised the value of workers. We have screens on our windows to prevent malaria. We wash fruits and vegetables to prevent food-borne illness. We treat drinking water and build sewage systems to prevent cholera. COVID-19 will undoubtedly leave a mark on our society, but we don’t yet know what it will be.

Worse than stupid: Trump withdraws funding for the WHO

Posted on by Carolyn Brown

It was one thing when it just involved trade. Although countries’ industries and people’s jobs were on the line, the bluster and brinksmanship seemed to be just tactics for the world’s largest toddler to get the toys he wanted.

But the health of all people on the planet is not a game. US President Donald Trump’s withdrawal of funding for the World Health Organization (WHO) puts us all in jeopardy. Here’s why.

Until 2007, there was no global public health system. I hope you find that surprising — I did! If a disease outbreak hit more than one country, there was no agreement to share information, no system to track the disease, no funding to help a country bring in public health measures. Countries were on their own to decide what to do.

But that changed in the wake of SARS in 2003, as countries agreed to adopt international health regulations. And pandemics like the current COVID-19 crisis were precisely why countries agreed to put a global public health regime in place. That’s what’s at stake here.

As a reporter for the Canadian Medical Association Journal, I covered the international health regulations in 2013, during an outbreak of the Mediterranean respiratory syndrome (MERS). At that point, 195 member states had agreed to abide by the regulations, which involved developing national disease surveillance and response systems by 2012. But 110 of those countries asked for a 2-year extension and only got on board in 2014. Today, these countries — including several with authoritarian governments and repressive regimes — have signed on to counting cases and reporting outbreaks.

Without this agreement, the WHO could not be telling us, as it is, how many cases of COVID-19 there are day by day. It also has the right to investigate reports of outbreaks from media and social media that have not been reported by governments. And to walk into a country to ensure it’s managing an outbreak effectively or to help it contain spread.

Part of the regulations is declaring an emergency — the technical name is a “public health emergency of international concern” — for an outbreak that has gone beyond one country. The WHO has declared an emergency five times before COVID-19 and has taken some flak for getting two of these wrong.

The first emergency was influenza H1N1 in 2009, which arguably should not have been declared. It was a bad pandemic influenza, but nowhere near, say, the scale of the current emergency.

The third emergency was the Ebola outbreak in west Africa in 2014, to which the WHO reacted too slowly. As the International President of Médecins sans frontières, Dr. Joanne Liu, a Canadian physician, told me in 2015, “It’s a failure of political will that prevented the world from responding in the first six months,” rather than any problem with funding, expertise or technology. “The location [West Africa] is not a priority in terms of trade or political leverage.”

In light of its failure on Ebola, the WHO did a full review of the International Health Regulations, completed in 2016, and revamped its emergency program.

Which brings us to COVID-19. The parallels with SARS are obvious: a new coronavirus that jumped to humans from a live wild animal in a Chinese “wet” meat market. Early denials and lack of information from Chinese officials, which were replaced by official admissions of the outbreak and public health measures as the contagion spread. Confirmed reports that doctors who shared information about the virus were harassed and intimidated. US intelligence reports that the true number of cases was underreported. The rest of us thought, “Did China learn anything from SARS?”

To its credit, the WHO worked with China. Under the regulations, the WHO needs to play ball with member states to get them to report and to take action to control outbreaks. It clearly has to walk a fine line with states that are less open and transparent, in order to get them on side. The Chinese government did turn around quickly, containing the virus’ spread more successfully than many other countries. The WHO send its experts to work with the Chinese government — to what extent they were involved in China’s turnaround we cannot know.

Crucially, the WHO needs to remain apolitical and work with any member state. Sometimes it does this successfully and even creatively. WHO Director-General Dr. Tedros Adhanom Ghebreyesus stated outright at one of his daily media briefings that some countries were underreporting cases. When asked which countries, he explained that the WHO could not single out members. He faced the camera and said, “You know who you are.” Some countries are lying, some are in wilful denial of the pandemic. And they do know who they are. As do we.

When Dr. Ghebreyesus talks calmly to the world each day and cleverly calls out member states, the WHO is doing its job. Its continuously updated dashboard on the pandemic is unlike any source of data the world has previously seen in a disease, and it has been emulated by several countries. These steps have arguably caused member states to take preventive action and saved millions of lives.

At some points, though, I have been disappointed to see the WHO toeing China’s political line. In an interview with a reporter from a Hong Kong media outlet, Dr. Bruce Aylward, a Canadian and a senior advisor at the WHO, first pretended not to hear the reporter’s question about Taiwan, then said he had answered about China, then ended the Skype call. He was clearly refusing to acknowledge Taiwan as separate from China. Perhaps he was concerned about alienating Chinese officials after efforts to get them on board, but it came across as taking a political position, which the WHO should not do.

Of course, such incidents do not justify Trump’s accusation that the WHO is biased toward China, or that it “mishandled” the early days of the pandemic. The WHO has a responsibility to work with all member states, but it is always going to be difficult to get authoritarian (or just plain ill-equipped) governments to report cases, as they have committed to under the regulations.

Now, Trump is pulling the US funding, estimated at 10% of the WHO’s budget. In fact, the US is in arrears on its funding to the WHO already. And it provides a handy place for Trump to lay the blame for his own mishandling of COVID-19. He is shooting himself in the foot, as usual, because the WHO has helped all of its member countries, including the US, understand and respond to COVID-19. The International Health Regulations work because all member countries commit to them and follow them. Without the compliance of member countries, the regulations could fall apart. And that would be a disaster.

Because, without the WHO and the regulations, COVID-19 would have been worse. Much, much worse.

What is the evidence for medical use of cannabis?

Posted on by Carolyn Brown

“Results reflect the … relative dearth of high-quality evidence related to cannabis for therapeutic purposes”

“The level of evidence for the use of medical marijuana among people with disabilities varies greatly and has a clear lack of methodologically sound studies”

“Evidence is gathering … but further research is required to declare cannabinoids a medicine”

“These studies suffered from multiple limitations, including selection bias, lack of standardized dose and route of administration, absence of blinding, recall bias and lack of a control population”

“The long-term safety profile of chronic cannabis use has not been well defined, mainly due to the heterogeneity of preparations, varying routes of administration, and the lack of controlled studies addressing safety”

“Evaluation of these low-quality trials … was challenged by methodological issues such as inadequate description of allocation concealment, blinding and underpowered sample size”

These are some of the things the experts are saying about the research into medical uses of cannabis to date. To prepare this article, I read 11 “review” articles — articles that pull together all of the research out there and reach conclusions.

The authors are unanimous in saying there is little research, and many of the studies that have been done are really small — less than two dozen patients. Some lack another treatment for comparison — either a placebo or another drug. Other studies can’t be blinded, because patients can tell whether they are getting cannabis, either because they are smoking it or they feel stoned. Others are “observational” studies (some patients are given cannabis and the researchers see what happens), considered the poorest type of evidence.

But there is some good research, and it shows that cannabis might be useful in a few health conditions:

  • Pain
  • Epilepsy
  • Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)

These medical uses of cannabis are not just based on folklore (or, in this case, folk-singer lore). Science has shown that some of the chemicals in cannabis (cannabinoids) mimic natural chemicals in the human body that are important in the nervous system and the immune system. This is why its use is being taken seriously as a potential addition to the drugs we already have.

Pain

The toughest pain to control is cancer pain. A review of five randomized controlled trials looked at cannabis to treat this type of pain. Although one of the studies didn’t find any difference between cannabis preparations containing both THC and CBD (nabiximols) and placebo, there was definite effect in two larger studies with more than 150 patients each. Two earlier studies that had looked at short-term effects in small numbers of patients also found an effect. This review was funded by a Canadian medical cannabis company but was conducted with Sunnybrook Health Sciences Centre and the University of Toronto, so the oversight, ethics and evidence should be solid.

Epilepsy

I have known someone with very serious epilepsy who must cope with several seizures each day. This type of disability limits a person’s life and can even pose a danger. In some cases, the well-established drugs that control epilepsy in most people don’t work or cause serious side effects.

Four reviews of the research found evidence that cannabis preparations can reduce or even stop seizures in people with severe seizure disorders. But the effectiveness seems to vary from patient to patient.

A review that looked at cannabis research for many different disabilities found robust evidence only for epilepsy and pain. Another review that looked specifically at the non-intoxicating cannabinoid CBD for epilepsy showed that it was effective but also showed high rates of side effects, including sleepiness, loss of appetite and diarrhea. A third review found positive effects of CBD in the worst types of epilepsy: Dravet syndrome and Lennox-Gastaut syndrome.

Inflammatory bowel disease

There was a lot of hope that cannabis could help with IBD through its effects on the immune and gastrointestinal systems, but findings are mixed.

A review of five studies (only two of which were high-quality and all of which were small) found positive and remarkable effects on symptoms of IBD. However, two systematic reviews (one for Crohn’s disease and one for ulcerative colitis) by the Cochrane Collaboration — well known for its high-standard reviews — found that the effects were uncertain, the studies small, and conclusions unreachable. However, because of the positive findings of some studies, treatment of IBD needs to be tested in larger groups.

Why not more, better, larger studies?

That’s the question. When I attended a panel on medical cannabis earlier this year (2018), one of the panellists representing a cannabis company buttonholed me afterward about the difficulty in conducting studies. He pointed out that the best level of evidence is provided by randomized controlled trials involving hundreds or thousands of patients. But running those trials is incredibly expensive. He also argued that it is difficult to use placebos when testing cannabis, since those taking cannabis may be smoking it and it may be unethical to let patients go without some kind of treatment. This also means it might be impossible for the trials to be double-blinded — when neither patients nor researchers know who is getting the drug and who the placebo or comparison drug.

These are good points, but they sound like companies are throwing up barriers to running studies.

First, many randomized controlled trials compare the test drug with the standard treatment or best treatment (“gold standard”) rather than with a placebo. This is certainly the case for drugs for mental health problems, as it would be unethical to let a serious mental health problem go untreated. So, trials do not need to use a placebo.

Also, many trials are single-blinded rather than double-blinded. That is, the patients can figure out what they are getting, but the researchers don’t know who is getting what and aren’t influenced by that knowledge. In many trials, this is necessary, if not optimal.

The real issue is money. Running the kind of studies that you need to submit to Health Canada to have your drug recognized as a safe and effective treatment for a particular condition takes years and millions of dollars. Right now, cannabis companies are not that rich.

But in Canada the cannabis companies have formed a consortium that could fund trials. As well, disease foundations in Canada and other countries (like, the one to the south) are interested in the promise of cannabis, and they put money into research. With its open regime, Canada is a good place to carry out international studies of medical cannabis, which would not face the legal hurdles that exist in many other countries.

There are many conditions for which safe and effective drugs are needed. If cannabis can help, it should be prescribed and monitored by doctors to ensure it works for patients, and it should be covered by drug plans. It should not be bought at a dispensary for self-treatment, often by patients who can’t afford it.

As I mentioned to the cannabis company representative, doctors were burned on opioids. The manufacturers claimed opioids weren’t addictive, which wasn’t true. Studies would give doctors full information on cannabis’ effects and risks, so they could inform their patients. Doctors and patients deserve no less.

 

Medical cannabis use carries a risk of dependence and of lung cancer

Posted on by Carolyn Brown

I like to make my position clear from the outset: I support the legalization of cannabis (marijuana and hashish). I think criminalizing it makes criminals out of otherwise upstanding people who use it recreationally, either harmlessly or harmfully (of more, anon). And criminalizing it is a latter-day prohibition, often putting its sale in the hands of organized (and, frankly, disorganized) crime. The fact that cannabis has been illegal has never stopped anyone in Canada from using it and has probably stopped users from admitting their use to their doctor, social worker, parents, etc.

But does it have legitimate medical benefits? Should it be used to help with symptom control in pain, chronic neurodegenerative diseases and so on? Should it be prescribed and monitored, rather than just leaving patients to buy it at Shoppers Drug Mart and experiment with the dosage?

This spring, I attended a panel discussion by cannabis producers as part of the Science Writers and Communicators of Canada conference in Vancouver. Naturally, the producers were in favour of the medical use of cannabis, as this is a potential market for them. It also gives the leaf a patina of credibility and respectability.

I am all in favour of treating cannabis as a potential drug, including research into its safety and effectiveness and licensing for proven uses.

But I heard a few things said that were untrue, skirting serious issues in the medical use of cannabis. Sometimes I wondered whether the speakers had been smoking something.

I want to review a few things that were said.

  • Only 3% of cannabis users become dependent.
  • Cannabis doesn’t cause lung cancer, or does so at lower rates than tobacco.

Let’s look at these claims. The best study I have found on rates of cannabis dependence is a 2012 review of data to date [Degenhardt and Hall (2012). Extent of illicit drug use and dependence, and their contribution to the global burden of disease. The Lancet 379(9810): 55-70].

It found a 9% rate of dependence among users.

A later study by the same authors estimated the rate of cannabis dependence in Canada at 0.6% of the high-income population in 2010 [Degenhardt et al. (2013). The global epidemiology and contribution of cannabis use and dependence to the global burden of disease: results from the GBD 2010 study. PLoS One 8(10): e76635, Table S4]. The rate is undoubtedly higher for the low-income population, as the authors’ 2012 study found.

This is in line with the recent Statistics Canada survey that found that 14% of Canadians over 15 had used cannabis recently (previous three months), with 56% of that 14% saying they used cannabis daily or weekly.

I have seen people become dependent on cannabis, and my observations are in line with the higher estimates.

So, definitely more than 3% of users.

But whether it causes dependence shouldn’t matter anyway, because, evidently, smoking cannabis doesn’t cause lung cancer. Except that it certainly does.

In fact, it increases the overall risk by five times, according to a case–control study carried out in New Zealand and published in 2008 (Eur Respir J. 2008 Feb; 31(2): 280–286. doi: 10.1183/09031936.00065707. For each year of cannabis smoking, the risk increased 8%.

For every study, there is another that contradicts it. Some other studies have not found this association. One of the problems is that a lot of people who smoke cannabis also smoke tobacco, or smoke both together. The New Zealand study used statistical analysis to separate the effects of cannabis smoking from tobacco smoking, but some other studies have not found a separate effect.

An analysis that combined data from several studies had mixed conclusions [Int J Cancer. 2015 Feb 15; 136(4): 894–903]. On one hand, the authors found that having ever smoked cannabis did not alter the overall risk of lung cancer. On the other hand, risk was clearly higher when they looked at a particular kind of lung cancer – adenocarcinoma – especially if the patient smoked a joint or more per day, and especially if they had smoked for more than 10 years. The difference also showed up in people who had smoked cannabis for 20 years or more, for all types of lung cancer.

OK, the risk of lung cancer associated with cannabis smoking appears to be lower than the 23-fold higher risk linked to tobacco smoking (US estimate in men only). But yes, you could get lung cancer.

There is a growing body of evidence on medical use of cannabis, and more trials are needed. I’ll try to get to this in future blog posts.

But arguments for medical use are not helped by unsupported statements and claims. Risks of dependence and lung disease need to be addressed in medical use. Downplaying them or wishing them away doesn’t help anybody.

The anti-vaccination movement goes back more than 150 years: its history holds lessons for today

Posted on by Carolyn Brown

To be clear: when there’s a new vaccine, I’m the first in line, with my sleeve already rolled up. I’ve had a lot of diseases I wish I had been vaccinated for: measles, mumps, rubella (or German measles), chickenpox, influenza H1N1 (just before the vaccine was available), and pertussis (childhood vaccine must have worn off). So if you read the title and you’re looking for confirmation of anti-vaccination views, you’re in the wrong place.

Until recently, my view of vaccination was the standard one that I read in the Canadian Medical Association Journal when I was working there: humanity was plagued by terrible illnesses; Edward Jenner discovered vaccination in 1796; smallpox has been wiped out; we’re working on the other ones. The end.

IMG_0809But my view changed last month. It started with a book I found among my parents’ collection, called Man’s Redemption of Man by Sir William Osler, who basically invented modern medicine at McGill and Johns Hopkins universities. It was the text of an address he gave at the University of Edinburgh in 1910. He said, “A great deal of literature has been distributed, casting discredit upon the value of vaccination in the prevention of smallpox… Some months ago, I was twitted by the Editor of the Journal of the Anti-Vaccination League…” Whoa, whoa. There was an anti-vaccination movement in 1910? They had a journal?

I began to read about the history of the anti-vaccination movement. And I discovered the following, which I didn’t know and I bet many of you didn’t know either:

  • The anti-vaccination movement was born shortly after the discovery of cowpox-based vaccination for smallpox.
  • At the time, no one understood how vaccination worked, least of all its discoverer Edward Jenner, simply because doctors didn’t yet understand what caused diseases.
  • Compulsory vaccination was enforced in many countries on an unwilling populace.
  • Many children died as a result of vaccination, mainly, it seems, because of infection of the cowpox blisters with bacteria such as strep.

I started with Bodily Matters: The Anti-Vaccination Movement in England, 1853-1907 by Nadja Durbach (Duke University Press, 2005), an academic study of the birth of the movement. As Durbach shows, the early rollout of smallpox vaccination in its home country was a public policy disaster.

During this period, people tended to practise folk healing using herbs. Only well-off people had ever even had a physical exam by a doctor. Nobody really understood how illnesses happened, or that one illness was spread in a different way than another, so people blamed “filth” and “miasma” (bad smells from sewage and swamps). Some people thought that quarantine and isolation were a good way to prevent disease spread, but others experienced serious stigma from a disease “placard” posted on their house and tore the placards down. Medicine and physicians were just becoming a scientific, regulated practice and profession, and trying to stake out territory among a suspicious population. Civil liberties were a strongly held concept, and citizens defended their freedom to make their own choices. Working people had acquired a basic education and started to complain about how they were treated, at the same time as public health officials saw them as the source of “filth” and contagion. Into this morass came a smallpox epidemic, and the first compulsory vaccination law in 1853.

At a certain point in this story, I started seeing the situation from the parents’ point of view. They didn’t know what caused smallpox, or how this vaccine worked. Public health officials literally broke down their doors and attacked their children with a lancet, often causing wounds in several places. And a percentage of children died of after-effects. Other parents heard these stories. Talk in the streets was that the vaccine came from cows or the grease on horses’ hooves and would turn your baby into a cow-monster. While parents were used to a certain risk of child mortality, attributed to God’s will, they were afraid of an unproven, manmade “operation” that they couldn’t control. One man who was convicted said he would pay the fine rather than have a baby vaccinated, as a previous child had died as a result of vaccination.

I can see it. If you feel there is a risk of losing a child, you don’t care much about the greater good of society.

At the same time, middle-class protestors opposed vaccination on the grounds of civil liberties and often conflated it with opposition to vivisection. They felt the government was conducting a huge experiment on the population without consent.

Did the officials allay parents’ fears and provide them with reassurances? Somewhat in the public press, but not in the actual encounter, which looked like state oppression to the working people targeted by the law.

So the whole thing got mixed up in class perceptions, the role of the state and civil liberties.

Which brings me to the anti-vaccination riot in Montreal in 1885. Quebec was in the middle of smallpox epidemic that ultimately claimed around 3000 people in the city and around 2500 in the rest of the province. As Michael Bliss documented in his excellent book Plague: A Story of Smallpox in Montreal (HarperCollins 1991), the anti-vaccination movement had come to Montreal as well. Top doctors were divided on the effects of vaccination, and there was a rough division by ethnic group and class, with working-class francophone people targeted for vaccination and defended by francophone doctors who treated them. Newspapers and employers urged compulsory vaccination, but many Catholic priests and a few influential intelligentsia argued against it. On September 28, a crowd of men and boys pelted an East End health office with stones, breaking windows. They paraded around the city, breaking windows of pharmacies that handled vaccine. They also converged on the private homes of a member of the provincial board of health and an alderman who promoted vaccination. They called out “Down with vaccination!” The same day, 79 people died of smallpox.

Back in England, a royal commission on vaccination sat for seven years before recommending, in 1896, exemptions for “conscientious objectors.” Once this was introduced into law two years later, much of the wind slowly went out of the anti-vaccination movement. It had, in fact, won.

But the movement has flared up again with each new vaccination, as you can read more about on the History of Vaccines, a fascinating site created by the College of Physicians of Philadelphia.

Why does anti-vaccination keep coming back? Can this history teach us anything?

Most countries do not make vaccination compulsory or punish objectors, because governments have learned that that does not work. In fact, it backfires. But in Australia, the government has withheld social payments from parents who do not vaccinate their children since January 2016, fanning an anti-vaccination movement. The measure also targets people on welfare, repeating the mistake of treating the poor as a reservoir of disease.

What does work is education — about the causes of disease, about how vaccines work, about the real but rare risks involved in vaccination. And about the real risks of disease.

I think the cause might also be aided by admission that “mistakes were made” in the past and that today’s scientific and ethical oversight prevents the gross excesses of early vaccination.

In most communities, parents weigh the benefits against the risks of vaccination and opt for vaccination. There is also peer pressure to vaccinate children as the right thing to do for their health.

But I wonder how many people remember their parents or grandparents speaking against vaccination and are influenced by that history. How many are still fighting a 150-year-old fight for what they see as their liberty?