constipation.

even hearing the word might make you flinch, or snicker, and for good reason. it’s from the latin com- “together” + -stipare “to cram”.

some say that the leading cause of constipation is “lofty expectations.” people do expect to “go” quickly and easily and on a somewhat regular basis, and can become quite alarmed if this is not the case.

i don’t know how reassuring it is, but i often review with folks some details about how the bowel works.

the only reason we get any benefit from food at all, really, is because of the friendly microorganisms that live in there (including normal bacteria, protozoa, and fungi). for example, about 1/3 of fecal matter by weight is made of “normal flora”, dead and alive.

at the digestive level, humans are less individuals than they are ecosystems. and all ecosystems have their ups and downs.

science!

babies are born with a sterile gut, and normal flora are quickly added by mother’s milk. addition of other kinds of food change the ecosystem by adding completely different bugs.

a diet full of simple carbohydrates – white flour, corn syrup – changes the ecosystem. a diet full of meat versus fish versus beans changes the ecosystem.

various germs may not make a human sick, but might change the ecosystem, so that some kinds of flora become more or less dominant. antibiotics, laxatives, and probiotics all affect the balance of power in the ecosystem. and all of these issues influence “regularity.”

joke! kidding!

the ecosystem is also subject to the vagarities of the “enteric nervous system.”

the guts have their own nervous system, with more nerve cells than the spinal cord has. it is connected to the central nervous system (brain and spinal cord) through the vagus nerve, but if the vagus nerve is cut, the enteric nervous system keeps working independently. sensory nerves in the guts carry information about the chemical environment and mechanical conditions (for example, stretching or cramping). motor nerves make the muscles work and manage secretions. the neurotransmitters that carry these data, fluctuate adaptively according to conditions.

researchers in this field write papers like “Influence of anxiety on visceral sensitivity” and “Inflammation and visceral hyperalgesia.” (hyperalgesia means abnormal pain sensitivity.) the ecosystem is affected by conscious and unconscious stresses.

the take-home message in most cases is, don’t worry about it, because it is always going to be subject to change without notice.

you might be a person who is prone to constipation, or you might be taken by surprise when you’ve never had it before. don’t worry about it! change is normal.

do what you can to help the healthy normal flora thrive, and to keep life easy for the nervous system of the guts – drink plenty of water, eat a healthy whole-foods diet, don’t binge or purge, get plenty of sleep and whole-body exercise, maintain healthy spiritual practices. don’t freak out if the ecosystem gets out of whack once in a while – just gently guide it back into balance as best you can.

just look how happy these folks are.

there are other cases, though, where constipation can be health- or life-threatening. it is not ordinary constipation, but is called severe constipation (technical term!).

it can occur
– when people take narcotic pain relievers (which sedate the bowel muscle)…
– or other constipating drugs (calcium channel blockers, “overactive bladder” drugs),
– have hormone problems (for example, thyroid disease)…
– or nerve damage (for example, due to diabetes, parkinson’s, or MS) that changes gut function,
– or have anatomical issues (surgery, fissures) that make it difficult to move the bowels.
(many people have more than one of these issues.)

these folks are at risk for severe constipation, with no bowel movements at all for days on end, and usually with belly pain, bloating (belly full of gas, without burping or farting it away), nausea, and loss of appetite. they often become dehydrated, and can easily end up in the hospital.

break “the laxative habit”… with a laxative

as you can tell, severe constipation is not the same as “occasional irregularity” or “sluggish metabolism,” and is not a problem of “lofty expectations.” it is a medical problem!

unfortunately, most doctors get no training in how to deal with severe constipation, and, when they don’t simply turf the question to a nurse, they may mistakenly treat it the same way they’d treat “lofty expectations”: recommending fiber, water, and exercise, or vaguely suggesting “a stool softener.” one exception is in palliative care, where they take constipation much more seriously, probably because so many of their patients use narcotic pain medicines, and also because their main business is improving comfort rather than curing disease.

i personally am rather aggressive with severe constipation (i learned about it from a palliative care doctor!). my motto is “treat it daily, and on day 3″ (see this handout for details).

i’ve been known to send patients to the hospital for this problem: an older man whose usual routine (which i had just found out about) of dis-impacting himself with a tiny spoon no longer worked, and who had severe pain (no b.m. for 3 days); a younger man on opioid pain medicines who became “blocked up” and could not stop vomiting (nothing for 10 days); an older lady who was very thin and stopped eating and drinking due to nausea caused by the problem (5 days)… and more. i am often consulted when the person has gone much longer than day 3! …which makes me sad.

phenolphthalein, “medically proven” carcinogenic! (no longer found in ex-lax)

i also have seen quite a few young children with this problem.

just like with adults, it usually starts with one episode of severe constipation from which the child never fully recovers. with kids, the bad news is that they are even less communicative about the issue than adults. the good news is that parents are usually very vigilant with their child’s long-term “aftercare” or re-training of the bowel to function normally… much more vigilant than they would be for themselves, unfortunately.

when a person of any age has an episode of severe constipation, the bowel muscle usually becomes stretched out and thin, and it takes time to shrink down and become thick and strong again. this is why, without proper aftercare, episodes can occur over and over again.

during recovery, people benefit greatly from a daily regimen of fiber, softener (e.g., prune juice!), and plenty of water, as well as a month of probiotics (the ecosystem is often pretty messed up from all the chemicals needed – natural or pharmaceutical – to clear the blockage), and special exercises to restore mobility and tone to the belly and pelvic floor. (see handout!)

my final advice: treat it daily, and on day 3!

dad vs. m.o.m.

here in oregon, it has been cool and breezy until this week. we have missed the life-threatening heatwaves seen around the rest of the nation. for example, at the lilith fair (women’s music festival) in portland, according to rolling stone magazine, fans huddled under blankets, and performers turned blue with the cold, when they opened on july 2nd!

july 4th weekend couldn’t have been more lovely, with blue skies, bright flowers, and cheery breezes.

despite the weather becoming more and more beautiful, more and more patients with chronic pain have been running out of pain medication early. why would this be?

at first i was puzzled. but now i think it’s because of the beautiful weather! people are feeling a little better, or at least a little more ambitious, and are overdoing it on activities. that knee-high lawn won’t wait another day for you to mow it – but if you overdo it, you’ll have a bad day tomorrow!

because narcotic pain medications are dangerous drugs – something you might underestimate if you have been taking them daily, for months or years, for chronic pain syndrome – their use must be strictly controlled. let’s talk about some common mistakes people make, who take these medicines.

first, a review. this part is important, because it explains the proper approach to this problem:

– chronic pain is not the same as regular pain. the “nociceptive” pain-sensing system of the body evolved to alert us when we are injured. if you sprain your ankle, the pain caused by inflammation keeps you from walking on it – then when it heals, the pain goes away.

– in chronic pain, the original injury healed months or years ago – yet the pain remains. one example is “phantom limb” pain, in which, for example, a missing foot still hurts, aches, itches, or burns. (in other cases, as in fibromyalgia, there may not even be an identifiable injury.)

– in regular, acute pain, you can easily say, “the pain comes from the sprained ankle.” but in chronic pain, you have to say instead, “something changed in the nervous system.” due to this change, the body-mind continues to register pain.

– chronic pain does not tend to get worse and worse. over time, it tends to get better. for example, in phantom-limb pain, often the nervous system eventually recognizes that the amputated foot is gone, and stops sending pain signals. this can take days, weeks, months, years, or decades. it stands to reason that the same thing may happen with other forms of chronic pain – the nervous system re-tunes and heals.
(due to the acute-problem focus and funding of western medicine, there’s very little research on long-term outcomes for a lot of conditions.)

note: even though chronic pain itself does not tend to get worse, the effects of an altered lifestyle can take their toll. if your back hurts too much to exercise, your muscles will waste away and your bones become weak, and these cause their own aches, pains, and exhaustion.

– in my opinion, the goal of using chronic pain medication is to keep a person functional – preventing worse physical, mental, and social problems – while the person works on re-tuning and healing the nervous system, over years or decades.
to achieve this goal, a person takes a stable dosage of pain medicine on a regular schedule, maintaining a steady amount of partial pain control at all times.

– a person who has chronic pain can also get injuries causing regular acute pain! for example, a person with chronic daily neck pain, can suddenly get a gout attack in their foot. a person with chronic pain from sickle cell disease can suddenly get a toothache. these sudden pains are different (are not chronic pain), and should be treated differently!

– a person with chronic pain can also have it get worse temporarily due to over-exertion, emotional stress, lack of sleep, illness, doing too much yardwork, etc. this pain is also different, and should be treated differently.

…this brings us to 3 common mistakes that pain patients make, and how (and why) to avoid them.

mistake #1: taking “extra” chronic pain medication to deal with temporary acute pain.
do you remember when you did not have chronic pain? in those days, when you tore up your hands doing outdoor work, or got a migraine headache, or twisted your ankle or knee, what did you do?

solution: treat acute pain acutely.
– REST the injury, and rest yourself.
– take tylenol and ibuprofen as appropriate for your situation.
– use ice and heat, soaks and wraps, ointments and rubs, massage and gentle stretching.
– if you think a procedure is needed – an x-ray, a dentist visit, etc. – call your doctor and/or go to the urgent care or emergency room.
– do NOT take more of your chronic pain medicine.

mistake #2: taking “extra” chronic pain medication to get through a special project or a special event.
this is challenging, because friends and family members often have activities they want or need you to participate in. narcotic pain medicine could help you to feel and act like your “old self” for a short period of time. however, if you misuse your medicine this way, you will run out early, and then be much more disabled by pain AND drug withdrawal later.

solution: plan ahead for events that are likely to be hard for you.
– do NOT arrange to do more than you can tolerate, hoping for the best. do NOT allow others to plan over-strenuous activities for you.
– PLAN how you will combine an event with a reduced level of activity (for example, how you will participate in some parts of a wedding or a family vacation, and NOT participate in other parts).
…arrange for assistance with tasks, chores, and transportation (for example, get help with packing, etc.).
…plan how many hours you will be up at a time, and where you will rest in between.
…make a plan for how to politely explain your limitations to others, or remind them about your situation (over and over, if necessary), in a way they will understand.
– use tylenol and ibuprofen, as well as the other treatments listed above, to minimize the impact on your body.
– do NOT take more of your chronic pain medicine.

mistake #3: “overdoing it” on a day when you feel good, then “needing extra” chronic pain medication.
everybody has good days and bad days… but when you have chronic daily pain, these extremes are accentuated! over time, you’ll start to predict that the worst days often follow a few days of “overdoing it.”

solution: you need to have steady levels of activity and rest that are about the same every day, whether it’s a good day or a bad day.

one important way to enforce enough rest and prevent “overdoing it” is to commit to taking a siesta (daytime nap) at a certain time every day. plan your daily schedule around it. don’t let anyone interrupt it. it’s very important for recharging your daily energies.

you should also redistribute your activities, so you’re not trying to get everything done on a “good” day. you can re-purpose the old nursery rhyme of “wash on Monday, iron on Tuesday, mend on Wednesday,” etc. – in other words, have a revolving list of tasks, one a day, so you don’t get behind.

for example:
“laundry Monday,
groceries Tuesday,
recycling Wednesday,
tidy up Thursday,
vacuum Friday,
yardwork Saturday,
visiting Sunday.”

this is much better than
“laundry/ groceries/ garbage/ vacuum Monday,
collapse in pain and exhaustion Tuesday/ Wednesday/ Thursday/ Friday.”

don’t “overdo”, and do NOT take more of your chronic pain medicine!

… you’ll notice a motif among these three mistakes and their solutions.
it’s a motif that applies, not just to chronic pain, but also to chronic fatigue, chronic effects of brain injury, and other chronic issues (many of which overlap).

the motif is: “the new normal.”

before, maybe years ago, when you were younger, back in the past, there was a certain set of conditions in your life that you defined as “normal.” perhaps “normal” to you meant “i get eight hours of sleep every night,” or “i do my own heavy lifting,” or “when i need something from the store, i just walk there and back.”

if you have developed a chronic disabling health issue, the “old normal” is not very likely to ever come back. that is the truth. you can make yourself very frustrated and depressed, and waste thousands of dollars, desperately chasing after the ultimate surgery, perfect practitioner, magical treatment, or medicine and dosage that will allow you to “get back to normal,” if you are still operating under the “old normal.” unfortunately, there are a lot of smooth operators out there who are quite willing to take your money and give you nothing in return but false and temporary hopes.

but you can trade false hopes for realistic control of your life. you need to create and claim your own “new normal.” it is much better to choose your own definition of “normal life” than to have others impose it on you. you need to be able to say, “here is how i normally operate, given my current limitations, day by day,” rather than having friends, family, or doctors tell you, “this is what you SHOULD be able to do, so just do it.”

– avoiding mistake #1 will help you to juggle your chronic limitations along with the unexpected, temporary problems that naturally arise.
– avoiding mistake #2 will help you rearrange the important events in your life to fit the capabilities you now have.
– avoiding mistake #3 will help you move on with your daily life in a sensible, organized fashion.

as a doctor, of course, i would be relieved if i knew that YOU knew how to keep from over-relying on pain medicines inappropriately. if the medicines were harmless, of course you could take them whenever, for whatever you saw fit! unfortunately, drugs don’t work that way. not even vitamin pills work that way.

please keep your eyes on the prize! the goal is, again, for you to be able to work and play “normally” (according to whatever is the “new normal” for you), while your body, mind, nervous system, spirit, and all, re-tune and recover from all that has happened to you.

work carefully, play joyfully, rest patiently! (and drive safely.)
have a great summer!

this puts it in the same category as morphine, oxycodone, amphetamine (Adderall), and methylphenidate (Ritalin), which would make it seem that we can now start writing prescriptions for it.

why do we write prescriptions, anyway? it’s to tell a patient what strength of medicine, taken how often, will be likeliest to help them. in schedule II, we provide just a 30-day supply with no refills, because the drugs are dangerous and must be closely monitored. if they aren’t helping you, they can only hurt you. you have to take them according to very specific directions.

now, your doctor doesn’t try each drug out, to see how it works in different strengths and frequencies, before prescribing it – that would be crazy. instead, we start from standardized prescribing instructions, based on scientific studies, in which the drug was first given, in certain doses at certain frequencies, to strong healthy people, so we know it doesn’t make you sick – then to sick people, so we know it makes you better. from this, we get a list of known effects – helpful/desired effects, known side effects, and possible adverse effects. these data tell us how we should write the prescription.

how are we going to do this with a plant? it’s like trying to write a prescription for tuna casserole!

there’s only one Ritalin, but there are many, many “marijuanas,” from the mississippi ditchweed that is (inappropriately) used in research studies, to the highly refined and concentrated strains currently cultivated for medical use by horticultural scientists in 14 states and the District of Columbia. if you used them identically, you’d get completely different results.

map by norml.com

if you’re reading this blog, you probably use echinacea at home, when you get a sore throat, right? well, what if echinacea were a controlled substance, that i was supposed to prescribe to you? i would have to name a very specific preparation (preferably one you could make at home*). the rx might say,

echinacea angustafolia, aerial parts
30% alcohol tincture
take 2mL PO scheduled four times a day for 5 days
please dispense 40mL
no refills

this will never happen, because this plant is regulated as a food, not a drug. so, instead, you have shelf after grocery shelf of teabags, tablets, capsules, and tinctures, of various species, from various locales, of all ages and degrees of freshness. i really have no way to tell you what these “echinaceas” are, which one you should take, how much to take, or how often to take it. i have no idea how to prescribe a plant – whether it’s “echinacea” or “marijuana.”

yet “schedule II” is a set of instructions for prescribing. so i’m confused.

no worries, though; nobody will be scribbling any rx’s anytime soon, ’cause the federal Controlled Substances Act bats last. my DEA license won’t cover marijuana, as long as it stays on schedule I for the feds – along with PCP, LSD, and other not-so-medicinal drugs.

(under the current Oregon Medical Marijuana Act, physicians never “prescribe” marijuana, they merely provisionally, and with many caveats, advise that marijuana might be one kind of treatment that could maybe possibly partly mitigate some of the effects of an individual patient’s particular illness – with only some illnesses being considered legit.)

i would like to remind everyone that the AMA (american medical association) did make the following statements recently:

“The AMA calls for further adequate and well-controlled studies of marijuana and related cannabinoids in patients who have serious conditions”
AND
“This effort should include… confirming that marijuana of various and consistent strengths and/or placebo will be supplied by the National Institute on Drug Abuse to investigators”
AND
“The AMA believes that the NIH should use its resources and influence to support the development of a smoke-free inhaled delivery system… to reduce the health hazards associated with the combustion and inhalation of marijuana”
AND
“Discussion of these alternatives between physicians and patients should not subject either party to criminal sanctions.”

the AAFP puts it in a little more backhanded frame:
“The American Academy of Family Physicians opposes the use of marijuana except under medical supervision and control for specific medical indications. (1989) (2007)”

here’s what i’d like to see: medicinal marijuana legalized universally (nonscheduled, and added to the United States Pharmacopeia) – with strong enforcement of antiprofiteering laws (much stronger than those currently benefiting pharmaceutical corporations and natural-remedy hucksters) – and immediate engagement of serious clinical research amongst the huge patient panels already in place.

you could start, in oregon alone, with the 1,294 cancer patients, 509 glaucoma patients, 791 epilepsy and seizure disorder patients, and 7,843 patients with intractable spasms caused by multiple sclerosis and other neurological diseases, who are current cardholders.

many of california’s 37,624 cardholders being treated for PTSD, mood disorders, and substance abuse (you heard right), could undoubtedly provide statistically significant samples.

and the (anecdotally) strong and effective medicines these patients use – “silver haze” for epilepsy, “granddaddy purple” for adverse effects of chemotherapy, “sour diesel” for multiple sclerosis, “new york diesel” for migraine headache, etc. – are a very far cry from the mississippi ditchweed employed in otherwise rigorously-constructed scientific studies.

it’s like studying carrot juice as a treatment for acne, when your patients are actually using accutane (both substances bearing a resemblance to vitamin A, but in completely different strengths, get it?).

“sour diesel?!”

meanwhile, as reported by my crusading-journalist spouse, there’s a fake-pot panic brewing in the deep south. “herbal incense” that is supposed to “simulate marijuana” (yeah, right) has been outlawed in louisiana.

but that’s not all. from the same article, “HB173 would prohibit a number of plants from being blended and smoked or inhaled. The plants in question include mugwort, honeyweed, sacred lotus and dwarf skullcap.” ditto arkansas, georgia, kansas, and others.

see why they call it ’skull-cap’?

and why? “It’s in our high schools and it’s spreading rapidly“! jeez, in my day it was banana peels, “lettuce opium,” morning-glory seeds and nutmeg. perhaps these states will someday have to institute a “Medical Skullcap Program”, where diagnosed insomniacs may register to use herbal sleep aids without fear of going to jail. have they already developed the random drug testing programs that will detect mugwort in the urine? if so, i’m quite impressed – creating many jobs, no doubt, in a nation of unemployed.adults and at-risk youth. (whoops, they’re already on it.)

mugwort, coming soon to a DARE program near you!

my young and glamorous spouse comments that next on the lawmakers’ target lists might be “spinning around really fast, masturbating, or any other activity that might alter a young person’s consciousness,” and wonders “where the natural health community is on this issue, or if they are laying low because it’s targeting head shops instead of Whole Foods.”

meanwhile,

*how to make the aforementioned echinacea tincture:
Blend equal weight to volume (1:1) of flower heads and leaves (fresh) to alcohol [100 proof]… This provides approximately 30% alcohol tincture which is ideal for extracting polysaccharides (water soluble), cichoric acid (alcohol soluble) and akylamides (alcohol soluble).

…100 proof is 50% alcohol. When you add an equal weight of Echinacea flowers and leaves, you in effect reduce the alcohol percentage to about 30%, because the Echinacea flowers and leaves contain about 85% water. Thirty percent alcohol is adequate to preserve the tincture.

observe me NOT prescribing it. because it’s a PLANT!

many of us, who don’t have insurance and/or don’t like or trust doctors, have a relationship to “health care” that entails a set of self-help books, websites, and a library of anecdotes from friends and family. i think participating in “the health care system” would be more like this, if insurance were out of the picture – except the home medical manual and anecdotes would be continually reality-checked with a thoroughly educated, constantly updated, and emotionally invested live physician who also lays their hands on your body and asks how you’re sleeping.

note: the health insurance industry hates “subscription”-type medical practices, and
wants them to be regulated as if they each were a large insurance corporation. so it is possible that the 5000 of us who practice this way, may turn out to be a flash in the pan one day – crushed, like national health, by the juggernaut of the massive american insurance industry.

unfortunately, the “subscription plan” still sticks a patient with a monthly bill.

if we had national health, that monthly bill would be paid by the government, and would be invisible to the patient, just like their contributions to their local fire and police departments. after all, we don’t make a cost-benefit analysis about how our relationship with the local firefighters and cops stand, before we buy a smoke alarm, lock our doors, or call 911. we presume that we’re covered, because we’re entitled to be covered, because covering our safety is a legitimate part of the public good. nobody really questions this, and in terms of responsibility for safety, we split the difference between public and private responsibility.

our relationship to safety is so different from our relationship to health.

this past week, i’ve had three different patients ask me how often they “need to be seen.” gosh, there are so many different ways to answer this! technically, if you take medicine, we should check every so often, one way or another, to make sure it works and isn’t having side effects.

“the guidelines” state you should have a yearly check-up, but i believe “the guidelines” are designed around a model of large group practice, where you are always a stranger “seen” by a stranger. (and i could literally go on 4EVER about the problems inherent in “stranger-based health care.”)

if you’re my patient and i’m your doctor, i can see you, and you can see me, by emailing me or phoning, any time. hopefully we’ll also “be seen” at the farmer’s market, the thai restaurant (mmm), and the park (howdy!), when your “health” is not a separate entity from your “life.”

if our relationship is based on fee-for-service, and either you or your insurance pay for each visit, but i never “see you,” i will, of course, go broke.

on the other hand, if you have to pay in full for every visit, and/or you’re penalized by your insurance company for visiting a doctor, you’re likely to avoid ever “seeing me,” to keep from going broke.

yet you know your blood pressure is too high, you should quit smoking, god only knows about your cholesterol, you’re just 5 pounds away from the dreaded “obesity,” and to top it all off, you’re going crazy from allergies… and, truth be told, you can’t sleep, back hurts, feel depressed…

right there, that’s eight health problems you’re trying not to think about – so add anxiety (with tension, restlessness, and irritability), to the problem list. “the guidelines” would say we coulda-shoulda covered all this in a 15-minute conversation, including a physical exam, for $112 (last year’s medicare rate).

for last year’s brief visit with your doctor, you paid $789.57 per month, on average, for your health insurance (in oregon; see here for your state’s monthly average health insurance premium).

maybe you saw your doctor three times last year. then your doctor got paid $336 or so, and you and/or your employer paid $2370. it’s at this point that americans often start to feel “lucky” if something went wrong and they had to go to the hospital; paying $3,000 instead of $30,000 starts to feel like winning the lottery.

do you agree with the guidelines – or indeed with this system? were your blood pressure, cholesterol, overweight, back pain, allergies, insomnia, depression, anxiety, and smoking “cured” by the 15-minute appointment you had with your primary doctor a year ago? will they be cured by this year’s visit?

do you feel like you saved $30,000, or even $3,000, by going for your yearly checkup? what if you could call your doctor’s cell phone whenever you had doubts – or your doctor emailed you to make sure you are, in fact, quitting smoking, or eating right?

what would your life be like if you were confident you’d live to a happier, healthier, old age, starting today (or last year) with less pain, better fitness, and a clearer mind? how would your plans change? what would you imagine as realistic possibilities for the future?

this is the ultimate potential, i think, of taking money out of the relationship between doctor and patient, and building a system where you can get comprehensive “health caring” whenever you and/or your doctor think you need it. let’s stop prioritizing problems, and people, according to monetary potential, and get down to living with care.

just like we do with the food co-op. the childcare collective. the car pool. the fire department. and so on.

i often state that i never actually wanted to become a doctor. it’s true. i was not one of those kids who dreamed of someday wearing a white coat. i did not bandage the legs of neighborhood dogs. my earliest career aspirations were to be a roller-derby skater or a boarding-house proprietor; later, a poet.

my parents were graduate students, then college teachers, then professors (chemistry and english). my earliest understanding of adult work was that you went to your job every day, august through may, from 7 am until 8 pm – then you got summer off. as far as i could tell, the amount of money you got paid depended on how old you were. as you got older, you got paid more, until you were too old to work, and then you wrote books.

i was horrified to learn that most adult americans work all year round and never get a vacation. it just seemed uncivilized. (still does. in europe, the average worker gets 6 weeks paid vacation a year.) so, relative to most americans, i suppose i am at base a slacker.

as a young hippie mom, i was quite taken by famous midwife ina may gaskin’s vision, in Spiritual Midwifery, of how a community should support a midwife.

in her vision, members of a community should contribute resources appropriately, to provide their local midwife with an equitable standard of living, so that she would be able to counsel and care for clients without any financial conflicts of interest. the example ina may gave, as i recall, was that a midwife would not be constrained from advising clients to work on their attitudes, if she were not concerned about their payments.

a midwife supported by her community would also not be obliged to pack more clients onto her schedule to earn enough money, and would not be tempted to provide a lower standard of care to those who could pay her less. this economic model was removed from later editions of the book without elaboration, unfortunately. it was the “greed is good” reagan years; i suppose too many readers complained about such “unsustainable” high ideals, for the democratically-minded ina may to retain that part in the book.

but i agreed. i felt that, as we do with food co-ops, cooperative childcare, car pools, and community gardens, we should all chip in, with money and/or labor, each according to their means, to make a healthy standard of living – fresh vegetables, safe daycare, efficient transportation, neighborhood health care – affordable for everybody.

my intuition was that immediate hands-on care, by someone who knows you well, when you are sick or hurt, or when you need a midwife – just like fresh vegetables, safe daycare, and efficient transportation – are not commodities. they are not the same as fancy cars or high-end stereos, which are available only to those with plenty money. everybody needs them. everybody is entitled to them. and the people who provide them? they should not be given the opportunity (the temptation) to be motivated by profit.

even now as a doctor, it seems sensible.

this is the reasoning behind my “subscription” plan (i couldn’t think of a better name for it).

if each family of four that i see were on my subscription plan, it would cost them an average of $35 per month per person for unlimited access to primary care services (provided by me) – about $1680 per year for the four-person family.

if i saw a hundred families like that, it would pay for the costs of my office, the costs of keeping up with the medical research (fifty hours of coursework are required yearly), allow me to pay off my student loans ($200K, unfortunately), and sustain the current, reasonable, standard of living for my family (rented house, rabbit-ears-not-cable, ordinary car – maybe even basic catastrophic health insurance, which we currently can’t afford).

this “subscription plan” fee is based on current local primary-care fees, spread over an average of 5.5 visits per year per person (click here for services i offer).

i’d expect to see 100 four-person families for a total of about 1100-2200 hours a year, at least. (if you worked 40 hours a week all year, with no time off, you’d work 2080 hours.) so that seems fair, compared to what many family docs do (average 50 hours/week).

the subscription plan is most cost-effective (if that’s your main concern) for people who need more frequent visits. these are folks who often put off seeing a doctor, especially when they have insurance.

if you have high blood pressure or high cholesterol, have chronic stomach pain or headaches, need to lose weight or quit smoking (for example), you really should spend a transitional period of time “under treatment,” seeing your doctor on a very frequent basis. most people won’t do this, because they have to take time off work and pay out of pocket for it, and they don’t feel sick.

but by not, carefully, for once and for all, taking care of these conditions, they end up much sicker later – sometimes unable to go to work at all, hospitalized, with shortened lifespans.

although the plan is cost-effective for many of my patients, i am most interested in the effect it may have on the doctor-patient relationship, and on the place of “health care” in people’s lives (and on the place of “patient care” in my life). (let’s leave aside the question of how “health care” is to health as the “justice system” is to justice, and just presume that when i “do health care,” i am having an effect on your actual health.)

of course i know lots of ladies who had births that were medically “abnormal” (my daughter’s 48-hour labor last week, or my own three postpartum hemorrhages, for example), yet who bounced away whole and hearty, who’ll testify they had a righteous, flamboyantly amazing, “wild-good” experience. but i also know someone whose labor, birth, and postpartum were dangerously mismanaged, practically from start to finish. i wasn’t there and am not an eyewitness. however, from her accounts, i have to wonder whether the primary problem wasn’t the egocentrism of her caregivers, both alternative and orthodox – who didn’t want to acknowledge that something was going wrong under their care; who blamed her for it; who handled her callously; who made her pain worse not better; who lied to her about her baby’s health; who frightened her in ways i believe were manipulative; who denied accountability, abandoned her, and stuck her with the bill.

fortunately, she’s not much the self-blaming type. my anger and outrage don’t hold a tiny birthday candle to her own. on top of all that rage, i sense a deep betrayal, not least because she hesitates to tell her story, what with all these happy birthers around. it reminds me of the burning silence of a rape survivor at a wedding shower. sometimes we can’t speak because we know we won’t be able to stop.

don’t worry, i’m not going to bring you down! today, she’s the strong, healthy, creative, kick-ass, go-to gal she was before it all started, older and wiser, but still a beauty, with a cute funny awesome firecracker of a preschooler, who has a thing for the number 5. (or used to – i may be behind the times!)

it’s humbling and frightening to me to meditate upon her journey, because i’m strongly aware of my own pernicious egocentrism, plus the defensiveness that haunts the awareness that you don’t know all the medicine you should; you don’t know so many things; you weren’t taught so many more; you haven’t seen so much that’s so important… dreadful things could go wrong under your nose, because you’re not all-seeing, all-knowing. worse than that – many of the things you do know, that you were taught, may be menacing and indeed harmful in uncertain situations. the authority of the caregiver – be they surgeon, physician, psychotherapist, or midwife – is like plutonium! toxic when handled carelessly, difficult to control, creating a false illusion of magical powers.

my friend might not tell her story much, but i do (just not on the internets). i began using my friend’s birth story as an object lesson when training other future caregivers. as i told her, the story provides “ten things NOT to do.” i am annoyed by the cautionary yarns spun around birth by most doctors, which often betray a great deal of suspicion of the female body; mine betrays my own suspicion of the medical establishment, which is reciprocally annoying to them, no doubt. you can read her story in detail, yourself, elsewhere.

a wise and gentle neurologist once gave me the rule, “do what you know – know what you do – and don’t lie a lot.” i sure can’t top that! yet here are my…

TEN THINGS NOT TO DO for doctors, nurses, and midwives:

1. do not neglect pelvimetry, even though you know there is no “evidence base” for this old-fashioned, hands-on technique.
2. do not ignore it, if her cervix reverses dilation during labor. and do not pretend it doesn’t happen, even though your old professor assured you that it doesn’t.
3. do not omit careful palpation of the uterus when a woman’s in labor, and do not ignore it if you find something strange, like a bandl’s ring (look it up!) or an unexpected fetal part (dehiscence).
4. do not cast aspersions on the sincerity of a woman’s desire for normal/ natural birth, as a putative reason for her labor slowing or stalling – neither aloud, nor by facial expression/ tone of voice – even though your clinical intuition is like a finely honed steel.
5. do not give substandard, less comprehensive, or more interventive care to a woman of whose birth plan you disapprove. do not voice or otherwise indicate your disapproval, in the room, the hallway, or the chart.
6. do not administer “wound care” that is painful. do not omit pain prophylaxis.
7. do not dismiss a sick baby’s NORMAL vital signs, clinical signs, labs or images, as unremarkable at best, or temporary/ illusory (“the damage just hasn’t shown up yet”) at worst – even though doing so would allow you to greatly consolidate your authority.
8. do not counsel a newly-delivered mother to abandon hope for her sick baby’s life or health, or ask her to focus on some other imaginary (better?) future baby – even though it may you a chance to demonstrate how very, very smart and/or “realistic” you are.
9. do not try to convince a mother, who is (perhaps invisibly) grieving the catastrophic end of her birth plans, that “saving the baby” is what “really” matters. this would only demonstrate that you are an asshole.
10. do not indulge in immature defense mechanisms – denial, passive-aggression, projection, etc. – that may be provoked by clinical situations that threaten you, such as, oh, say, ANYTHING INVOLVING CARE OF PEOPLE IN CRISIS. i use the word “indulge” advisedly. do not be self-indulgent, when others need your compassion, in addition to your incredibly big and fancy diploma.

i could go on and on and on. i’ll round it out to a baker’s dozen:

11. do not get me started on “evidence-based obstetrics”!!!
12. do not allow a sick baby to develop and maintain oral aversion caused by multiple intubations!!!
13. do not ignore the oversized impact that further medical “help” – screening, imaging, snipping, sampling, trying one, then another, medication on for size – will have, on the woman (the child, the family) who has been medically traumatized.

the gentle neurologist who was my teacher also told me, “they don’t care how much you know, til they know how much you care.” i hope it’s true! i don’t know EVERY SINGLE WAY TO SAVE A PERSON’S LIFE, but i do care about a person’s life, including how they feel when they leave my office and go home.

plus, i know at least ten things NOT to do.

although there have been multiple important campaigns to guarantee clean water to citizens, from the worldwide United Nations level to local (Lane County) efforts, very little attention (or money) is devoted to the “sanitation” (i.e., toileting) problems that are the major source of dangerous water contamination. this is why many, many parts of the world have very high death rates from gastrointestinal diseases.

this last entry on how to recognize childhood diseases that are usually prevented by vaccination, concerns gastrointestinal diseases. polio, rotavirus, and hepatitis A are transmitted by means of “sanitation” or lack thereof. hepatitis B, on the other hand, is blood-borne and transmitted through contact with body fluids – including ways you might not suspect.

rotavirus:
this is the main cause of severe diarrhea in babies and young children, and before vaccination, 55,000 babies were hospitalized with it every year in the US. it’s a “sanitation-bourne” virus – spread by contact with diarrhea, including diapers, clothing, washcloths/towels, and surfaces. unlike most forms of diarrhea, “rotavirus season” is in the winter, from november through april.

rotavirus is easy to describe. the incubation period is about 2 days, followed by vomiting and diarrhea for about a week. some kids have fever and abdominal pains as well; about half of babies and kids will also have breathing symptoms like cough and wheeze. seizures and encephalitis occur rarely. about 1 in 40 babies and young children will need to be hospitalized due to dehydration.

the only treatment is symptomatic. you would need to safeguard against dehydration to the best of your ability, using oral rehydration fluids to preserve vital electrolytes lost through the intestinal tract. if your child stopped urinating, stopped crying tears, or had any suspicious change in behavior, you’d need to get them evaluated – they might need IV fluids to prevent worse consequences.

after having rotavirus once, it’s possible to get it again, but repeat infections are less severe. some individuals will have long-term problems with digestion after the acute virus is cleared. they can continue to have loose stools, belly pain, and carbohydrate or lactose sensitivity or intolerance. in some cases, long-term irritable bowel syndrome appears to have resulted from a severe gastrointestinal virus.

polio:
the gastrointestinal virus causing the disease poliomyelitis (“polio-my-a-LITE-is”). recall, “myelo-” means spinal cord, and “-itis” means inflammation. “polio” means grey; the virus can infect and inflame the grey matter (nerve tissue) of the spinal cord, causing paralysis.

polio virus is transmitted hand-to-mouth, usually through contaminated water or food, most prevalent in summer and autumn (may be year-round in tropical areas).
the incubation period is 6-20 days, and the virus is contagious for 10 days before and 10 days after symptoms first appear. there are no treatments, so control focuses on prevention.

as you probably know, polio outbreaks caused many public-health panics in the first half of the twentieth century (58,000 cases in the US in 1952 alone) and led to widespread vaccination campaigns. this also led to the first anti-vaccination campaigns, after 120,000 contaminated doses of vaccine caused polio in 56 kids and killed 5.

north and south america were declared to be effectively polio-free in 1994, and europe was declared polio-free in 2002. currently, polio is still a widespread problem in India, Pakistan, Afghanistan, and Nigeria, so unvaccinated kids are at risk mainly when they or their close contacts have visited these areas.

in about 90% of cases, polio causes no symptoms and the person is not aware they have been infected. in the remainder of cases, the virus causes mild illness, including sore throat, fever, body aches, nausea, vomiting, abdominal pain, and constipation.

in about 3% of cases, polio goes on to infect the nervous system, causing paralysis. when polio infects the nervous system, it usually occurs after the person has been feeling better for a day or two.

2/3 of people develop meningitis, with fever, headache, stiff neck, vomiting, and sometimes seizures. they will need a spinal tap to rule out any bacterial infection that could be treated with antibiotics (antibiotics can’t help a viral infection). this meningitis usually resolves completely. some kids are left with lasting nervous system development problems.

about 1/3 of the time, the nervous system infection advances to paralytic polio, causing death of the spinal nerves, and resultant wasting away of the muscles. (muscles need nerve signals to stay strong.) symptoms of paralytic polio begin with high fever and muscle pain and weakness (usually one-sided), without loss of sensation – for example, can’t stand on one leg, and no knee-jerk (or ankle-jerk) reflex in that leg, but can feel touch and temperature on the leg. the muscles are limp rather than spastic.
the paralysis gets worse quickly, over 2-4 days. sometimes brain tissue is infected and brain damage results, with difficulty talking and swallowing, and even with breathing.

polio does look like some other causes of “flaccid paralysis,” including west nile virus (from mosquitos; check with a blood test in the first week of symptoms) and botulism (from infected canned food including honey).
polio does not look like guillain-barre syndrome, which causes two-sided muscle weakness starting at both feet/ankles and spreading up the legs. guillain-barre syndrome can be treated with medicines, while polio can not, so it’s important to distinguish between the two.

hepatitis A virus (HAV):
“hepatitis” means “hepato-”, liver, and “-itis”, inflammation. this is a virus that is very contagious, spread through the feces (stools). it is notorious for appearing at restaurants and childcare centers.

it makes adults much sicker than babies and small children; in the childcare setting, it’s not usually noticed until an adult staffer becomes jaundiced.
older kids and adults are more than twice as likely to need hospitalization from HAV due to liver failure (13% risk for under 5 years old; 31% risk if older).
this is why HAV was added to the standard childhood vaccine schedule in 2006 – to protect older kids and grownups. the liver damage is caused by the immune system’s overreaction to the virus.

hepatitis A can be prevented by handwashing, although it is difficult to enforce this in small children. household bleach solutions also deactivate the virus.

the incubation period is 2-6 weeks, followed by symptoms in about 30% of children under six years old and 75% of older kids and adults.
the symptoms include fever, nausea and vomiting, belly pain, and diarrhea.
jaundice (yellow skin and whites of the eyes) usually occurs one week after symptoms start; the urine can turn dark and the stools can become pale.

the symptoms can last for 1-2 weeks in younger kids, or 2 weeks to 6 months in older kids and adults. it is recommended that people who have been exposed to hepatitis A get the vaccine to avoid developing the disease, up to 2-6 weeks after exposure.

hepatitis B virus (HBV):
this is a blood-borne virus that infects the liver and causes cirrhosis (scarring) of the liver, and an increased risk of liver cancer.

many folks don’t see why there is a child vaccination program against this virus, since they know HBV is spread by sharing needles (for recreational drugs or tattoos), by blood transfusions, and by sexual body fluid contact. they say, “my newborn baby is not having sex or shooting drugs, so there is no point to this shot.”

there are three reasons why the US started the vaccine program:
1. when babies catch HBV, they have a 90% chance of it becoming a chronic, cirrhosis-producing infection, compared to adults who have a 1-5% chance of chronic disease. (the risk is 30-50%, in young kids.) 1 in 3 of the million adults with chronic HBV are believed to have caught it in infancy and young childhood, through cuts, scratches, bites and punctures, and from others who didn’t know they had it (see below).
2. when babies and young kids catch HBV, they often have no symptoms, or very vague ones. it’s estimated that for each young child who has symptoms, there may be 100 who are carriers and have no symptoms.
3. HBV can be transmitted in unexpected ways, including in medical, alternative health, and dental settings, sports, fitness, and cosmetological settings, etc. – see here for more.
the HBV shot is unusual in that it isn’t meant so much to protect against a typical childhood diseases, as to protect against cancer (of the liver) occurring in adulthood. the shot has been around for almost 20 years. the purpose of the program is to eliminate this infectious source of cancer.

for those who do not vaccinate, how can we recognize this childhood illness?

the incubation period lasts one to four months, followed by loss of appetite (and/or “failure to thrive”), nausea, jaundice (skin and whites of the eyes turning yellow) and discomfort in the upper right belly, where the liver is. these symptoms last one to three months. blood tests indicate the liver damage, but even after these return to normal, the child can still suffer fatigue.

some babies and young kids can can get Gianotti-Crosti syndrome, a flat-topped bumpy dark-red non-itchy skin rash on the arms, legs, bottom, and face (not the trunk or scalp). it is possible to have this rash and no other symptoms – for example, no jaundice. ( Gianotti-Crosti syndrome can occur as an immune reaction to any number of viruses, and is harmless in itself.)

breastfeeding is safe. although HBV has been found in milk of infected mothers, their babies don’t appear to go on to develop chronic disease.

kids are diagnosed with chronic HBV when blood tests show the virus has not gone away over six months. it doesn’t usually affect their growth and development. the risk of adult death from cirrhosis and liver cancer caused by HBV that started in infancy or childhood is around 25%. in the united states, HBV accounts for 5-10% of all liver transplants, even though people with chronic HBV have a high risk of having the virus damage the new liver.

even if you already have a handle on the readily-recognizable diseases discussed below (chickenpox, for example), it’s still wise to know how to recognize possible complications of childhood diseases – the reasons the vaccines were developed in the first place! – which could require hospital care.

we already discussed complications of HiB and Pneumococcus, which can be severe, even though in most cases these bacteria cause milder illness or are asymptomatic. these complications include:
pneumonia (lung infection),
empyema (lung abscess following pneumonia),
pericarditis (heart infection/abscess),
meningitis (brain and spinal-cord infection),
epiglottitis (throat/airway infection),
mastoiditis (skull bone infection following ear infection),
peri/orbital cellulitis (eye infection/abscess following sinus infection),
and septic arthritis (joint infection).
note that these complications can follow other childhood diseases as well (including diseases caused by bacteria and viruses we can’t vaccinate against anyway, like staph aureus or fifth disease).

now let’s discuss the childhood diseases that have well-known, characteristic signs and symptoms: diphtheria, pertussis, measles, mumps, rubella, and chickenpox.

diphtheria (“diff-THEERY-a”):
this is an upper respiratory bacterium that is spread by airborne droplets. it usually attacks the tonsils and throat, causing development of a “pseudomembrane” – a skin of grey gunk covering the tonsils that bleeds when scraped (e.g., during a throat culture); also can cause massive swelling of the neck. illness is caused by a toxin that the bacterium makes. the more pseudomembrane (it spreads from the throat down into the airways), the higher the toxicity.
here is a picture of the pseudomembrane:

complications: the toxin mainly affects the heart muscle (myocarditis); the heart rhythm can become irregular, and heart failure can occur.
the toxin also affects the nervous system, causing paralysis of the throat and facial muscles, and sometimes progressing to generalized paralysis days to weeks later.
again, the severity of these effects depend on how much toxin is present in the blood before treatment.

diphtheria is treated with antibiotics, to stop the bacteria from growing, and antitoxin, to stop complications. because vaccination (starting in the 1920s) has made diphtheria rare, the antitoxin is not commercially available in the US. the CDC has a diphtheria hotline for this reason.

the incubation period is about 3 days (takes 3 days to start getting sick after exposure). it’s contagious for 2-6 weeks from the start of illness, if untreated. antibiotics reduces contagion to 4 days.

close contacts need to be treated with antibiotics. the last major american outbreak was in the 1970s, in seattle. here’s a list of some countries your family members might visit, that have widespread and longstanding diphtheria problems: Egypt, Brazil, the Dominican Republic, Ecuador, Haiti, Afghanistan, China, India, Indonesia, Laos, Malaysia, Nepal, Pakistan, the Philippines, Thailand, Vietnam, Iran, Iraq, Saudi Arabia, Turkey, Russia, and countries of the former Soviet Union.

pertussis (also known as “whooping cough”):
this is an upper respiratory bacterium that is spread by airborne droplets. you should consider it in a child that has a cough for at least 2 weeks, if one of these is also true:
– the cough is paroxysmal (“pa-rox-IZZ-mal”), coming in uncontrollable coughing fits.
– the bursts of coughing are followed by a “whoop” – a gasp for air.
– the child vomits after and/or during coughing fits.
– one of the child’s close contacts has already been medically diagnosed with pertussis.
in babies, the classic whooping cough may be absent. sometimes babies simply stop breathing. in fact, this can be one cause of sudden infant death syndrome.
here is a video of a baby with pertussis:

in case you can’t play the video, click here for a .wav sound file of a typical cough in a 3-year-old.

the usual course is that pertussis incubates for about a week without symptoms, then causes an illness that is like a bad cold for a week or two (shorter in babies). after that, the cough gets worse and stays bad for 2-6 weeks. during recovery, the cough can continue to come and go for months. chest x-rays look pretty normal, unless pneumonia develops.
antibiotics may shorten the course and stop it from spreading throughout the community. kids need to stay home from school or daycare until they have gotten 5 days of antibiotics (or whatever the school’s rules say). close contacts (including someone they’ve spent an hour with, at arm’s length) should be treated within 3 weeks of exposure to the cough.

complications: pneumonia is number one (see previous post for symptoms). sleep deprivation is a real problem that makes it hard for kids to live and grow normally. some kids get mechanical complications of the severe cough, like incontinence (urine leakage/rectal prolapse), nosebleeds/red spots in the eyes, collapsed lung, broken rib, etc. some kids develop seizures. the complication rate is higher in babies.
a baby or child with complications may be hospitalized for supportive care, but the cough still lasts a long time. they will go home when they’re able to keep breathing, and able to eat and drink, despite the cough.

having pertussis once in the past does not prevent a person from getting it again. if you were vaccinated as a child but are now an adult, you also are able to get it again (the childhood shots don’t last a lifetime).

measles:
this is an upper respiratory virus that is spread by airborne droplets. (don’t forget, never give or take aspirin with a virus.) the incubation period lasts 10-14 days after exposure.
at first, when a baby or child gets sick, they feel terrible, eat poorly, and run a fever. after this, they usually get a typical triad of symptoms called “conjunctivitis, coryza, and cough,” which usually lasts about 3 days (but can last a week). this means red, swollen, itchy-sore eyes (inflammation of the eye conjunctiva), a very runny nose (coryza: “ko-REE-za”), and cough.
this part of the illness seems like the flu, so check the child’s mouth for “koplik (“COP-lick”) spots,” a kind of rash on the inner cheeks, toward the back. koplik spots are small red spots, some with a blue-white dot in the center. koplik spots appear about 48 hours before the skin rash.

the intense red measles rash starts on the face and washes down the body over the course of a week or so. the fever should go down after the rash appears. the rash “blanches,” meaning it will turn pale when you press on it – so you can distinguish it from bleeding into the skin, which does not blanch and is an emergency danger sign. (if you’re not sure, press on it firmly with a water glass you can see through.)

after the first few days, the rash fades to brown, then the outer layer of dead skin starts to flake away. here is a picture of a measles rash. note also the red eyes and runny nose:

there is no specific treatment; treat the symptoms, just as you would with the flu.
usually the child starts to feel better a couple of days after the rash appears. they may keep coughing for a couple of weeks.

the measles virus lowers a person’s resistance to other infections for several weeks (causes immunosuppression). they are more vulnerable to other viruses in particular, so continue to be very careful about hand-washing and don’t share towels or toothbrushes, etc.

if the fever persists after the 3rd day of rash, you should wonder if a complication is developing, and watch closely for the appearance of new symptoms.

complications: pneumonia is number one (see previous post for symptoms of pneumonia).
since measles is a virus infecting the whole body, complications can occur in various parts of the body, from eyes to the the heart sac and heart muscle, to the liver, and even the intestines (appendicitis).

late nervous system complications include post-infectious encephalomyelitis (a.k.a. ADEM, acute disseminated encephalomyelitis), and subacute sclerosing panencephalitis (SSPE).
post-infectious encephalomyelitis (“en-SEF-a-low my-a-LITE-us”): “encephalo-” means brain, and “myelo-” means spinal cord; “-itis” means inflammation. this inflammation of brain and spinal cord is caused by the body’s immune system reaction, not by measles virus itself. the nerves in the brain and spinal cord lose their myelin coating and don’t conduct signals normally, similar to multiple sclerosis. this seems to occurs in about 1 in 1000 cases of measles.

post-infectious encephalomyelitis starts during recovery, usually after the rash is gone. the symptoms include fever and symptoms of brain inflammation (headache, confusion, unresponsiveness or restlessness, falling or uncoordinated movements, seizures) and spinal-cord infection (neck or back pain and stiffness, paralysis, loss of bowel and bladder control).
the child needs blood tests, a spinal tap, and imaging to rule out any infection that could be treated with antibiotics (antibiotics can not help a viral infection.).
because this is an immune system reaction, the treatment is immune suppression with steroids or other medications. without treatment, there seems to be a 10-20% chance of death; with treatment, 5%.
after this illness, many kids have lasting problems with nervous system development.

SSPE: “subacute” means it drags on after the acute illness is gone; “sclerosing” (“skler-ROE-sing”) means scarring; “pan” means all-over; “encephalitis” means brain inflammation.
this is caused by measles infection that is never fully cleared by the immune system; a spinal tap shows an unusually high level of anti-measles antibodies.

symptoms appear 7-10 years after the acute measles infection, usually in people who had the measles when they were under two years old (a time of rapid nervous system development). the person develops personality changes, strange behaviors, and intellectual/school problems (usually before age 20). if diagnosed at this early stage, treatment with strong anti-viral medications can be tried.
the early stage is followed by progressive nervous system damage, with uncontrollable muscle jerks, limp paralysis, and death within 3 years.

these late complications are very rare!

after having measles once, a person is very unlikely to ever get it again.
a case of measles should be reported to the local public health department, either by you or your doctor.

mumps:
this is a virus (don’t forget, never give or take aspirin with a virus!) that is spread by airborne droplets, or by contact (sharing a glass or toothbrush, etc.).

the incubation period (without symptoms) lasts 14-18 days after exposure, but the person is contagious before symptoms appear, especially in the three days before swelling develops.

the infection starts with a low fever, loss of appetite, headache, and low energy. after about 2 days, “parotitis” (“pare-ott-EYE-tis”), meaning inflammation of the parotid (“pa-ROT-id”) glands – the big spit glands on the sides of the jawbone and neck – develops, usually on one side first.

the parotid glands make an enzyme called “amylase” (“AM-a-laze”) that breaks down starches when you eat food. a blood test showing higher levels of amylase in the blood will show that the swelling comes from the parotid glands, and not the lymph nodes or other parts. this can be helpful, because blood tests for the mumps virus can be negative even when the person clearly has the mumps.

the parotid swelling and tenderness lasts about 10 days. anything that makes one’s mouth water will cause parotid pain.

here is a picture of a child with the mumps:

there is no specific treatment; treat the symptoms, just as you would with the flu.

complications: can occur even when the parotid swelling is minor or absent. this can make mumps complications hard to diagnose.

the most frequent complication is meningitis (see previous post for symptoms of meningitis), which is usually mild, and usually goes away entirely, without permanent damage. it occurs more often in boys than girls, and about half of mumps meningitis cases occur without parotid swelling. the child needs a spinal tap to make sure it’s not a bacterial meningitis.

older (usually at least teenage) boys get testicle inflammation (a.k.a. orchitis, “ork-EYE-tiss”) about 40% of the time. the pain is severe, and the scrotum swells up and turns red-hot; about a third of the time it’s double-sided. double-sided inflammation can impair future fertility. older girls can get ovarian inflammation, which is similar in nature, but occurs only about 7% of the time.

children can also develop deafness as a consequence of mumps infection – usually one-sided and sudden, sometimes with dizziness and vomiting. without vaccination, this was the leading cause of one-sided deafness in kids.

in the US, there are about 250 cases of mumps even in a good year, usually in teenagers and young adults, because the vaccine is only about 85% effective. new york and new jersey are currently having an outbreak affecting nearly 2000 kids.

rubella:
this is a virus that is spread by airborne droplets. (don’t forget, never give or take aspirin with a virus.)
the illness that it causes is very mild, and a child or adult might not even know they have it.
it is important because if an unvaccinated pregnant woman catches it, it causes severe birth defects in her fetus, including deaf-blindness, brain problems, heart problems, and blood-cell abnormalities.

in the last major US epidemic in 1964, about 30,000 fetuses were affected. a widespread vaccination program started in 1989, and in 2005, the CDC announced that rubella had been wiped out in the US. however, unvaccinated pregnant women traveling to other countries, where it has not been wiped out, may be at risk.

it is routine in the US to do a blood test early in pregnancy to show whether the woman is already immune (from vaccination or from previous infection) or not. if a woman thinks she has been exposed to the disease, and doesn’t think she’s immune, she can get a series of blood tests to see if she is developing new antibodies to the virus.

rubella, when it has any symptoms, behaves like a mild form of measles, starting with head-cold-like symptoms (1-5 days) and progressing to a measles-like skin rash (3-5 days) which does not darken as measles do. adults get sicker than kids do. it causes arthritis – pain in the knees, wrists, and fingers – about a third of the time, starting when the rash appears and lasting for about a month.
there is no specific treatment; treat the symptoms, just as you would with the flu.

because of the implications for fetuses, it’s good to know how the contagion works during pregnancy.
rubella becomes infectious, with a high viral load, 7-10 days after first being exposed, and stays infectious for 2 weeks after the rash appears. it becomes less infectious after the rash starts (the viral load goes down as antibodies are made).

– if a non-immune mother is infected in the first trimester of pregnancy, rubella infects the fetus and causes defects 80-85% of the time, and miscarriage results from about 20% of infections. unfortunately, the kind of birth defects caused by rubella are very hard to see on ultrasound.
– if a non-immune mother is infected in the second trimester, the rate of fetal infection drops to around 25%. after 20 weeks, when the organs are fully developed, it is rare for the infection to cause any birth defects.
– if a non-immune mother is infected at 27-30 weeks in the third trimester, the rate of fetal infection is around 35%. the rate rises to nearly 100% around 36 weeks and beyond. again, it is rare for the infection to cause birth defects at this stage.

we don’t have any treatment for exposed fetuses.

about the shot: although women are advised to avoid pregnancy for a month after getting vaccinated, occasionally a woman accidentally gets a vaccine during early pregnancy. this has never been documented to cause birth defects the way the full-blown infection would.
it’s okay to get the shot while breastfeeding.
if you have had rubella once, you can catch it again, but your blood is full of antibodies that keep the viral load low, so you are unlikely to infect others. (unlikely does not mean impossible, unfortunately.)

varicella (chickenpox):
this is a virus that is spread by airborne droplets (espcially sneezes and coughs) and by direct contact with the blisters. (don’t forget, never give or take aspirin with a virus.)

varicella is a member of the herpes virus family (related to cytomegalovirus, epstein-barr virus, and herpes simplex virus which causes cold sores on the mouth and genitals).
all herpes viruses are very wimpy, and to protect themselves, they hide out in the nervous system (spinal cord), where the immune system is less vigilant. once you get a herpes virus, it lives in the nervous system forever, but only comes out and causes symptoms when the immune system is stressed (hence, for example, the name “cold sores” when you have a cold).
when the chickenpox herpes virus comes back out (“reactivates”), it is in the form of shingles, a blistery skin rash. having chickenpox once is no protection against the shingles (because the virus isn’t dead, just hiding).

incubation period: about 2 weeks. infection begins as fever, low energy, and loss of appetite (sometimes a sore throat). the rash usually starts 24 hours later and lasts 5-10 days.
the rash has a characteristic “dew on a rose petal” appearance, red spots with small blisters (pale or clear) that turn into scabs. it is itchy, so cut and file the child’s nails, and keep the child’s hands clean to prevent additional skin infection and scars. the rash will come and go in waves. here is a picture:

you can treat the rash with acetaminophen and ibuprofen (a.k.a. Tylenol and Motrin) for fever and discomfort, and with anti-itching measures, like oat-flour and baking-soda baths, calamine lotion, and antihistamines (diphenhydramine/Benadryl).

chicken pox is contagious from 2 days before the rash to until every blister has scabbed over.

chicken pox is dangerous to fetuses, but the rate of infection is lower than with other viruses. before 20 weeks of pregnancy, about 2% of fetuses become infected if the non-immune mother gets chicken pox; in the first trimester, only about 1%. effects to the fetus include permanent scarring of the skin, eye malformations, and nervous system problems (seizure disorder, intellectual disability).
there is no evidence that exposure to or infection with shingles (re-activated varicella) during pregnancy causes any of these problems.

chicken pox is most dangerous to newborn babies whose non-immune mothers were exposed to chickenpox within 2 weeks of birth. the reason for this is that the baby was born infected, before the mother’s own protective antibodies were developed enough to get into the fetus before the birth. about 25% of these babies die. it’s worst if the mom gets sick with symptoms 5 days or less before delivery.
a newborn who gets chickenpox after 10 days old is in much less danger (presumably because the mother’s antibodies got into its system before birth).

perinatal treatments:
– pregnant women who are not immune to chickenpox can be given immunoglobulin (concentrated anti-chickenpox antibody serum) +/- antiviral medicine, if they are exposed or if they get sick during pregnancy.
– a newborn can be given immunoglobulin +/- antiviral medicine if their mom got chickenpox 1 week before to 4 weeks after giving birth, or if their siblings have chickenpox and their mom is not immune.
– the newborn and mother do not need to be isolated from each other or from the baby’s siblings (breastfeeding is okay despite chickenpox).

complications: encephalitis is number one. there are two kinds associated with chickenpox: postinfectious encephalomyelitis (a.k.a. ADEM), and acute cerebellar ataxia.
see above in “measles” section to review postinfectious encephalomyelitis; remember, it causes fever, signs of meningitis (stiff neck), and sometimes seizures.

acute cerebellar ataxia does NOT cause fever, stiff neck, or seizures.
“acute” means sudden, “cerebellar” means the part of the brain that controls coordination, and “ataxia” means “can’t walk.”
it causes headache, vomiting, trouble with walking and talking, shaky eyes and hands. it does NOT cause one-sided symptoms or weak leg muscles with loss of reflexes. kids usually recover fully after a few weeks, without permanent nervous system damage.

both of these nervous system complications usually develop near the end of the first week of rash and are more common in kids aged 2-5.

varicella pneumonia is a rare complication in kids. it occurs much more often in adults who get chickenpox, with worsening fever, trouble breathing, and dry cough starting in the first week of the rash. the death rate of varicella pneumonia in adults is 10-30%. in pregnant women, varicella pneumonia is considered a medical emergency, with a death rate around 40%. presumably this is because women are in a somewhat immune-suppressed state during pregnancy.

it is possible to get chickenpox more than once, and when this occurs, it tends to run in families. some kids can still get chickenpox although they were vaccinated; they have milder illness and a lower complication rate, though.
a “varicella titer” (blood test for immunity) indicates whether you have had an actual chickenpox infection. if you were vaccinated as a child, the titer might be negative (and you may be poorly immune) as an adult. some people were only partly vaccinated (got one shot instead of two), and some of the vaccines may have worn off early.

stay tuned for part 3 – gastrointestinal childhood diseases, including polio, hepatitis B, and rotavirus.

i dreamed that i had a patient, a little toddler, who suddenly became terribly terribly ill, with an all-over red rash, a high sweaty fever, delirium (with staring, scary eyes), gasping for breath. i sent the family straight to the emergency room, where the toddler was admitted to the intensive care unit and put on a ventilator – at death’s door. the family was bewildered and very angry. they told the hospital workers that of course they knew that if they didn’t vaccinate their child, their child could get a childhood disease – but “nobody ever told them” that it could mean their child could get that sick. and the hospital workers were all hating on me directly, because i was the family doctor that did not vaccinate this child.

i think i had this dream because i went to bed thinking about the toxic fungus that is raising alarms in oregon. i went to bed wondering if i’d recognize it – i don’t ordinarily order up a lung biopsy when somebody has a cough!

the dream made the wonder – not for the first time – if i’d recognize, for example, diphtheria.

would you? if your child got the measles or mumps, would you be able to recognize it? what if the illness went from simply “terribly ill, can’t sleep, fretting and fusssing, throwing up,” etc, to empyema or encephalitis? how would you know if your grade-schooler was developing liver cirrhosis from chronic hepatitis? what are the warning signs of tetanus? of polio?

doctors who went to medical school in the last couple decades simply do not see these cases – unless we are lucky enough to take a field trip to a faraway land that doesn’t have a modern public-health infrastructure – a place like haiti – or afghanistan – or germany (?) – or british columbia (?!) – or minnesota (??!!!). or, you know, ashland.

let’s talk, not about shots, but about “childhood diseases.”

HiB and Pneumococcus:
HiB is named “hemophilus influenzae B,” but it’s not a flu virus, it’s a bacterium. the Pneumococcus is named “streptococcus pneumoniae,” but it is not the same kind of strep as the one causing strep throat (or the GBS that we test pregnant ladies for). if you live in a community where less than about 85% of the population is not fully vaccinated against them, then your unvaccinated child will not have the benefits of “herd immunity” and is likely to be exposed to them. how the disease affects your kids will depend on a lot of other factors (age, genetics, nutrition, stressors, virulence of the bacterial strain, etc.).

Pneumococcus and HiB are both respiratory diseases spread by airborne droplets – highly contagious. they don’t have an instantly-recognizable sign (like chickenpox does), but instead cause your basic bad cold and/or ear infection (often coming on after an upper respiratory virus) – if they are uncomplicated.

these germs have a high frequency of complications. these include pneumonia, empyema, pericarditis, meningitis, epiglottitis, mastoiditis, orbital cellulitis, and septic arthritis. kids with these are usually admitted to the hospital and sometimes need surgery and/or life support.

so let’s review these complications.

signs of pneumonia (lung infection): fever, cough, fast breathing. respiratory distress danger signs: in a baby, look for retractions and flaring (muscles around the ribs sucking in and nostrils opening wide when the baby struggles to get a breath). children will often try to stay still, to concentrate on breathing. pneumonia can usually be heard with a stethoscope (decreased breath sounds over a lobe and/or wet crackles) and shows up on x-ray. if a pneumonia is very bad, the baby or child might need to be admitted to the hospital and given IV antibiotics and other medications.

signs of empyema (lung abscess): same as pneumonia, and usually develops from pneumonia. fluid and pus from the pneumonia collect in the membranes that normally surround the lungs, and form a jelly that stops the lung from expanding. it hurts when they breathe in, and a child might breathe shallowly, holding their ribs, or lie down on the affected side to “splint” it (keep that lung from moving and hurting). fever and other pneumonia symptoms continue despite taking antibiotics. the child simply does not get better, and often starts to lose weight and stop growing. they need to be hospitalized and have the jellied abscess removed surgically. note: pericarditis, or heart inflammation, has similar symptoms. the child might need to have pus drained from the sac around the heart.

signs of bacterial meningitis (infection of the membranes surrounding the brain and spinal cord – a medical emergency): can start in two different ways: gradually, after a feverish illness, or suddenly, with life-threatening illness. because meningitis is a disease of the nervous system, many of the symptoms reflect this: headache, worse head pain when lights are bright, confusion, unresponsiveness or restlessness, seizures. nausea and vomiting, not eating or drinking, and fever or abnormally low temperature can also occur. a baby may have a bulging soft spot (on top of their head), or, if dehydrated, a sunken soft spot. some kids get a very stiff neck, and can’t bend their head so their chin goes to their chest. kids with symptoms like these are usually “pancultured”: the blood and urine are cultured, they get a chest x-ray and a head CT, and they need to have a spinal tap, to be sure of the diagnosis and guide treatment. they would be hospitalized with IV antibiotics and other medications. if not treated, this disease is usually fatal.

signs of epiglottitis (throat/epiglottis infection – a medical emergency, usually caused by HiB when not vaccinated): the epiglottis is the muscle that closes off your airway when you swallow. if it gets infected and swells up, you can’t breathe. kids with this infection usually have a high fever and appear very sick. they struggle to breathe and lean forward, drooling (can’t swallow). if they can speak, they have a characteristic muffled “hot potato” voice – like someone trying to talk with a piece of hot potato in their mouth. their breathing is horse and noisy. they need to go to the emergency room immediately, to have an artificial airway placed (a breathing tube or tracheostomy) until antibiotics clear the infection.

signs of mastoiditis (infection of the skull bone): this is usually a complication of bacterial ear infections (usually pneumococcus and HiB, when not vaccinated). the baby or child has a current or recent ear infection, and the area around the affected ear is swollen, red, and very tender; sometimes the ear canal is narrowed by swelling, and the ear sticks out on that side. the child might have a fever. if not treated quickly, it can turn into a brain or bone abscess, meningitis, facial paralysis, or deafness. the baby or child would need to be in the hospital, with spinal taps, CTs, blood cultures, antibiotics, and possibly surgery.

signs of orbital cellulitis and periorbital cellulitis (eye infection): these are usually complications of bacterial sinus infections (usually pneumococcus and HiB, when not vaccinated). they appear as a sudden red-hot swelling of the skin around the eye and the eyelid, and are very painful. may or may not cause a fever. orbital cellulitis (infection in the eye socket itself) is a danger to the brain (abscess, meningitis) and the vision. peri-orbital cellulitis is an infection that is just in the skin around the eye, not in the eye socket itself, and is less dangerous (though the infection can spread to the orbit). how to tell them apart? orbital cellulitis causes swelling that makes it hard to move the eye, causing double vision. however, this can be hard to observe when the eye is swollen shut. the baby or child will need a head CT or MRI as well as the usual tests for blood infection and meningitis.

signs of septic arthritis (joint infection): usually appears after a feverish upper respiratory infection (especially HiB); basically, the bacterial infection spreads to the joint. usually affects hips, knees, ankles. the fever continues (sometimes with “picket-fence” spikes and drops), the baby or child appears very sick, the affected joint swells, and the child can’t move it due to pain (“pseudoparalysis”). the child will need a joint tap (fluid taken out of the joint with a needle, often under anesthesia) in addition to blood tests, to guide the choice of antibiotic. if untreated, the infection can spread throughout the body; also, the joint itself may be damaged and not grow correctly. this is a particular problem when it’s the hip that is infected.

when kids develop complications of HiB and Pneumococcus, like these above, other kids in close contact (if unvaccinated or partly vaccinated) usually need to be treated, too, due to how contagious and virulent these diseases are. adults who are immunocompromised (for example, diabetic, on chemotherapy, or taking steroids) need to be treated too, if they are in close contact.

can i tell you your child’s risk of getting sick, or getting a complication, from these diseases? no – because it depends on so many factors (age, genetics, nutrition, stressors, virulence, etc.). i can tell you that if your child has perfect health and a perfect immune system and encounters a very imperfect strain, then the risks are practically nil. odds of this? also practically nil.

we can look at the histories of these diseases, which are as old as the hills, and see that the Pneumococcus and HiB have been a major source of heartbreak through many generations – but the conditions that pertained to those stories are likely very different from your individual child’s/family’s condition. so it’s just hard to say. i can confidently predict that, as “herd immunity” deteriorates, we’ll unfortunately develop a brand-new set of stories – the stuff of bad dreams for doctors, if not for everybody else.

stay tuned for part 2 – childhood diseases that have more distinctive signs (like measles and mumps), even when they don’t cause these particular complications.

fish oil is an inexpensive natural anti-inflammatory.

what’s inflammation?
inflammation is part of our immune system.

the immune system has 2 parts:
1. what we usually think of as “the immune system” (white blood cells, T-cells, antibodies, etc.);
2. inflammation (swelling, red-hotness, pain, fever, etc.).

inflammation is the body’s response to an infection or injury.
swelling, red-hotness, and pain are all caused by chemicals made by the body. these chemicals allow special immune cells to leave the bloodstream, and actively creep into the infected/injured tissues. in the tissues, the immune cells engulf and try to dissolve any germs or foreign bodies (splinter, piece of glass, etc). after doing this, the inflammatory cells die off, leaving pus.

inflammation also causes heart attacks and strokes. how? one way is that cholesterol plaque inside our arteries (“hardening of the arteries”) causes an inflammatory response, too – and the immune cells try to engulf and dissolve the plaque (just like they’d try to eat up a splinter in your thumb). the other way is that inflammatory chemicals make blood platelets stickier. wherever the blood flow slows down, due to narrowing of the arteries, a clot can form. if a clot (of platelets, cholesterol, and remainders of dead inflammatory cells) blocks a heart vessel, it’s a heart attack. brain and other blood vessels can get blocked too, causing strokes and other problems.

chronic inflammation – when the inflammatory chemicals are not properly counteracted – causes a variety of illnesses, like rheumatoid arthritis and lupus (and rufus – the smaller, slyer cousin of lupus). most of the studies on fish oil have been directed at reducing heart disease (the #1 killer in the US), but there’s evidence that fish oil is helpful for chronic inflammatory diseases, too.

the main inflammatory chemicals that we know about are:
– prostaglandins (“PROSS-ta-GLAND-ins”)
– and leukotrienes (“LOO-ko-TRY-eens”).
– they are made from a fatty acid called arachidonic acid (“a-RACK-a-don-ic acid”) found in cell walls.

“steroids” are anti-inflammatories that stop the body from making arachidonic acid. examples:
– hydrocortisone cream for eczema
– prednisone pills for rheumatoid arthritis
– budesonide in asthma-control inhalers
…less arachidonic acid = less prostaglandins and leukotrienes = less inflammation.

NSAIDs are anti-inflammatories that block prostaglandin production.
prostaglandins are made from arachidonic acid by enzymes called cyclo-oxygenases (COX). NSAIDs are “COX blockers.” the different side effects AND medicinal effects of these drugs, are due to blocking different prostaglandins, by blocking different COX enzymes.
– “typical NSAIDs” block both COX-1 and COX-2, and also make the stomach vulnerable to acid, causing ulcers. examples:
aspirin/ Exedrin
ibuprofen/ Advil, Motrin
naproxen/ Aleve
indomethacin/ Indocin
ketorolac/ Toradol
diclofenac/ Voltaren
– Vioxx, Bextra, and Celebrex block COX-2 only, with fewer stomach side effects, but may cause more blood clots.
– acetaminophen (Tylenol) blocks COX-3, reducing pain and fever only, but not blocking other forms of inflammation. acetaminophen isn’t usually thought of as an NSAID, but it appears to work on the COX system too.

LOX-blockers are anti-inflammatories that block leukotrienes.
leukotrienes are made from arachidonic acid by enzymes called lipo-oxygenases (LOX). “LOX blockers” include Singulair, Accolate, and Zyflow, all for allergic asthma. LOX-blocker research has mainly been directed at asthma drug development – so far.

other inflammatory chemicals include:
thromboxanes (“throm-BOX-anes”)
and prostacyclins (“PROSS-ta-SIKE-linns”).
thromboxanes make blood platelets more sticky, and prostacyclins make them less sticky. they need to be in balance, so you have neither too much or too little blood clotting. they are both blocked by NSAIDs.

there are also a lot of anti-inflammatory chemicals the body makes, to turn off the inflammation. these are newly discovered, and have names like “resolvins” and “protectins.”
inflammation is supposed to be a very short-acting response (lasting only hours), and is supposed to be carefully targeted, so the body’s own cells don’t get too damaged as innocent bystanders. “resolvins” and “protectins” turn off the reaction.
these anti-inflammatory chemicals are made by the body from omega-3 fatty acids.

this is where fish oil comes in!
– arachidonic acid is an omega-6 fatty acid. it is used by the body to make inflammatory chemicals (prostaglandins, leukotrienes, etc.).
– fish oil provides omega-3 fatty acids (named EPA and DHA). these are used by the body to make anti-inflammatory chemicals, called “resolvins” and “protectins.” (there’s also some evidence that aspirin speeds up the production of “resolvins” and “protectins.”)
– another omega-3 fatty acid is ALA (alpha-linoleic acid) found in plants like borage, walnuts, and flax*. however, the body must convert ALA to EPA and DHA first, in order to make anti-inflammatory chemicals. this process is not as simple and efficient as making them from EPA and DHA found in fish oil.

*note: evening primrose oil contains GLA, gamma-linoleic acid. this is an omega-6 fatty acid that is converted into arachodonic acid in the body. (not to be confused with alpha-linoleic acid, an omega-3.) but because the conversion process is not very efficient, it can act against inflammation by slowing other arachidonic acid pathways.

that is the end of the science class.
this is the part where you get to raise your hand.

Q: why do fish have omega-3s?
A: omega-3 fatty acids are polyunsaturated, liquid oils. cold-water fish need polyunsaturated fatty acids to keep their cells fluid and flexible at low temperatures. (waxy cholesterol does the opposite, stiffening cells so they keep their shape in warm places, like in our warm-blooded bodies.)
fish eat algae (also known as phytoplankton) and krill (tiny shrimplike creatures) that contain these fatty acids – and then they eat each other. that’s where they get their omega-3s.

Q: is it better to just eat fish?
A: if you are vegetarian, you may not want to do this. if you are busy, or low-income, you may not be able to do this in a healthy way (fried fish sandwiches, or tuna salad with gobs of mayonnaise, are not as heart-healthy as you’d wish).
the American Heart Association recommends eating baked, low-fat, low-salt fish twice a week, every week. pregnant women and children should eat less. they say people at risk for heart disease/heart attack (including high cholesterol) should take fish oil, on top of eating fish twice a week.

Q: are vegetable sources better?
A: plant-derived oils (flax, borage, evening primrose, etc., containing ALA or GLA) are more complicated and less efficient for the body to convert to anti-inflammatory molecules (EPA, DHA). taking them does no harm, but they may not have as much effect as fish oil.
if anti-inflammatory effects are important to your health (due to illness or risk), then i’d recommend taking plain old fish oil, instead of plant-based oils.

Q: which fish are the best?
A: most fish oil is produced from menhaden, a small schooling fish. it can also come from sardines, anchovies, tuna, salmon, etc.
there are only a few producers in the world. basically all the different brands of fish oil come from these few sources, and they are all basically the same. don’t pay extra for exaggerated claims on a label!
– they all come from cold, deep waters, so a label saying “cold, deep waters” makes no difference.
– all the world’s oceans have some degree of pollution, so saying it comes from “pure ocean waters” is a lie.
– medically, it doesn’t matter what fish is “richest” in oil, since the oil capsules are a refined product anyway.
– “molecular distillation” is the way most oils are purified industrially, and i find no evidence that it makes fish oil any better or worse. don’t pay extra for this claim on a label.
– there’s no such thing as “pharmaceutical grade” fish oil, because fish oil is not classified by the USP (United States Pharmacopeia) as a pharmaceutical ingredient. it is classified as a dietary supplement. find out what brands have been USP verified as safe and authentic dietary supplements at www.usp.org. note: just because it’s not USP verified does not necessarily mean it is fraudulent or unsafe.
– we don’t have enough research on krill or algae oil to say if it is any different, medically, from fish oil.

Q: how about fish liver oil?
A: fish liver oil (cod liver, shark liver) is a byproduct of fish meal manufacturing. both contain omega-3 fatty acids, but also contain very high levels of vitamin A.
vitamin A is a structural part of the eyes (chemical name: “retinol” – after “retina”).
vitamin A can build up in the body, and too much is dangerous. for example, if used for acne treatment while pregnant, it can cause severe birth defects. too much vitamin A also blocks the effects of vitamin D and weakens the bones.

i recommend avoiding fish liver oils, to avoid getting too much vitamin A.

fish livers, like all livers, also concentrate pollutants, like dioxin and PCBs. when fish oil comes from the entire body of the fish, this concentration is reduced.

traditionally, cod liver oil was prepared by fermenting codfish livers and seaweed in brine for a long period of time, then scooping off the oil. again, there’s no medical evidence that this method produces oil that is substantially different from other types.

there have been periodic claims over the years that shark liver oil contains chemicals that prevent cancer (alkylglycerols, squalene, etc.), but no solid evidence at this time.

Q: what about pollution?
A: in spring 2010, a lawsuit was filed in California against the major fish-oil manufacturers, claiming their products contain PCBs (which cause cancer). the outcome is pending.
PCBs, dioxin, mercury, and other industrial contaminants (as well as e.coli, salmonella, and other foodborne contaminants) can be found in all sorts of foods and supplements. i find no evidence that fish oil is any more contaminated than the rest of what we eat and use.

Q: what about endangered species?
A: menhaden have been overfished in multiple areas, but are not on the endangered species list. overfishing is a problem worldwide for lots of kinds of fish, and the demand for omega-3 oils is a new pressure on ocean communities. to find out more about local overfishing situations, see the National Marine Fisheries Service website at www.nmfs.gov.

Q: what kind to buy?
A: i advocate buying the least expensive, simplest product you can find. fish oil doesn’t help you if you can’t afford to take the right amount (approximately 1000 mg twice a day). see the links below to find the Environmental Defense Fund’s list of safest brands. only four brands were found by this group to be poor quality (K-Mart, Rite-Aid, Omega Protein, and Solaray brands).

Q: what is the correct omega-6 to omega-3 ratio?
A: the usual american diet contains a lot of pre-prepared foods which are high in omega-6 fatty acids, from corn, peanut, and cottonseed oil, and low in omega-3. best evidence shows that this imbalance is unhealthy.

it doesn’t matter what your personal ratio is, because if you eat closer to a “mediterranean diet” (lots of vegetables; low red meat; garlic and herbs instead of salt; olive oil; nuts*) and take fish oil, your health will be better, regardless of the “ratio.”

*meditarranean-type diets include anti-inflammatory tree nuts (unsalted walnuts, pecans, almonds), not peanuts. (peanut products contain an omega-9 fatty acid called oleic acid, which is neither anti- nor pro-inflammatory.)

more reading (click on link):
what is inflammation?
chronic inflammation and cancer
arachidonic acid
omega-3 vs -6; alpha- vs. gamma-linoleic acids
resolvins and protectins
environmental impact of the fish oil industry
about cod liver oil
about shark liver oil
about dioxins in fish liver
what is the USP?
Environmental Defense Fund list of safe fish oils
should i eat the fish i catch? a guide
American Heart Association’s fish-eating guidelines
aspirin vs ibuprofen
fish oil vs. statin anti-cholesterol medicine