Remdesivir - Better Than Nothing for COVID-19?

As the world struggles to find solutions to the pandemic, numerous treatments have been proposed, offered by sources ranging from credible experts to fringe crackpots. The U.S. government has made both formal and informal suggestions, but at this time the only medicine with provisional FDA approval is Gilead’s remdesivir, a nucleoside analogue prodrug. The curious and convoluted story of this medication raises questions, however, both about its efficacy and safety, as well as the possible political and financial motivations behind the FDA recommendation.

Gilead debuted remdesivir in 2009 as a potential cure for hepatitis C. After proving ineffective, the drug was proposed as treatment both for ebola and the Marburg virus, but no benefits were seen in the clinical trials. Based on animal research that suggested activity against the corona viruses, a Chinese study earlier this year took another look at this three-time loser as a treatment for COVID-19. Although the study was discontinued early owing to serious safety concerns, preliminary data showed no improvement in either clinical symptoms or mortality rates. Even more telling, the research found no detectable decrease in viral load in the upper respiratory tracts of infected patients.

Nevertheless, the governmental National Institute of Allergy and Infectious Diseases—whose director is Anthony Fauci, well-known as the spokesperson for White House Corona Virus Task Force—launched the ACTT-1 study on February 21st to look at whether or not remdesivir offered any benefits to patients with COVID-19. On March 20th, President Donald Trump announced to the nation that remdesivir has been approved for extended use access. Two days later, an NIAID team met behind closed doors and agreed to change study parameters. Instead of a set end date, the ACTT-1 research would conclude when 400 patients had recovered, with the revised study evaluating only three, rather than eight, general criteria. The update in study methodology was followed the next day, on March 23rd, by Gilead’s decision to voluntarily suspend extended use due to supply shortages.

The well-connected pharmaceutical company, whose past board members include conservative Secretaries of State George Schultz and Donald Rumsfeld, had, in fact, begun preparations early in 2020 for approval and distribution of remdesivir. In January, Gilead not only began testing of the orphaned drug for COVID-19 benefits, the reactors at its Edmonton, Alberta plant were also reactivated for the production of large quantities of remdesivir, while the raw materials poured in from their contract manufacturers. On February 2nd, one hundred kilograms of residual stock from the Ebola production was sent to the factory in LaVerne, California to be packaged in vials. When a fresh batch of the drug was completed in Edmonton in April, Gilead was poised for formal FDA approval for extended use on May 1st. Although public announcements for extended use access had first occurred on March 20th and, later, on May 1st, it has been revealed that the earliest compassionate use for COVID-19 patients had actually begun on January 25th, long before study outcomes indicating effectiveness.

As the available facts demonstrate, both production and clinical use of remdesivir occurred before the tax-payer funded ACTT-1 study began. Extended use continued despite Chinese study evidence showing the drug was ineffective and risky, and the NIAID modified its study just two days after the drug was enthusiastically touted by the White House. Many have since criticized the ACTT-1 study for its failure to establish whether remdesivir improves mortality rates in patients, as well as for flaws in its research methodology.

In the face of facts that indicate that remdesivir was likely approved not on the basis of solid scientific evidence but largely for political and financial gain, we can only wait for objective findings from the WHO’s international Solidarity Trial to either deny or confirm the conclusions of the ACTT-1 study. In the meantime, NIAID’s own Clinical Director, H. Clifford Lane, M.D. may have said it best when he characterized the use of remdesivir for COVID-19 as “better than nothing”. On the other hand, as a drug with an number of serious known adverse effects, including respiratory failure, there seems to be insufficient proof to show that remdesivir for COVID-19 is truly better than receiving no treatment at all.

Clinical Protocols in Supermarkets

In the U.S. today, few of us are self sufficient. We do not make our own furniture, build our own homes, and, perhaps most importantly, we do not grow and raise our own food. In other words, without the support of a wide range of business, we simply would not survive.

While most of us may be able to shelter in place, complete isolation is impossible. At the very least, we must be able to have essential goods and services delivered to us. If the pipes burst, we have to call the plumber to avoid property damage and the growth of toxic mold. Many Americans, especially the elderly, take several kinds of prescription medications which have to be delivered or picked up at the pharmacy. And, of course, without groceries, almost all of us would eventually starve to death.

A small minority have the option of just staying at home and asking delivery people to set the parcels down on the doorstep and run. Even precautions this scrupulous, however, do not firmly guarantee that viruses have not hitched a ride on packages or produce, and the one minute spot we miss disinfecting may turn out to be the vector for transmission of COVID-19. Our basic dependence on others for the goods and services needed to exist in 2020 puts us all at risk.

The average individual, of course, will choose to go out and shop in person for food. So the most careful don full battle gear, others rely on general social distancing guidelines, while the contrarians throw caution to the wind and act as if it is all business as usual. At any rate, every human being must eat to stay alive, so out to the grocery stores we go in search of sustenance to get through the lockdown.

Unfortunately, everything ultimately depends on supermarkets using suitable practices to minimize risk, putting grocery store managers and employees in the impossible position of applying protocols for reducing the transmission of infectious disease—a task normally reserved for clinics and hospitals. Certainly larger chains employ health and safety experts who set broad corporate policies based on current information, but each individual store and its employees will inevitably vary in their ability, and willingness, to correctly follow the company guidelines.

Admittedly, even healthcare providers differ widely in their level of training and adherence to hygiene and safety practices, but some core concepts and methods are incorporated throughout healthcare. For example, the golden rule of universal precautions, where the only right assumption is that everyone, even without a diagnosis or any symptoms, should be treated as if he or she had a contagious disease, is known to almost every healthcare worker. On the other hand, for the general public—including grocery store cashiers, deli staff, and meat cutters—this precept of universal precautions is a novel idea that can be difficult to fully grasp. “You won’t get it from me…I’m not sick!” And no one, not even the store manager, is likely to be able to tell you whether the spray used on cart handles is a low, intermediate, or high level disinfectant.

As healthcare professionals roll their carts through the aisles and observe supermarket employees doing their best to climb the steep learning curve of working out how to minimize the risk of infectious disease, mistakes are all too obvious. Recognizing that store clerks cannot possibly adhere to clinical protocols in no way detracts from the great respect and admiration deserved by these employees who continue to serve the customers, despite the real risks. Instead, our intention is to raise the awareness that, whenever venturing out for crucial supplies, everyone needs to be personally responsible. We cannot depend solely on others to keep us safe and healthy through this crisis. Be smart and stay vigilant.

Explanation of the Obesity Paradox with Immunotherapy in Non-Small Cell Lung Cancer

In a December 26th article in JAMA Oncology, researchers reported that overweight patients who receive immunotherapy for NSCLC (non-small cell lung cancer) enjoy better overall survival rates than patients at a healthy weight. Survival rates for overweight patients were 19% better than those at normal BMI, while obese patients demonstrated a whopping 30% gain over those at a healthy weight. The investigators, from the Flinders Centre for Innovation in Cancer in Bedford Park, Australia, generally cited the “obesity paradox” but offered no specific explanation for the startling discrepancies.

From a TCM point-of-view, overweight and obese patients present a Chinese medical pattern of phlegm-damp accumulation. For anyone who reaches middle age, it is all too obvious that we gain weight more easily as we get older. According to Chinese medicine, it is the decline of qi which is responsible for this phenomenon. The five primary bodily functions of qi are movement, transformation, protection, containment, and warming. As the digestive movement and transformation mechanism weakens with age, unprocessed residue accumulates as dampness and phlegm—what is referred to in Western medicine as adipose tissue.

Following the Chinese medical syllogism, the overweight and obese patients observed in this study all present patterns of phlegm-damp accumulation with varying degrees of underlying spleen qi vacuity. The immunotherapeutic agent administered—unlike more traditional oncological care which directly destroys cancer cells—harnesses the innate power of the immune system to eradicate tumors. From a traditional Chinese medical perspective, we would describe this approach as using the body’s own qi to fight cancer. The fact that overweight and obese subjects survive longer is attributable to the fact that the treatment suitably fits their Chinese pattern, providing qi where qi is conspicuously absent.

Chinese medicine has long utilized the effective strategy of fu zheng or “supporting the right” to manage cancer cases. Like innovative Western medical immunotherapy, the Chinese approach works by helping the body to help itself and, in doing so, improves baseline energy levels and stimulates bodily function. One curious difference between traditional Chinese fu zheng treatments and the primary drug, atezolizumab, featured in this study: while Chinese treatment energizes tired patients, the immunotherapeutic agent often causes shortness of breath, poor appetite, and fatigue—all indications of qi vacuity. It would seem that while Chinese herbal formulas boost qi systemically, this new drug selectively enhances the movement and transformation actions of qi while depleting qi in its other forms and functions.

Tamagozake

With anxiety building regarding the Wuhan coronavirus and the cold and flu season upon us, it is helpful to take a break from medical philosophy and ethics to introduce our readers to a simple traditional Japanese home remedy for the common cold.* The Japanese name for this palatable treatment is tamagozake which literally means “egg sake”. For any household that keeps a little sake in the cupboard for cooking Japanese dishes (or drinking), this folk cure for seasonal illness is readily available and a snap to make. Think of it as the Asian equivalent of drinking a hot toddy when one is feeling under the weather.

Our favorite recipe begins with a good quality egg yolk, preferably pasture-raised, whisked together with a tablespoon of honey. Heat 3/4 cup of sake in a pot until it is warm enough to just cook the egg (approximately 130° F). Add the heated rice wine to the egg and honey mixture, whipping vigorously while slowly dripping in the sake as if making mayonnaise. The end product will be lemony yellow with a nice, airy froth on top.

From a TCM point-of-view, egg yolk is sweet and neutral and enters the heart and kidney channels. Egg yolks nourish yin and moisten dryness, supplement blood and extinguish wind. Notably egg yolks or ji zi huang appear in the classic formula Huang Lian E Jiao Tang, a decoction mainly indicated for vexation and insomnia due to non-interaction of heart and kidney.

Like egg yolks, feng mi or honey is sweet and neutral. Honey enters the lung and large intestine channels, supplements lung and spleen, moderates tension and relieves pain, moistens the lung and checks cough, and moistens the intestines and frees the stool. Always try to source honey from bees not exposed to the pesticides or antibiotics commonly used in commercial beekeeping. We like raw honey best but remember not to give it to children under one-year old (obviously alcohol is not appropriate for babies either).

Finally, alcohol (jiu) is warm in nature and enters the heart, liver, lung, and stomach channels while quickening blood and freeing the vessels, warming the center and dissipating cold, and arousing the spleen and supplementing qi. Alcohol also upbears and effuses qi, the primary tactic in TCM for treating the exterior patterns typically associated with common cold and flu. Historically, Chinese doctors utilized bai jiu or white liquor, naturally fermented wine with alcohol content similar to Japanese sake. Traditional Chinese bai jiu should not be confused with the notorious bai jiu of today, a pungent and potent drink favored at banquets and by heavy drinkers.

As an empirical formula, tamagozake is a warm, exterior-resolving combination which also supplements qi and blood to support the right and eliminate the evil qi. From the perspective of TCM, this Japanese classic remedy could be compared to Jing Fang Bai Du San and Ren Shen Bai Du San which are indicated for wind-cold exterior invasions complicated by qi and blood dual vacuity. For those American patients who suffer from persistent fatigue and then contract a common cold or flu with symptoms including more chills than fever, clear and copious nasal discharge, and scratchy—but not sore throat—tamagozake may fit the bill and provide welcome relief. We have actually found it quite effective and hope you will have the chance to give it a try!

*Consuming raw or undercooked meats, poultry, seafood, shellfish, or eggs may increase your risk of a having foodborne illness. These statements have not been evaluated by the FDA and should not be taken as advice about preventing, diagnosing, treating, or curing any disease.

A Sign of the Times

In the YouTube video, a middle-aged woman, recently graduated from an Acupuncture and Oriental Medicine program, explains how her clinic delivers personalized care. Depending on the particulars of the patient and the complaint, she draws from what she refers to as her bag of tricks—containing, among other things, Richard Tan’s Balancing Method, Trigger Point Acupuncture, Chinese herbal medicine, nutritional supplements, diet and lifestyle counseling, and Traditional Chinese Medicine. Not unlike Amazon, this clinic boasts the convenience of one-stop shopping

Not so long ago, acupuncture choices were limited, and Chinese medicine was a treasured lineage rather than a convenient option. Some who wandered off the beaten path of Traditional Chinese Medicine ended up at places like as Worsley Classical Five Element Acupuncture or Toyohari, but all of these models ultimately claimed the common ancestor of Chinese medicine. More recently, as the research studies demonstrating the efficacy of acupuncture have multiplied, there is a perception that the benefits of acupuncture treatment derive primarily from the modality itself, with the theory of Chinese medicine, consciously or unconsciously, relegated to the status of window dressing.

The shift is revolutionary. For decades, acupuncture derived its credibility from lengthy clinical experience; today, however, many acupuncturists are more likely to reference modern research as proof that acupuncture works. Vaguely scientific reasoning—no Western physiological theories adequately describe the effects of acupuncture—is, however, not just affecting how acupuncture is described to the public. Western research models are also eroding professional confidence in traditional Chinese medical thinking. The end result is a pragmatic approach to care where any approach that affords patients temporary relief is tossed into the haphazard mix of daily practice.

In the rush towards greater success in business and more prestige in the field of healthcare, we risk forgetting that the real value of Traditional Chinese Medicine lies not in its methods of treatment but in its capacity to solve problems and its deeply perceptive insight into human health and illness. As remarkable as the effects of ST-36 or LI-4 may be, the advantages of these acupuncture points do not provide an understanding of the causes, development, and progression of disease. Estranged from theory, the overemphasis on treatments can only deliver palliative care, demoting the Chinese doctor from the status of healer, committed to patient health and vitality, to a technician selling a quick fix.

Classical Chinese Medicine

The concept of classical Chinese medicine is currently enjoying considerable popularity in the West. Much of the interest in returning to more traditional styles of practice derives from the common belief among some Western practitioners that Chinese medical history should be bifurcated into a historical period, prior to the founding of the PRC in 1949, and the modern era which has followed. These ersatz historians describe a distinctively pre-Communist form of traditional Chinese medicine, dismissed by medical scholars as myth who view the 20th century as a time of evolutionary development in the long course of Chinese medicine rather than revolutionary upheaval.

In China, the term 经 jing is used to denote “classic”. Interestingly, the same character is translated as “channel” in acupuncture theory, with both usages recalling the earliest use of this ideograph to describe the warp of textiles. This etymology implies that texts or knowledge designated as classic should be understood as the foundational framework underlying contemporary medicine instead of a separate set of ideas.

Although many Western practitioners perceive any older medical texts as classics, the Chinese themselves only identify four sources as classical: the Huang Di Nei Jing, the Nan Jing, the Shang Han Za Bing Lun (including both the Shang Han Lun and the Jin Gui Yao Lue), and the texts of the Warm Disease School. Taken together, this group of materials spans the course of more than 1,500 years and, like the inner matrix of fabric, provides a durable and sturdy base for TCM today. These essential principles not only serve as antecedents for modern medical practice but also provide alternative perspectives to solve particularly intractable cases.

In China, the other common application of the term classic or jing in medicine appears in the context of the jing fang or classical formula methodology. Jing fang proponents focus on the Shang Han Lun and Jing Gui Yao Lue—the works Han Dynasty maverick Zhang Zhong-Jing—and mostly adhere to his approaches to diagnosis and treatment. Jing fang practitioners are viewed in China not only as clinicians but are also considered textual scholars and medical historians.

Back in the West, there is little consensus regarding what exactly constitutes classical Chinese medicine. As the trend has gathered momentum, books, trainings, and, even, copyrighted methods have adopted the terminology, with most applications addressing a vague desire to restore Chinese medicine to its golden age. In some cases, Chinese instructors have made the most out the opportunity to market training in jing fang methods, finding a captive audience among Western practitioners unable to read Chinese but eager to learn “real” Chinese medicine.

Fortunately recent years have seen an increase in the availability of high-quality English translations of the seminal medical texts. Nigel Wiseman and his collaborators, for example, have provided our profession with meticulous English renderings the Shang Han Lun and the Jin Gui Yao Lue. Intrepid Western readers can now utilize these exceptional books to explore the Chinese medical tradition firsthand. Face-to-face with the less tenable practices on the one hand—one classic formula, for example, calls for the burnt crotch from trousers—and the innate ambiguity of classical language on the other, the Western student quickly realizes that classical Chinese medicine is neither sacrosanct nor simply reproduced. Instead classical texts lure the reader into deeper investigation and contemplation to plumb the depths of Chinese medical insight.

Osteoarthritis: Modern Western Discoveries, Ancient Chinese Insights, Part II

Unlike the Western medical quest for answers at the microscopic level, ancient Chinese doctors sought an elegant model, derived from the study of nature, that would accurately explain the clinical features of osteoarthritis. Their investigations led to the concept of bi zheng, or impediment pattern, a theory that provides insight into the origins and presentation of arthritis. This traditional model not only fits with the clinical symptoms of osteoarthritis, it also offers pragmatic solutions beyond pain management.

In ancient China, as today, arthritis tended to develop with aging. The Chinese concluded that the prevalence of osteoarthritis among the elderly stems from a degeneration of anatomical structure and function, resulting in increased vulnerability to the elements. This theory explains why individuals who tend to be habitually weak or chronically ill often experience accelerated arthritic changes.

Many arthritis patients report exacerbation of pain and joint stiffness in response to cold, damp weather. Inexplicable from a Western structural point-of-view, mainstream medicine frequently dismisses this crucial symptom. In Chinese medicine, however, this finding gave rise to the hypothesis that elemental pathogens of wind, cold, and dampness, exploiting a body compromised by aging, catalyze the break down of our joints. This discovery shed light on the origin of arthritis and pointed to possibilities for effective treatments.

The Chinese tactic of dispelling wind-cold-damp is the primary method used to treat patients with osteoarthritis. The efficacy of the Western medical treatments of hot compresses and physical therapy, both of which also dispel cold and dampness, echo this approach. Corroborated by lengthy clinical experience and more recently by scientific research, the good clinical outcomes of the Chinese medical treatment of osteoarthritis confirm the value of the Chinese medical perspective on this disease and offer an alternative to risky and only moderately effective Western options.

Osteoarthritis: Modern Western Discoveries, Ancient Chinese Insights, Part I

Osteoarthritis is one of the most common human diseases. Arthritic changes first begin in middle age, and those who live into their 80’s all experience, to some degree, the joint pain, swelling, and limited range of motion of arthritis. The severity varies widely, ranging from occasional moderate discomfort to intense pain and crippling joint immobility that prevents the performance of even the most basic tasks.

After more than a century of scientific scrutiny and study, Western medicine has raised more questions about osteoarthritis than it has definitively answered. Medical imaging and cadaver studies have demonstrated that arthritic joints involve narrowing of joint spaces and the development of bony growths and cysts. According to the prevailing theory in rheumatology, this degenerative process results from mechanical wear and tear compounded by low level, chronic inflammation.

Clinical reality, however, does not corroborate this view. Runners, for example, whose lower limbs are subjected to violent, repetitive impact have no greater incidence of arthritis in the knees than the general population. On the other hand, simple overuse does not explain the prevalence of arthritis in post-menopausal women or obese individuals with the latter group prone to arthritis in all joints, not just the weight-bearing ones. Clearly, there is more to the story.

Despite increasing numbers of patients affected by arthritis, options for treatment in Western medicine remain limited. Symptomatic relief is primary, with familiar over-the-counter drugs playing a key role. COX-2 selective inhibitors have been used to temper chronic aches and pain, while addictive opioids are tapped for the most stubborn cases. Unfortunately, the unrelenting progression of the disease necessitates a lifetime of pain management, raising many concerns about long-term adverse effects.

Unable to curb the inevitability of painful articular deterioration and deformation, many doctors eventually recommend surgery for larger joints. Stakes are high, with rogue blood clots being common enough to necessitate blood thinners as a standard prophylactic protocol after surgery. Although joint replacements are, in modern medical terms, archaic—the first hip replacements were performed in 1948—newer implant materials and surgical methods have improved the outcomes. Nevertheless, some reports still suggest that as many as 40% of arthritis patients who resort to surgical correction continue to experience chronic pain.

American Life Expectancy Dropping

For the fourth year in a row, the average lifespan of Americans has declined. Following the decrease of 0.2 years from 2013 to 2014, life expectancy in the U.S. shrank another 0.1 years from 2015 to 2016. Although the change may seem minimal, it puts Americans— who, ironically, pay more for healthcare than any country on earth—even further behind the more than two dozen nationalities who already outlive us.

Given the stark contrast between the self-congratulatory reports of medical progress in the media and the sobering reality of lagging life expectancy figures, healthcare authorities are quick to pin the blame on the opioid crisis. If one understands this catastrophe as a drug problem, this assessment might seem to let American healthcare off the hook. In fact, primary responsibility for opioid deaths lies with a system that develops and produces highly addictive drugs, struggles with the management of chronic pain, and fails to successfully identify and treat many addicts.

Despite widespread agreement that the cost of medical care is bankrupting the U.S., we are frequently told that we pay a premium for the best healthcare system in the world. While it is true that the United States leads the world in cutting-edge medical research and education, high infant mortality, poor accessibility to care, and mediocre life expectancy place the United States below all of the other wealthy nations for its healthcare. As the average lifespan continues to dwindle, one has to wonder how long we will continue to put up with paying so much for a healthcare system that consistently receives failing grades?

A Rather Misleading Study

According to the American Cancer Society, the medications used in IVF assisted reproductive treatment can cause cancer.  In a recent Medscape editorial, however, Dr. Arefa Cassoobhoy argues that a new study of 250,000 British women proves that exposure to the high levels of hormones used by reproductive specialists does not significantly increase cancer risk.  Based on the size of the study and the fact that the women were tracked for an average of 9 years after IVF care, the results of the British study seem compelling.

The epidemiology of reproductive system cancers in women, however, raises some questions.  For breast and ovarian cancers the mean age is in the early 60’s.  Since the average age of the recipients of IVF treatment in the study was 35 and the researchers followed patients for an average of 9 years, the majority of the women were only studied until age 45.  In other words, the U.K. research team stopped looking at the subjects almost two decades before they were statistically likely to be diagnosed with cancer. 

There is an argument to be made that if cancer occurred more than 9 years after treatment it would not be a direct consequence of the IVF treatment.  Although the better part of a decade may seem like more than enough time to figure out whether or not a carcinogen has resulted in cancer, a review of latency periods challenges this assumption.  In fact, for many kinds of cancer, the time between exposure to a carcinogen and the onset of a cancer, the latency period, is measured in decades.  This explains how a patient who quit smoking 15 or 20 years earlier might still end up with lung cancer.

Given the lengthy duration and notable size of the UCL Great Ormond Street Institute of Child Health study, the good news is that cancer risk from IVF fertility medications during the first decade subsequent to treatment has been shown to be reassuringly low.  But, as the study’s researchers themselves observed, "We cannot exclude the possibility of different risk profiles for any studied cancer on longer follow-up, at ages when most reproductive-related cancers occur."  If we want "to put the IVF-Cancer connection to bed", as Dr. Cassoobhoy suggests, further studies of women who have received fertility medicines and whose age puts them at high risk of developing a reproductive system cancer are essential.

Acupuncture: Expectation or Expertise?

While recently listening to a lecture by Honora Lee Wolfe, co-founder of Blue Poppy and one of the best teachers and practitioner of acupuncture in the U.S.,  I was struck by her comment that the function of an acupuncture point depends on the expectations of the practitioner.  Ms. Wolfe's intriguing observation started me thinking about one of the central conundrums that I have been mulling over throughout my professional career:  what role does intention play in the clinical outcomes of acupuncture treatment?  Now almost two decades into practice, I finally have enough experience to be able to come to some conclusions on this topic.

During my teaching career, I supervised students in clinic for more than a decade.  As a specialist in diagnosis, I carefully reviewed the patient charts to ensure that students developed good diagnoses based on the evidence.  Furthermore, on my watch students were expected to generate logical treatment methods and select points or formulas consistent with their treatment plan.  Occasionally I would run across a case where, despite a diagnosis unsupported by the evidence and a lack of coherence in the clinical process, the patient reported considerable improvement.  When the student practitioners themselves were unable to explain their treatment choices or why they had led to good results, I was perplexed.

Given the deviation from the proven clinical methodology, I came to the only reasonable conclusion:  the sincerity, compassion, and attention of eager students had a beneficial effect on the patient's qi.  If we recall that qi gong and tai ji practitioners tell us that the "mind leads and the qi follows", it is not surprising that the care and concern of a student could positively influence the flow of qi in the body.  These experiences seem to corroborate the theory that intention is a key ingredient in a successful acupuncture treatment.

On the other hand, it would be an egregious mistake to dismiss the critical role of expertise in the effectiveness of acupuncture care.  Although it is difficult to definitively parse out skill from the expectations of the practitioner, clinicians with years of experience have many stories of treatments where the outcomes exceeded anything for which one could have ever hoped.  Of course, there is also no shortage of cases where, despite expectations for great results, success can only be had by reassessing the situation and devising a better treatment plan.  From these experiences one realizes that intention alone simply will not yield the best results. 

I recall a student many years ago who was required, as part of clinical training, to demonstrate the ability to do a point joining needling method.  She selected a point, and I left the room to check on other students.  When I returned, I discovered that she had not joined points with a through-and-through method but, instead, had inserted the needle just into the superficial surface of the skin. When questioned about why she did not perform the required technique, she replied that she had “joined” the points with mental intention alone.

The point of the story, of course, is that intention and action naturally go hand in hand.  Imagining an activity is not to be confused with intending to act a certain way followed by actually performing that act.  I have long contended that great acupuncturists spend a lifetime moving back and forth from study to practice, honing their skills and knowledge through clinical experience, tempered and guided by the insight of historical doctors.  Considering the recent popularity of mindfulness, we should remember that thousands of years ago in the acupuncture classics, doctors were encouraged to bring complete attention to their practice, as if “holding a tiger by the tail.”  Cultivating this serious attitude, we see how both intention and technique could be developed to the highest level in order to provide our patients with superlative results.

Food Additives and Children

For those of you have endured criticism, even ridicule, for worrying about the chemicals in the food we eat, your fears have now gained credibility from a well respected source, the American Academy of Pediatricians or AAP.  The AAP is voicing its concerns over the proven adverse effects of food additives and the chemicals used in packaging, as well as calling for more due diligence in reviewing the safety of other substances not fully vetted for safety.  This statement coincides with the findings of a new study that demonstrates a strong connection between the nitrites and nitrates in preserved meats and mania.  The lead investigator involved in the latter study has gone on record as saying that his research is just the tip of the iceberg of understanding of how diet affects our behavioral health.

Although we touched upon this topic in an earlier blog post, it is impossible to overstate the critical importance of feeding children not only nutritious food but also ensuring their diets as natural as possible. It has been estimated that as much as 70% of the chemicals we encounter in our daily lives have never been tested for long term effects on human health.  As detrimental as these synthetic substances may be to adults, it is only reasonable to assume that the effects on children are much greater.

The AAP is especially calling attention to chemicals likely to leach into our children's food from containers and packaging.  The BPA found in many plastic products, for example, has already been shown to negatively impact human health.  In one study, there was a close correlation between the levels of BPA present in urine and weight gain in the teenage females subjects.  Questions about the safety of food containers adds an additional task to parenting.  Not only do we need to read labels for chemical additives, we should also make sure that packaging is free from risky compounds.

Many parents today, tired of having to constantly discipline their children, take a more laissez-faire approach to diet.  Unwilling to swim upstream against the mainstream current that has come to embrace processed foods, these parents allow their kids to eat all of the things that "normal" kids do.  With many diseases on the rise, however, we have to remember that poor nutrition and the chemicals in many foods may eventually threaten the well-being--even the lives--of our most vulnerable family members.  As a mentor of mine was found of saying, you would never standby while your son or daughter tried to run out into the middle of a busy road.  Why, then, would a parent choose to ignore the very real risks posed by letting children eat foods that might harm them? 

The American Suicide Epidemic - Pt. II

In our last blog, we discussed the remarkable fact that, although prescriptions for antidepressants have increased 65% over the last fifteen years, we have also seen an unprecedented two-decade increase in the number of people committing suicide.  With the high profile suicides of Kate Spade and Anthony Bourdain this week, it is hoped that more attention will be given to this troubling crisis, resulting in better ways to address the American depression epidemic. In our second blog on the topic, we not only explore Chinese medical options for treating depression and preventing suicide but also touch upon some of the underlying factors that may be contributing to the shocking number of people annually who take their own lives here in the U.S.

Studies have shown that, while the rates of depression are typically low in the developing world, people from those countries who then migrate to the United States will, within 7 years, be as likely to be depressed at the rest of us.  This information demonstrates that depression, and suicide, involve not only our own personal health but also reflect the wellness of an entire society.  Despite our high standard of living, life in America today takes a toll on our mental and emotional balance.  Burdened by massive debt, overwhelmed with the flood of information (much of it negative), and often lacking the fundamental support of a solid family structure, it is challenging to stay positive and mentally and emotionally healthy.

Due to the possibility of suicide, any discussion of CAM care for depression must begin with a reminder of how high the stakes are and how important it is to have a Western healthcare professional on the team.  Access to fast-acting medications and the ability to deliver 24/7 care can prevent suicide and save lives.  Without the right sort of oversight and treatment, depression can spiral out of control and transform into a fatal event mercilessly fast.

To the team effort of helping those with depression live better quality lives, Chinese medicine offers both an understanding of unipolar depression and supportive care.  From our TCM perspective, the disease of emotional depression always arises from the pattern of binding depression of liver qi.  In binding depression of liver qi, the global qi of the system is stagnant and depressed, necessitating treatments and self-care which facilitate qi movement.  In the clinic, this translates into the use of acupuncture points to course the liver and acrid, aromatic formulas to move qi and lift the spirit.

For self-care, the Chinese medicine practitioner will recommend regular, moderate exercise to get the qi moving.  This idea is also corroborated by scientific studies that have shown how physical activity can improve mood.  Of course, nutritious food, adequate relaxation, and social interaction can assist in maintaining a good, healthy, and balanced flow of qi.  Even medicinal incense, which delivers an acrid aroma to stir the mind, may be recommended to raise a patient suffering from depression to a more joyful and active emotional state.  Please speak with an experienced, licensed TCM health professional for guidance with these self-care methods and additional ideas about how to get more out of your life

The American Suicide Epidemic - Pt. I

Today we woke to the sad news of the suicide of chef and TV personality Anthony Bourdain whose love of food and acerbic commentary delighted millions.  Bourdain's passing follows on the heels of another celebrity suicide, that of noted fashion designer Kate Spade who took her own life earlier in the week.  Although the suicides of two well-known individuals in the same week may be coincidence, the publication a few days ago of a new CDC report warning about the increase in the number of suicides in America over the last two decades confirms that we are in the midst of a suicide epidemic.

In August of last year, the CDC reported a startling 65% increase in prescription antidepressants in the U.S. during the last 15 years.  Despite the fact that one-in-eight Americans over the age of 12 is now medicated for depression, in half of the states suicides have increased by 30% since 1999.  This raises the obvious question of why the current standard-of-care for unipolar depression is so clearly failing to prevent more individuals from taking their own lives.

Of course, the issue involves a complex web of factors, and it would be unfair and unrealistic to lay all of the blame a the feet of American psychiatry.  According to the CDC findings, 46% of suicides have never received a diagnosis of clinical depression, suggesting that treatment failures only account for about half of suicides.  We can assume that, of the remaining half who are not being treated, some receive regular medical care while others do not.  We can also safely state that some of the individuals who make up the untreated half present with obvious symptoms of clinical depression but remain undiagnosed, while others end up taking their own lives without ever having manifested any signs or symptoms of depression. 

Accordingly, in order to stem the rising tide of American suicides, healthcare professionals need to take steps to ensure that patients who present with the symptoms of clinical depression do not slip through the cracks.  It is also necessary to reach out to Americans who may not regularly see a healthcare professional but need help managing their unipolar depression.  Not only should our public healthcare measures target potential patients, it is also imperative to inform a broader group who might be able to identify a potentially lethal depression in their friends and family members.  In other words, it is high time to raise national awareness regarding suicide.

Finally, we return to the elephant in the room:  why do 54% of suicides occur despite medical treatment?  We must recognize that there currently exists no comprehensive biological model of mood in modern psychiatry, so behavioral healthcare professionals do their best through therapy and the manipulation of certain components of brain chemistry to battle this dangerous disease.  At some point, however, as more and more Americans reach the apex of clinical depression that tragically culminates in self-inflicted death, we need to admit that our current model of care is inadequate and rethink our approach to helping those crippled by this increasingly common mental ailment.  Barring a thorough reassessment of the extant standard-of-care and a fresh, innovative approach to the treatment of depression, it is likely that suicide will continue to rise in rank among the leading causes of death in America.

The Not Quite a Doctor of the Future

A recent article highlighted the sometimes acrimonious dialogue between physicians and advanced practice providers regarding the capacity of the latter to function as PCPs.  Obviously, there are both pros and cons to substituting a nurse practitioner or physician's assistant for an MD.  On the one hand, many APPs bring extensive experience with hands-on patient care as well as a commitment to compassionate service to their work.  These qualities resonate with patients, some of which even prefer an APP as their primary care provider over an MD. 

Conversely, with some states only requiring an additional year in school to upgrade from an RN with a bachelor's degree to a nurse practitioner, many physicians point out that the training most advance practice providers receive could not possibly prepare them sufficiently for independent primary care provision.  Although many clinical encounters involve common conditions, the competent primary care provider must also be trained to identify and treat a broad range of unusual conditions in order to maximize clinical outcomes and minimize patient risk.  12 months of education, many would argue, is simply not adequate to master all of the necessary knowledge and skills.

Barring some major change in the current laws, advanced practice practitioners are, however, here to stay.  Between the support of enthusiastic patients and the cost benefits to healthcare companies, the number of APPs will skyrocket over the next ten to twenty years.  Given the reality of the changing landscape of American healthcare, it is critical to develop efficient and effective models of teamwork and to ensure, above all, that patients continue to enjoy effective and safe healthcare services.  What might this mean for patients and how will CAM providers fit into the new healthcare model?

Currently we see fewer and fewer MDs going into general practice, and salaries for family medicine providers languish far below that of most medical specialists.  At the junction where the disincentives for MDs who would go into family medicine intersect with the growing interest in advanced practice lies a trajectory carrying us towards a revolution in care.  In the American healthcare system of the near future, it is likely that MDs will primarily be specialists waiting on referrals for especially complicated or specialized cases, while APPs will provide the bulk of our basic healthcare needs.

As primary care service shifts from doctors to APPs, new tools will be developed, ranging from diagnostic aids to better treatments, that will allow healthcare workers with less formal training to practice better medicine.  For example, a nurse practitioner will be able to utilize genetic testing to ascertain which type of antidepressant is most likely to afford a good clinical outcome for a particular patient.  As another example, new electronic medical record systems will be introduced that will organize and prioritize data more efficiently.  By organizing medical information better, the APP of tomorrow will be able to avoid mistakes, improve diagnostic accuracy, and track the results of treatment.

Assuming that the torch of responsibility for primary care can be successfully passed from MDs to APPs without a significant impact on clinical outcomes, the immense savings of healthcare dollars will accelerate the evolution towards a system where primary care is exclusively provided by advanced practice practitioners.  Additional impetus in this direction will come from the limits placed on MDs who continue to provide primary care.  Despite their extensive medical training, if the companies that control healthcare services are only willing to employ general practitioners or family medical doctors who can sustain practices with heavy patient loads, inevitable medical mistakes coupled with crippling practitioner burnout will result in more and more MDs relinquishing the reins of primary care to advanced practice practitioners.

For CAM practitioners, the future looks bright.  Advanced practice practitioners tend to be pragmatic clinicians who are open to the consideration of alternative treatments.  Compared to their MD counterparts who spend more than a decade steeped in a singular perspective on healthcare, APPs are often more likely to have a broader background and perspective.  In the Acupuncture and Oriental Medicine community, we look forward to a collaborative effort with advanced practice practitioners to not only provide effective treatments but to also work towards a healthier society. 

Thoughts on the New Shingles Vaccine

For the last two decades, our practice has observed what appears to be a marked increase in the number of cases of shingles.  Not only has this condition apparently become more common, it would also seem to be affecting younger people than in the past.  Of course, clinical impressions do not always accurately reflect the broader national picture.  In this case, however, data from the National Institutes of Health confirm that the number of patients experiencing acute episodes of herpes zoster has dramatically risen as much as 50% in just three decades.

Some medical authorities have attempted to explain the explosion in herpes zoster cases with the theory that our success in vaccinating against chickenpox in children has, ironically, resulted in more cases of shingles in adults.  Like the popular hypothesis that the thimerosal in vaccines causes autism, however, the current studies have found no clear correlation between changes in vaccination protocols or formulation that correlate with changes in the prevalence of disease.  To date, no other compelling theory has been offered to explain the increase.

For British pharmaceutical giant GlaxoSmithKline, however, the present shingles epidemic is less of a mystery than it is a lucrative opportunity.  At the cost of $280 for the two requisite injections, GSK is salivating at the estimate that Shingrix will bring in over $1 billion dollars in revenue by 2022.  The vaccine, a blend of antigen derived from hamster ovaries, fats from salmonella, and herbal extract from soap tree bark, has performed well in clinical trials.  The adverse affects of muscle pain, fatigue, and headache in about half of vaccine recipients notwithstanding, Shingrix not only reduces the risk of getting shingles but also prevents the chronic pain of post-herpetic neuralgia. 

But, rewinding a bit, what of the elephant in the room?  While the manufacturer of Shingrix stands to benefit from the failure of medical scientists to identify a clear cause for the increase in the number of shingle cases, it may turn out to be critical for our public health and wellness to get to the bottom of this conundrum.  There are several important questions to ask.  For example, does the recent success of shingles indicate a widespread decline in the immunity of older Americans?  If a lack of immunity is to blame, then what factors are impairing our bodily defenses?  Or perhaps the problem lies not so much in our immune systems failing to keep the herpes virus in check as it does in as of yet unknown factors catalyzing the dormant pathogen. 

Unfortunately, the new vaccine threatens to lull both the public and healthcare workers into a false sense of complacency.  Disease, as uncomfortable and frightening as it may be, often has a silver lining: illness can be a tap on the shoulder - or slap in the face - from mother nature encouraging us to examine our lifestyles and devise better ways to live.  These "wake up calls" not only help us to make healthier personal choices but can also act as a referendum on societal trends.  Driven by the motivation of enormous profits, however, humanity today seems more inclined to hit the snooze button than learn a valuable lesson.  We do so at our own peril.

Two Different Standards for Diabetes Testing

At the beginning of this year, the American College of Physicians issued revised guidelines for the drug management of type 2 diabetes.  Central to their recommendations is a target A1C of between 7% and 8% for most patients.  Conversely, for the past several years, the American Diabetes Association has set a goal of an A1C below 7%.  The ACP and the ADA are both influential healthcare authorities whose directives impact the way we practice medicine in America today.

While the discrepancy has led to a robust discussion among physicians, patients are more likely to just end up confused.  How can two authoritative sources disagree on the basic standard for optimal blood glucose levels for those with type 2 diabetes?  Of course, as Dr Shubrook from Touro University argues, there is consensus that diabetes care needs to be tailored to the needs of individuals patients.  Recognizing the value of personalized care, the disparity between the two guidelines can be understood as being representative of a broad spectrum of possibilities that allow physicians to make case-by-case decisions.

It is even more important, however, to grasp that the numerical findings from lab testing are, ultimately, numbers on a page, subject to both a margin of error and different perspectives regarding their relevance.  Disagreements among healthcare professionals are not unique to the interpretation of A1C results but also impact our understanding of cholesterol numbers, blood pressures, and PSA testing.  The use of the PSA test, in fact, has even drawn the sharp criticism of Richard Ablin, the scientist who first identified prostate-specific antigen.

Returning to the subject of blood glucose, it is generally accepted that lower blood sugars are preferable over chronic hyperglycemia, so one wonders why the American Diabetes Association would set a higher average target A1C.  There are two possible answers to this question.  First, according to research, hospitalizations and fatalities in elderly patients treated for elevated blood glucose are, in fact, more often caused by hypoglycemia than hyperglycemia.  Furthermore, other studies have demonstrated that many of the diabetic drugs generate at least one common adverse effect.  Adding to a patient's drug regimen is, therefore, likely to result in additional health issues which also require treatment, trapping doctors and patients in a vicious cycle.

This dilemma for conventional care is actually an opportunity for  AOM (acupuncture and Oriental medicine).  As a Western medical condition, the treatment of diabetes is outside of the scope of acupuncture and Chinese medicine care, but, backed by 2,500 years of success in helping those suffering from diabetes to enjoy a better quality of life, AOM is not dependent on our modern diagnoses or testing to be effective.  The key to getting a good outcome is relying on the unique methodology of traditional Chinese medicine that facilitates authentically personal care.

The process begins with identifying the main complaint and all of the presenting patterns for each patient.  By focusing on the chief complaint, the Chinese medical practitioner sets a pragmatic goal to quickly make a difference in the patient's quality of life, while addressing all of the patterns provides holistic, individualized care to promote long-term wellness.  Although the explicit reduction of blood sugar levels is unrelated to the traditional treatment goals of Chinese medicine, patients who receive Chinese medical care typically report significant improvements in their daily blood glucose readings and A1C levels.

As the number of individuals with type 2 diabetes continues to rise, we need to use all of the resources at our disposable to ensure that patients live the healthiest and longest lives possible.  This means not only availing ourselves of the newest Western treatment options but also employing traditional medicine where appropriate.  When it comes to the epidemic of type 2 diabetes, we just cannot afford to discriminate against useful treatments that can deliver the personal, effective treatment that patients need.

Ode to Caregivers

This short poem was inspired by a friend of mine who has provided care not only for her own family but also for others around her in need.  In addition to being a tribute to one special individual, these words celebrate all of those care givers who show us the capacity of the human heart for compassionate action.

Return to Sender

Burden eased by kind befriender,

A companion steadfast and true,

Broken spirits find their mender,

Begin to walk together through.

Courage fierce in the face of strife,

Ne’er daunted by the struggle great,

Relinquish freedom dear in life,

Share another’s fate.

Tending care for every need,

No hard request denied,

Proof in doing each small deed,

Of a love implied.

Where winding path finds its end,

From suffering and loss break free,

The final gift preparations to dispatch,

A light across the sea.

For support never failing trust,

Provide respite from the woe,

Repaying kindness is a must,

Here earnest blessing we bestow.

Henceforth from this very day,

Without delay or hinder,

May care equal to that given away,

Be returned to grace the sender.

No Surprise Here - Benefits of Healthful Eating for Kids

This week Medscape posted an article written by gastroenterologist Diane L. Barsky entitled "The Anti-inflammatory Diet's Surprising Benefits in Children."  In her discussion, Dr. Barsky describes a diet that combines traditional Asian and Mediterranean food culture.  This fusion diet is rich in fresh foods, fruits and vegetables, and legumes while minimizing the intake of processed foods, high-fructose corn syrup, and saturated animal fat.  Research has shown that this anti-inflammatory diet benefits children suffering from allergies, asthma, obesity, fatty liver, and, even, ADD and ADHD.

From those of us who consider good diet indispensable for good health, the only thing that is startling is the fact that a medical doctor--a gastroenterologist, no less--would find the multitude of advantages of healthful eating surprising.  Far from being beneficial, our standard diet today is barely even fit for human consumption.  Until very recently in our history, human beings had always eaten fresh, natural foods with less meat and more vegetables.  The modern inventions of trans fats, high-fructose corn syrup, and chemical additives in concert with contemporary farming and ranching have led to what amounts to a long-term experiment to determine if human health can be maintained on a diet of engineered foods.

If the health of adults is affected by poor food choices, it stands to reason that children are even more at risk.  Thousands of years of astute Chinese observation have revealed several important things about children and their diets.  First, our children come into this world with immature digestive function.  For this reason, nature provides us a sublime, nourishing food in liquid form, mother's milk.  Once infants begin reaching out for solid food, it is appropriate to slowly introduce bland, digestible, nourishing food into their diets and wean them off breast milk.  Finally, between the ages of 5 to 6, human beings develop the capacity to digest a wide variety of foods, and our parents can feed us more like adults.  In other words, when it comes to diet, kids are especially vulnerable.

Modern life has resulted, however, in widespread amnesia, and we know longer rely on the grand legacy of human wisdom to feed our offspring.  Fake breast milk, a manufactured blend of powdered beans or animal dairy derivatives enhanced with added chemical nutrients, often replaces nature's live elixir.  Instead of regular meals, we instill a lifetime of comfort eating in infants by feeding them on demand.  Finally, once solid food is on the menu, we rush to try out new and unfamiliar foods, delighted when an expression of happy satisfaction signals that a child has succumbed to the seduction of an adult food.

Putting our faith in food scientists, we reason that if it does not hurt us then it must be safe for our children.  In a time when diet-related heart disease, diabetes, and obesity are epidemic, we are obviously in denial about the safety of our modern diet.  Furthermore, we sadly see all of the negative consequences of contemporary eating most apparently in our children.  The good news is that medical scientists are now gathering the evidence needed to show the dangers of engineered foods designed by their colleagues in the food industry, thus proving scientifically what any observant person with common sense should already know.

The Art of Happiness

In the West, we normally perceive thought and feeling as two distinct phenomena.  Thought is understood as an active process, reflected in certain English idioms such as "giving it some thought" and "spending time thinking about it".  Emotions, feelings, on the other hand, are seen as involuntary responses to experience.  The   language reflects this when we talk about how something or someone "makes us feel".  Although we may complain of "feeling down", the experience of a general emotional state instead of a reaction to a specific cause, this, too, clearly describes a passive process rather than a deliberate action.

Chinese medical theory, however, challenges our normal Western suppositions by grouping thought together with the seven affects of anxiety, sorrow, joy, anger, fear, and fright.  Based on this traditional group, it is evident that the ancient Chinese viewed cognition and emotion as synonymous.  From our modern Western perspective, this attitude towards thought and feeling is bewildering.  How is it possible, one might ask, to lump together the activity of thinking carefully through a math problem, for example, with the sudden feeling of sadness we experience when hearing of someone's death?

Examples both of thought without deliberation and conscious feeling do, however, abound.  We typically refer to the former as instinct or intuition, experiences many cultures tend to associate with certain individuals.  In Western societies, for instance, there is the popular notion of "feminine intuition".  This reveals the fact that, although our culture recognizes inclinations that arise halfway between heart and head, we often characterize these thought-feelings as special gifts instead of identifying them as part of a common human experience.

Conscious feeling, too, is not unfamiliar to us.  Actors are trained to consciously control their feelings with the intention of causing their audience to laugh wholeheartedly or cry bonafide tears.  The power of positive thinking converts optimistic thoughts into a state of joy, and we manipulate our moods with drugs, both prescribed and recreational.  Like the pumping of the human heart, our emotional responses reflect both voluntary and involuntary processes.

With the recognition of the proximity of emotions and thought a comes the potential for a new, revolutionary way of thinking and feeling.  On the one hand, intuition gains credibility as an alternative form of thinking, one where, instead of depending on plodding logic, we can spontaneously leapfrog to a conclusion.  Fundamental to the workings of the mind, our gut feelings and instincts are then seen not as the domain of the chosen few but a natural human response when we need to react urgently.

Perhaps even more relevant to modern life is the realization of how inextricably our moods relate to our thoughts.  While it is not only misguided but potentially fatal to try and will oneself out of a clinical depression, we should also understand that, behavioral illness notwithstanding, we can play a pivotal role in whether or not we wake up on the wrong, or right, side of the bed.  To a great extent, happiness is a choice.  The secret, in turns out, lies in cultivating gratitude and appreciation at every opportunity.  Great expectations and the ability to see the silver lining even in misfortune are the building blocks of a lifetime structured to provide satisfaction and joy.