Been thinking about reality of late. I have always been a big fan of the concept. Of course, comprehending reality is not so easy. Some concepts, like gravity, are relatively straightforward. Others, like quantum mechanics, are not. Yes, deliberate joke. And medicine is, more often than not, not so clear cut.
Because a lot of medicine is statistical. For example, say you grow Candida in a blood culture from a central venous catheter. As an intern it was not treated as the therapy was toxic and the risk of a complication from the fungemia was considered negligible. Now we have less toxic therapies and a better understanding of the risks. But not everyone has a complication from the fungemia and some have issues with the treatment. But you play the odds and treat. For me that was always the most problematic part of practice: applying group results to an individual. Cure rates mght be 98%, but for the individual it was all or nothing. As was wisely noted, doctors suggested that Nordberg had a 50 – 50 chance of living, though there was only a 10 percent chance of that.
We use the methods of science as our tools for understanding medicine and reality. I was always drawn to the idea of reality-based medicine rather than science-based medicine. So much of what we discuss on this blog is, at the end of the day, a fiction divorced from reality. But they had a good lawyer and took reality for all she was worth. Reality needed a good prenup, but the result is the SCAMers use science (of a sort) to justify their fiction.
It annoys me no end when talking heads say there are two realities in the US. Nope. There is one reality, often hazy, but there are 335 million interpretations of that reality. Those responses parallel the categories of Kübler-Ross’s 5 stages of dying: denial, anger, bargaining, depression, and acceptance. I know there are issues with that classification, and I am glad that she moved on to helping elves make cookies. And people do not move though these stages when confronting reality; they glom on to one and hold it tight. Denial has always been the most popular.
Which is quite amazing. I know that we have evolved to survive reality, not to understand it, but my flabber has long been gasted by people’s ability to deny the evidence of their lying eyes.
I have told this story before, but I got interested in SCAMs my first year in practice when I was consulted on a case of gangrene. It turned out to be a young female who had a cancer (sarcoma as I remember it) of her leg. Rather than get a probably curative amputation, she sought the care of a naturopath, who treated her. Very unsuccessfully. Her leg was a mass of rotting cancer (quite the smell, let me tell you) but she saw it, as did her ND, as the cancer being successfully treated. She refused any treatment (she was admitted to the hospital as she had passed out and could not refuse) and died that night when the cancer eroded into an artery and she bled out.
Forty years later I shake my head in disbelief at that particular reality denial. Not the last, unfortunately.
That is not the only advanced cancer that I saw in my long and storied career where the patient denied a very obvious problem. Melanoma the size of a large mushroom, cancers that ate away normal flesh to the size of a dinner plate, and massive fungating breast cancers. No, nothing wrong, nothing to see here. The ability of people, and, on occasion, their SCAM providers, to deny reality is amazing. I suppose it is but a more advanced manifestation of a common human characteristic. It is, as an example, manifestly obvious that walnuts are an abomination made by Satan for the sole purpose of turning brownies and chocolate chip cookies inedible. But huge numbers of people deny that reality. Go figure.
Denial comes at three levels.
Individual denial. It harms the patient and their immediate friends and family and sometimes enriches a SCAM practitioner. This is the one I saw most often.
There is group denial. These are groups that deny, not people who deny groups. The most egregious are the homeopaths, but most SCAM practitioners have tenuous relationship with the real world. Perhaps they don’t have cable? The group denial can be religious, like Christian Scientists, whose reliance on prayer to combat illness, often ends badly. The denial groups can be colored, like the increase in COVID morbidity and mortality in Red folks compared to Blue group. I suppose Blue Man Group did well during COVID. The old saying better dead than red doesn’t work so well any more. There are stories of people on their death beds dying of COVID refusing to the last to recognize they had COVID. I took care of buckets of COVID patients but never saw that particular manifestation, although it is part and parcel with how people can react to other diseases.
The worst is when reality denial becomes part of government policy, where ideology determines the science, if you can call it science, and reality is ignored. This approach was popular in the last century; its apotheosis was probably Trofim Denisovich Lysenko, Stalins chief agronomist, who denied all the precepts and modern biology and preferred a Marxist approach to farming. At least 7 million people died in the famines that followed. It is good that sort of reality denial can’t happen in the US. Nope. Everything is fine here as he whistles in the dark. Which only attracts the clickers, so I best keep it down.
That’s the thing about reality: it is one honey badger. It doesn’t care. It doesn’t give a shit what you think. Reality is going to do what it does regardless of ideology or your personal response to it. Which is kind of reassuring if the response to reality is acceptance, problematic if it is depression, and catastrophic if denial.
For most of my career, I was in charge of Infection Control in my hospital system. I think of the environment as filled with Ophiocordyceps unilateralis infected humans, constantly testing our barriers to infect us. Anyone care to guess what game I just finished?
My take home from a lifetime of infection control? If you want to prevent infections, you have to do all the interventions every time and perfectly. Reality needs to be fastidiously adhered to. Any breakdown in technique and the pathogen will use the opportunity to infect. Which makes it a pain when taking care of patients, but it tends to work. Forty years of taking care of infectious disease patients. HIV. Tb. COVID. Influenza. Stickittothemaneosis. I was always fastidious with infection control policies and proceedures and never caught an infection from a patient. I paid close attention to the reality of these infections. Infectious is the first word in my specialty, not kind-of-infectious diseases or sort-of-infectious diseases.
Now we have bird flu at the door. It was found in a pig in Oregon and that cues the music from Jaws. Pigs are the creepy castle on the hill in which Baron Frankenstein can construct his monster, perhaps to run amuck and kill the villagers. Or not. If we are lucky, the evolution to an increase human infectivity will come with a decrease in virulence. So far in humans bird flu is mostly causing a mildish upper respiratory tract disease. Perhaps it will stay that way. And perhaps not. Perhaps we will get some amelioration from partial immunity to the prior infections and vaccines that were N1. Again. Or not.
Like most ID (infectious disease, not intelligent design) doctors, I have been nervously drumming my fingers on the table waiting for an influenza pandemic like 1918-19. And we may be perhaps one mutation away from an infection that has a 30% death rate. Or not.
But it will be… interesting, yeah interesting, that’s the word, to see the federal response in the next 4 years to the reality of a bird flu, or any new influenza, going full pandemic. The flu vaccine is not the best of breed, but, like airbags and seat-belts in a high-speed collision, better than not. It is also a vaccine whose benefits are better noticed in populations than in individuals. I have written extensively about flu here, so to sum up, the vaccine decreases the odds of getting flu, getting sick with flu, being hospitalized with flu, and dying of flu. Note the key words, decreases the odds. And it decreases odds of pregnancy loss and, perhaps in some, stupid(er) children. You can’t make a silk purse out of a sows ear.
It was also interesting what COVID restrictions did to flu and an other respiratory illnesses. Shut them down. One influenza, B/Yamagata, looks like it went extinct. Amazing.
So we know the benefits of vaccinations and, from COVID, the benefits of restrictions, as well as the downsides. We have a fairly good understanding of reality.
So when and if bird flu hits, which stage of dying will the federal government embrace? Me? I’m investing in crypto-coffins. The best of both worlds.