I do not worry much about being dead although the process of getting there gives me pause. I have witnessed a few unpleasant deaths and I hope to never see the Grim Reaper coming my way.
One of the more awful and pointless deaths occurred early in my career. I had a patient with hepatitis C and cirrhosis. He had low platelets, low clotting factors (many of which are made by the liver), a previously undiagnosed clotting disorder, and a mouth full of bad teeth that were removed all at once when he acquired dental insurance.
Then he started to ooze blood from his extractions. An ooze that did not stop, it was a constant trickle of blood that would not clot. After several visits to his dentist he almost passed out and came to the emergency room. After 4 days he had bled out about half his blood volume, his haemoglobin had gone from 12 to 6. At this point we geared up for transfusions of red cells and clotting factors and he let us know that he was a Jehovah’s Witness and, no thank you, he would not accept any blood or blood products.
For the next week he continued to ooze despite all the interventions we could come up with to stop the bleeding and he remained adamant in his refusal of transfusions of any kind, despite the risk of death. At about a hemoglobin of 2 he had a large stroke and severe muscle pain from ischemia. At 1 he had a large heart attack and died. If you could rank deaths as pointless and horrific, this would be in my top 10. And I was struck at how nonplussed the family was, accepting this completely preventable death matter-of-factly.
The Jehovah’s Witness, at least by that name, started in 1931 and began the doctrine of no transfusions in 1944 based on two biblical verses, Genesis 9:4:
But you must not eat meat that has its lifeblood still in it.
and Leviticus 17:10-14:
I will set my face against any Israelite or any foreigner residing among them who eats blood, and I will cut them off from the people.
For the life of a creature is in the blood, and I have given it to you to make atonement for yourselves on the altar; it is the blood that makes atonement for one’s life.
Therefore I say to the Israelites, “None of you may eat blood, nor may any foreigner residing among you eat blood.”
‘Any Israelite or any foreigner residing among you who hunts any animal or bird that may be eaten must drain out the blood and cover it with earth,
because the life of every creature is its blood. That is why I have said to the Israelites, “You must not eat the blood of any creature, because the life of every creature is its blood; anyone who eats it must be cut off.
Sounds more like an admonition against steak tartar or vampirism to me. Jehovah’s Witnesses will accept some products derived from blood but not others, for example albumin. The fine points and the splitting of hairs of doctrine have always baffled me and perhaps are better explained by others.
Several years later we had a grand rounds on transfusion medicine. The head of the bloodless surgery program discussed ways to avoid transfusions and he kept using the word “respect” in relationship to Jehovah’s Witness avoidance of transfusions. Respect? “Admire (someone or something) deeply, as a result of their abilities, qualities, or achievements.” Nope. Understand? Yep. Accept? You bet. Part of what makes America a great place is we all get to do whatever dumb ass activity that suits us. But it is impossible to respect a belief that demands people to drip away their life’s blood.
Participation in SCAMs may not occur in a vacuum, isolated from other belief systems. There are a variety of other ways in which religious beliefs can influence medical care.
The deaths of children whose parents belong to sects of Christianity that rely on faith healing is an unfortunately common topic in the newspaper. It has been known for years that relying of prayer as a substitute for medical care leads to a shortened life expectancy, the archetype being Christian Scientists.
JAMA published a study that looked at outcomes in 5,500 Christian Scientists and compared them to a group of almost 30,000 controls using reality-based medicine.
There was an increased death rate for the Christian Scientists when compared to the control population, a difference made more remarkable as Christian Scientists neither smoke nor drink.
The JAMA study confirmed an earlier study that demonstrated the death rate from cancer among Christian Scientists was double the national average, and 6 percent died from preventable diseases.
Being a Christian Scientist led to 4 years less life for women and two years less life for men (Wilson GE. Christian Science and longevity. J Forensic Sci. 1965;1:43-60)
I would wager there would be similar outcomes in any group who avoids science-based medicine in favor of the topics covered in this blog.
There are belief systems of individual sects that avoid medicine or aspects of medicine. Then there is the effect on whole cultures where religious ideas dominate the culture. As an example, 13% of maternal deaths in South America are due to unsafe abortions, in part due to the Catholic Church’s ongoing opposition to birth control and abortion. Similar deaths can occur in the West, as Ireland recently demonstrated with Savita Halappanavar, who died from sepsis after a miscarriage. She was refused an abortion since “Ireland was a ‘Catholic country,’ she could not have (an abortion) while the foetal heartbeat was still present, although it was non-viable.”
There is a spectrum of influence from various faiths. Sometimes people use their position of authority to make medical pronouncements that run counter to reality, but are not really part of official religious doctrine.
The Bishop of Mozambique said that condoms and antiretroviral medications were manufactured to spread AIDS to Africans and, while not an official position of the Catholic Church, his comments have never been repudiated.
Polio was on the verge of eradication in Africa and the Mideast, but has seen a resurgence in part due to Muslims clerics who thought that vaccinations were a plot to sterilize the population and spoke against vaccination. In Pakistan they assassinated those in charge of vaccination programs.
Vaccinations are an area of doctrinal contention, since acceptance or denial of vaccines depends on whether to emphasize teachings in support helping and protecting each other or focusing on teachings where certain products are forbidden. You may focus on the body as a temple to deny a vaccine and ignore the part about stoning a disobedient child:
In multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se. Themes favoring vaccine acceptance included transformation of vaccine excipients from their starting material, extensive dilution of components of concern, the medicinal purpose of immunization (in contrast to diet), and lack of alternatives. Other important features included imperatives to preserve health and duty to community (e.g., parent to child, among neighbors). Concern that ‘the body is a temple not to be defiled’ is contrasted with other teaching and quality-control requirements in manufacturing vaccines and immune globulins.
Often religious reasons for refusing a vaccine are probably used to support a pre-existing anti-vaccine bias rather than a primary refusal based on religious principles, as was the case with polio vaccine in Nigeria:
Detailed consideration of the Nigerian situation revealed that what was described as ostensibly religious objections and assertions that vaccines spread the HIV virus or were vehicles for sterilization programs masked deeper struggles related to political power, inadequate health services, and a controversial clinical trial of an investigational antibiotic. While the boycott was centered within Islamic social networks, most of the objections raised related to social issues, rather than theological issues.
And the issues surrounding the Catholic Church’s opposition of condoms are not simple and the AIDS misinformation is more than one Bishop’s crazy opinion.
There are religious practices that have disease as a by-product of their participation. Many infectious diseases are spread by crowding: Group A Streptococcus and Meningococcus among many. The Hajj, the mass visit to Mecca every year, is a classic example and a well documented example of crowds facilitating the spread of contagion.
Years ago I was consulted on a patient with severe bloody diarrhea and the stool cultures grew Aeromonas, a waterborne organism. In asking direct questions looking for an exposure I discovered she had a gallon of holy water she had brought back with her from a trip to Mexico and she sipped a bit each day. We cultured the holy water and it grew Aeromonas as well.
Holy water is often contaminated with bacteria, and as a result I hypothesize that Pasteur went to hell:
Our aim was to assess the microbiological and chemical water quality of holy springs and holy water in churches and hospital chapels. Of the holy springs investigated, only 14% met the microbiological and chemical requirements of national drinking water regulations. Considering results from sanitary inspections of the water catchments, no spring was assessed as a reliable drinking water source. All holy water samples from churches and hospital chapels showed extremely high concentrations of HPC; fecal indicators, Pseudomonas aeruginosa and Staphylococcus aureus occurred only in the most frequently visited churches.
There are other infections spread due to religious rituals such as herpes and ritual circumcision, with at least 22 cases reported of newborns acquiring herpes as a complication:
Ritual circumcision has three parts: the ‘milah’ or excision of the external prepuce, the ‘peri’ah’ or slitting of the inner foreskin, and finally the ‘metzitzah’ or sucking of blood from the wound. The metzitzah originated in the 5th century Babylonian Talmud where it states metzitzah should be performed ”so as not to bring on risk,” although what the risk is, is not explicitly stated. Historically, if the mohel failed to perform the metzitzah he was barred from performing future circumcisions. During metzitzah, the mohel sips wine and applies his lips to the involved portion of the penis and then spits the wine into a receptacle, which may be repeated until hemostasis is achieved. Metzitzah with direct oral- genital suction was commonplace until the 19th century when Rabbi Moses Schreiber ruled that an instrument, such as a glass pipette, could be used as an interface between the mohel and the infant.
Can you say ick? That is not a form of hemostasis I would recommend in the operating room.
Hindus can get cutaneous larva migrans, a cat or dog tapeworm that wanders the skin after inoculation causing an intensely itchy serpentiginous rash, from an act of penance known as a side roll:
The most devout penance that a devotee may perform is known as the ‘side roll’ or angapradakshinam where the night prior they engage in a ritual fast, soak in the temple water tank, then lie on the ground and side-roll in the same path that the icons previously traversed. For the comfort of the participants the local government ships in sand from coastal areas and waters the sand twice daily to keep dust down.
Most of the cutaneous larva migrans I have seen have been tourists retuning from the beaches of Asia where they lay in the litter box, er, I mean sand of the beach. Beach sand is often the toilet for many animals and with it their parasites.
There have also been a few cases of primary amoebic meningoencephalitis after ritual ablution where the amoeba was introduced by washing the sinuses with contaminated tap water.
Behavior and risk is never simple. The more I try and understand the motivations for behaviors that lead to disease, the more complex and curious I find them. Of course many human behaviors are associated with infections and diseases. No, make that all human behaviors. It is why I am so much fun at parties, constantly pointing out the infection associated with a particular behavior.