Monthly Archives: October 2013

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Tainted Breast Milk

I have to admit I’m worried. I’m worried that we have so successfully indoctrinated new mothers that their babies will suffer irredeemable hardships if not given breast milk, that they will seek it out whatever the source and wherever the source… My concern is not over the long-since proven benefits of breast milk, nor whether mothers should be counselled to attempt breast feeding whenever possible; it’s the engendered guilt that bothers me.

I also have some concerns with the somewhat paradoxical issues around what has been called the tyranny of the breast and the stigma cast on those who dare to select formula-feeding for their neonates. But I suspect that is probably a manifestation of my concerns about a nanny system forcing its beliefs on any who would opt to choose for themselves even in the face of opposing evidence. We’re very supportive of mothers who accept our advice and then run into problems but less so -or smugly so- if they don’t accede to what we feel should be the norm.

No, my worry is about desperation and what it fosters. The New York Times reported on a study published in a recent issue of the journal Pediatrics which found that breast milk bought from two ‘popular websites’ was often contaminated with bacteria.  ( http://nyti.ms/1d9kiiR ) It also discussed milk-sharing websites in general that host advertisements from women offering to donate, sell, or buy breast milk. It goes on to say  “The researchers found that 64 percent of the samples from milk-sharing sites were contaminated with staph, 36 percent with strep, and almost three-quarters with other bacterial species. Three of the samples contained salmonella”.

With the exception of officially recognized Milk Banks, online breast milk sources are largely unregulated and free to advertise what they want with very little oversight. And, whether or not the intent is honorable and well-meaning, the quality is suspect. Milk is a sensitive, biological product requiring stringent conditions for its storage and subsequent use. Just like cow’s milk, it is easily contaminated and without sophisticated instruments this would be difficult to detect.  The average mother wouldn’t be able to determine if it was safe. Let’s be clear about this: how much trust can one attach to an essentially anonymous online producer -one who probably has no more idea whether her milk is safe than her buyer? And of course there is the whole issue of sterile transportation, packaging, not to mention storage on an ongoing basis. The article reported one of the authors, Dr. Keim, as saying: “There is no way for a consumer to be certain what she is getting from an online source. We looked at everything a buyer could know herself — temperature, the condition of the containers, how long it took to ship, what sellers were saying in their ads — and only the time in transit had any effect on contamination. Buyers have no way of knowing even what they’re getting — it could be cow’s milk or formula.”

There are regulated milk banks that offer safer products of course, but they are often expensive – I mean let’s face it, the average intake of a month old baby is probably around 25 ounces per day according to the article, so even at, say, a bargain $1.00 per ounce, that would amount to a minimum of $750 per month… and the supply is scarce so what is available is prioritized to premature infants with special needs.

No, sometimes a mother has to step back from the ideal, and embrace the practical. Babies may well do better if nourished from the start with breast milk, but the obverse does not necessarily obtain. I don’t advocate formula feeding, but nor do I castigate my patients if they feel that bottle-feeding is something with which they are more comfortable. It is not a choice between nourishment and malnourishment, love or abuse… Sometimes, it is an appropriate decision. A necessary decision.

I wonder if prenatal classes should include an introductory course in critical thinking -a lecture that advocates and facilitates stepping back for a moment to evaluate both the goals and the evidence that supports or refutes those goals. Pregnancy is a time of high emotion, and even higher hopes. Expectations often far outpace reality: a Better Homes and Gardens mentality where everything is tastefully displayed and always goes according to plan. “Is it just right for my baby bear?” one of my more imaginative and embarrassing patients who was obviously doing some prep work in Children’s Literature used to ask each time I measured her abdomen. I never knew how to answer…

But Life plays by its own rules and on its own field. Yes, we want the best for our babies, but what risks might that entail? Breast milk is good, but if yours is not available, what might be a reasonable next step? Depend on a putatively well-meaning stranger online who purports to offer something that you must accept on trust as safe? That you assume and hope is in fact really breast milk and not cow’s milk, or whatever? And, given the lack of guarantees or safeguards, would you really want to take a chance and give it to your baby? I wouldn’t.

Of course, you could always do some simple, basic research for an acceptable infant formula -there are several out there… No, it’s not breast milk; it contains no protective antibodies and nothing that your own body has worked so hard to produce, but at least it’s nourishing. At least it’s safe. There is an equation for all decisions: risks on one side, benefits on the other. Each has to be evaluated realistically; the equation has to be solved. There is simply too much at stake.

 

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An exploration of Menopause as a Boundary Phenomenon.

For years now, and especially as I age, I have been compelled by the idea of edges. Boundaries. Something different obtains there, something that differentiates them from whatever they demarcate. They are privileged areas, faerie-tale areas. Think, for example of silhouettes -treetops, say, against an evening sky; they are nothing but edges: intricately crocheted patterns, filaments of black against the dying pale blue background, they are trees and yet, strangely, they are not quite…

Edges are unique. They are where whatever was, is no more, but has not yet become other. It is a magic zone where the last remnant of something is defined, a demarcation that is at the same time inside and outside and yet really neither. Skin, which both contains what we are, and yet joins us to a place that we are not is a boundary; at what point, however does it cease to belong to the body? The surface -an area whose microscopic crevasses are deeply probed, caressed, and profoundly affected by molecules of outside? Or should there be a thin, arbitrary neutral zone where we allow that the skin has jurisdiction, though not strictly speaking, contiguity? A skin by virtue of proximity, not conquest; clothes whose owner is beyond dispute because they are being worn.

So boundaries are special: areas where ownership is not so much in dispute as definitionally obscure; where distal examination on either side is uncontested, and yet what constitutes the actual delineation of one or the other, nominally problematic. And functionally ambiguous, as well… Light, temperature, texture, authority -all are idiosyncratic, recalcitrant in the immediate vicinity.

We are constantly traveling through edges, aren’t we? Journeying from day into night, sleep to wakefulness, wondering to comprehending -these are some of the more obvious ones. Short term edges, if you will. But there are others less apparent as margins, that evolve more slowly, and whose fringes are so spread out we even categorize them differently: infancy, childhood, adulthood, old age… And yet, although their edges are also ill defined, they are equally magical and puzzling.

Take Menopause, as an example. It is a special edge: a junction -a phase-change, even. It is a bookmark between two Magisteria as different from each other as water and ice… But , menopause is a process rather than a boundary, it could be argued. A transition. There are no definitive edges to be contested, no uncontentiously delimitable state that precedes it, no clearly identifiable, and universally unique one that follows… no post hoc ergo propter hoc… Hence the vague, exculpatory and all inclusive concept of the Perimenopause –a concept that doesn’t so much explain, as encompass anything in the vicinity. Ambiguous. Nebulous, even. Ahh, but could this be an Edge description where the aforementioned boundary conditions obtain? A not-so-magic interregnum?

And yet, is that fair? Is any attempt to describe it thus, merely academic dissimulation?  Like a useless PhD thesis that is ultimately filed in the dark recesses of some seldom-visited library after its initial defence? Well, to start with, it seems to me that even if considered as an experiential phenomenon alone, examining the Menopause as if it were a boundary phenomenon has validity. And profit. The transition is palpable, the remembered state -that solidity away from the edge- different from the soon-to-come conditions temporally distal to the margin… So there is a vague and ill-defined border area that is clearly, if only subjectively differentiable from the rest: the pre and post menopause…

But, so what? Is there some relevance to describing the menopausal transition as an edge? Is there a believable and important justification for such equivocation? Remember that a boundary is a unique and special area, a marker as necessary for successful progression as a stop sign at a busy intersection. It is a biological divide that signals the need for reallocation of available resources. Unlike the almost imperceptible passage from childhood into adulthood, recognizable only in retrospect, and perhaps only by others, Menopause is a state, whose margins, although blurred, are acknowledgeable. Discernible. And borders that are distinguishable, even unwelcome, prompt reassessment. Reflection -albeit as if through a glass darkly.

As much as we may wish to deny it, we all change over time. It creeps up on us; the reflection in a mirror only revises the face of others, seldom our own. And yet the acknowledgement of Time and its passage is fundamental to growth -our own and theirs. Successful adaptation requires preparation, thoughtful anticipation. It is prudent to hesitate and plan the route before entering a forest.  And although from a distance it seems obvious where to stop, on nearing the trees, the boundary (again a border) seems less clear. Fortunately, unlike men, for women at least, there is a sign. An advantage: an Edge…

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A Canadian stem cell bank account?

There is method in the madness, the desperate rush for ontogeny. Cells huff and puff, some listening for instructions, others heading off in all directions like missionaries to new and just-discovered worlds. It is a busy place, the initial blastocyst turning into a multicelled embryo, as ontogeny recapitulates phylogeny, organs materialize out of apparent chaos, and form supersedes scaffold. Supervising all this, becoming all this, the Stem Cell quietly goes about its business of transformation: idea to blueprint to structure. Each starts off undifferentiated -uncommitted yet full of potential, a virtual library of plans; it then turns itself into whatever specialized cells the developing organism requires. It’s more complicated than that, of course, but a building usually is: walls hide a plethora of complexity, not to mention mystery.

And that these pluripotential cells, these nascent republics, hide in open view in the umbilical blood of every newborn baby -probably every newborn organism- should be grist for the just-so tales told to those same children years hence. It is truly a once-upon-a-time event that should thrill not only the wide-eyed child in the bed, but even the more sceptical adult storyteller. The Stem Cell is not just a progenitor, it is a gift almost too good to be true -an Aladdin’s lamp not to be ignored, nor, for that matter, to be trifled with. More -much more- needs to be learned before we rub it the wrong way, rub it roughly and are disappointed. Expectations too often outstrip reality. Much is promised, and no doubt much will be forthcoming. Currently, stem cells offer ‘promising treatments for leukemia, lymphoma, sickle cell disease and other blood, bone, immune and metabolic disorders’. But the path is unpredictable, tortuous, and meanders into the labyrinthine forest…

Stem cells were first discovered in the mid 1960ies in a type of cancer -a teratocarcinoma- that arose, not surprisingly, from cells that would ordinarily have formed gametes (germ cells). And the concept, the dream of pluripotentiality took off from there -more helpfully when a rich source of stem cells was found in umbilical cord blood. This eventually led to cord banks that would contract with parents to store the umbilical cord blood from their babies for their own future use -a relatively costly arrangement that charged more for potential than actual use. And anyway, not everybody could afford to store their baby’s blood. http://www.theglobeandmail.com/life/health-and-fitness/why-banking-on-cord-blood-isnt-necessarily-a-good-idea/article4209835/?utm_source=Shared+Article+Sent+to+User&utm_medium=E-mail:+Newsletters+/+E-Blasts+/+etc.&utm_campaign=Shared+Web+Article+Links  In other words, in Canada at least, a parent may pay as much as $1000.00 to start the process and then a premium each year to keep it stored in case it might be needed. And how often might it be needed? Well, apparently not very often at all. A 2007 American Academy of Pediatric policy statement on cord blood banking estimated that the use frequency was only one in a thousand to one in two hundred thousand! Other estimates have suggested higher usage rates since that statement was issued, but the point is that for an individual child, it is a substantial investment with a minimal yield.

So it has always seemed more appropriate to me that there be a national cord blood bank -one from which all in Canada could draw as the need arose. Other countries have done this… But until this year, only for-profit private banks were available in Canada. Now, at last, there is a national cord blood bank opening -albeit with limited branches at first: http://www.ottawacitizen.com/health/canada+first+national+cord+blood+bank+opened+doors+monday/8979216/story.html

Like adult blood donations in this country, cord blood should be donated free of charge. I don’t think profit should have any role in humanitarian projects. Health should not be something you have to purchase. Of course there is nothing stopping a parent from paying to store their infant’s cord blood for its own exclusive -or the family’s- use, although the above-linked 2012 article from the Toronto Globe and Mail, suggests that it is sometimes difficult to ensure a match for a family member even with that genetic kinship.

A national cord blood bank also offers a ready source of material for ongoing research. The ethics of using privately banked -reserved- blood for research is at the very least questionable, and unless agreed upon at the start, probably a breach of contract. And since the yield from any one umbilical cord is variable, but not excessive, if the parent is paying to store that limited quantity, it is cheeky to suggest they should not get all they’re paying for…

No, I applaud the new and national resource and wish them a speedy growth. And like the cells they guard, may the centers offering banks bloom like violets in the sun.

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Mental Health in prison?

The degree of civilization in a society can be judged by entering its prisons –Dostoyevsky got that right. But in the years since he wrote it, have we learned anything? Have we learned enough? Prisons may have changed over the years to include more individual rights, more facilities and even more education… But for the most part they still seem to function as warehouses: storage bins, where the troublesome -and the troubled– are secreted away so they are off the streets and out of the consciences of the rest of us. Out of sight, out of mind…

But as to who should be in prison, there seems to be some confusion. Some have argued that it should be a form of societal vengeance for any who have violated public normative behaviour -a way of avoiding the egalitarian justice suggested in the ancient babylonian Code of Hammurabi: the ‘eye for an eye’ principle. Some would argue that incarceration of one sort or another should be reserved for those who have both broken the law and are a danger to the public. Still others feel that for more obviously egregious transgressions -whether or not violent: white collar crimes, for example- justice is better served behind bars than with fines or mandated public service. Prison, in other words, is a punishment.

And yet, what if the crime was unintended, or indeed unappreciated? What if there was no criminal intent, no perception of wrongdoing? What if a minor misdemeanor and its subsequent detection led to behaviour that further incriminated, further entangled, and antagonized the system and its enforcers? The case of Ashley Smith and the investigation into her suicide in a prison cell while guards allegedly watched from outside the cell is merely the most recent and publically exposed example in Canada: http://www.theglobeandmail.com/commentary/editorials/canadas-next-ashley-smiths/article14645575/

Self-injury is increasing in prisons: http://globalnews.ca/news/873132/6-disturbing-facts-about-self-injury-among-canadas-prison-inmates/ -especially amongst women inmates. That, surely, is a sign that all is not well in our prison system… A sign that we ignore at our moral peril.

I suppose that this disturbing news could be treated with a simple shrug of the shoulders and an indifferent sigh. As Oscar Wilde said, “One of the many lessons that one learns in prison is, that things are what they are and will be what they will be.” Looking at it this way, however, we learn nothing. We improve nothing. These incidents are telling us something.

That prisons are for criminals would seem self evident; that they should not include those with treatable mental pathology is less so. At first glance, the two may seem inseparable -or at least similar: surely violent criminals, chronic offenders, or even overly greedy white collar convicts have some form of mental illness -something the rest of us don’t have: something alien, unfathomable, pathological…

Perhaps they do; perhaps all crime is attributable to some form of mental aberration. But in many ways, that dilutes the need to notice and treat those who have more recognizeable syndromes -syndromes more amenable to therapy. More rescuable. And it implies that such mental states are manageable within the prison system and don’t need separate facilities for successful resolution. The problem is that the primary contact with these troubled individuals is usually not by people trained for mental illness, but by those trained for suppression. Violence begets violence in response; it rarely engenders compassion, or a reasoned, helpful approach that might more successfully mitigate the behaviour. Mental illness unappreciated, is mental illness denied. Revoked. Abrogated.

No, prison is not a place for mental instability, or obvious, diagnosed mental pathology:  http://globalnews.ca/news/770460/get-severely-mentally-ill-out-of-prison-into-secure-hospitals-prison-watchdog/

I mean, this should be obvious, but is frequently deceptively so. Things are seldom black and white; mental illness is one of the ‘The Great Masqueraders’ as they used to call difficult to diagnose conditions in medical school. Indeed it’s often far from obvious, and may even languish in the background, overshadowed by the actions that occasioned the arrest. We tend to focus on actions, not motives -if that’s what one would call the underlying incentive, the mental aberration that engendered the violation in the first place… We tend to see the criminality of the result, not the intent (once again to ascribe, say, an hallucination or paranoia to something as logical and thoughtful as intent is problematic at the very least).

It is clearly not an easy problem to solve, nor, given the many other issues plaguing prisons -funding priorities, training of staff, and overcrowding, to name a few- is it likely to gain the level of government support it so obviously deserves. And yet it is a priority. The very problem speaks to who we are; who we want to be. Those unfortunate enough to suffer mental illness in the system can never be properly served within the confines of an institution designed to serve other needs -warehouse needs, dare I say.

As Dostoyevsky implies, a society is judged by how it treats the most vulnerable of its members: the old, the poor, the mental disadvantaged… Remember that hymn: God sees the little sparrow fall? Justice is served, not by vengeance, but more by understanding, remediating… Caring.