Bacteria, by and large, have received a bum rap (pardon the pun). Ever since they were discovered, there was a sense they were up to no good. Why were they always hanging around sick people, it was asked? And why did foul smelling things –the miasma (you gotta love these words)- always have bacteria skulking about in the background? There must have been some reason why -since the beginning of time, we have instinctively avoided rotting meat or putrescent items… Could it be the bacteria?

Of course, this eventually caused people –okay, Scientists– to wonder why our intestines are full of these malevolent creatures –and therefore why we weren’t all dead, or at least always ill on their account. The further paradox was when it became murkily clear that if this same intestinal effluvium were mixed with drinking water, we would be –very ill, that is.

So, how can you have your cake and eat it, too? Could it be that there was some sort of balance of good guys and bad guys in our guts that kind of neutralized each other in there? And maybe the balance wasn’t the same in the water near the sewage pipe?

And for that matter, because there were so many of them inside us, maybe it was for a reason? Even thinking like that seemed anathema to doctors –and companies- who had made their fortunes out of fighting them. And then, slowly, as the moon slipped quietly behind some clouds on the horizon, came the dawn. The paradigm shifted and it became acceptable to speculate that at least some bacteria might be on our side in Tennyson’s ‘Nature, red in tooth and claw’. Helpful bacteria living in secret bowel-caves, like traitors imbedded behind the enemy lines, were diligently hunted. And myriad uses were ascribed to their families. I even wrote about this a couple of years ago:

So it was only a matter of time until those who had hitherto persecuted all microbes, were persuaded to alliances -marriages of mutual convenience. Helpers of helpers were proffered: probiotics.

Probiotic –even the word has come to inspire hope. And its etymology: pro –on behalf of- and bios –life, nails it, don’t you think? I’ve touched on the subject before in my essays, as well:

But I’m not trying to reinvent the wheel here, nor seduce you into re-reading my old essays. I am, however, still interested in the subject and was therefore somewhat disappointed in an article in the BBC News that seemed, at first, to denigrate the concept of probiosis: There is a link in the article to the original meta-analysis paper in Genome Medicine.

I suppose it captured my attention the way any attack on my Confirmation Bias might: once I have been converted to a point of view, I take umbrage at any attempts to desecrate it… No, actually, that’s not true –I pay attention to the detail of the contention and see whether it could be refuted -what Carl Popper believed must be an essential component of all good Science.

This paper –a review of seven randomized, controlled trials (admittedly small numbers in each) of probiotics in healthy adults- concluded that there was ‘a lack of evidence for an impact of probiotics on fecal microbiota composition in healthy adults’. Fair enough, but contrary to the headline that might have attracted people to the article (Probiotic Goods a ‘waste of money’ for healthy adults, research suggests), buried near the end of the piece is the admission that ‘the real impact of the probiotics may have been masked by small sample sizes and the use of different strains of bacteria and variations in participants’ diets, among other factors’.

And the author of the Danish study, Oluf Pedersen, admitted: ‘“To explore the potential of probiotics to contribute to disease prevention in healthy people there is a major need for much larger, carefully designed and carefully conducted clinical trials.

“These should include ideal composition and dosage of known and newly developed probiotics combined with specified dietary advice, optimal trial duration and relevant monitoring of host health status.”’

So I think the final word on probiotics is still to come. It would make sense that one might not notice much of a change in fecal microbiota composition in those who are healthy and presumably already in possession of what Goldilocks described as ‘Just right baby bear’ stuff. But whether it could be further improved is the point at issue. There seems to be some evidence that it can be improved in those who need improvement –but at this stage, even that claim is contentious.

But it’s early yet, and as Robert Frost observed when he stopped by woods on a snowy evening: The woods are lovely, dark and deep, But I have promises to keep, And miles to go before I sleep… And so do we.




A Medical Chinese Curse?

Change. We are condemned to live in interesting times, as the Chinese Curse purportedly observed -although there seems to be no evidence that there ever was such a curse, nor does anyone appear to have any idea what it means… But I have always assumed that it had to do with change, and our sometime antipathy to it. Of course things have always been in flux but its only over the last hundred years or so that it has seemed exponential. We’ve had to accustom ourselves to a continuing and accelerating change and have come to expect that next year -if not tomorrow- may be significantly different from today. But although gradual change is readily assimilable, when the difference is abrupt or requires a significant adjustment we often rebel. Habits die hard. After all, an assumption of predictability and stability is what allows civilizations to function, groups to cohere.

It is under just such conditions that a fundamental dichotomy arises, however: knowledge is the enemy of stasis and progress requires modification, however incremental –a sea change into something rich and strange, as Shakespeare wrote. Change often comes upon us like contagion on the wind: pollution with an unknown virus. An unexperienced plague for which we have no defence. No immunity. And yet like the Siren’s song that lured ancient mariners onto rocks, it is seductive.

It’s hard to know what to make of Change. Not all of it is good; some of it is mere revision. As the poet Robert Frost once observed: ‘Most of the change we think we see in life is due to truths being in and out of favor’. Some of it, however, inevitably represents real advances, or even revolution -think of the concept of the paradigm shift popularized by Thomas Kuhn in his nineteen-sixties book The Structure of Scientific Revolutions. Something is conceived that is so new, so different from what we had come to believe, that it turns our belief system inside out.  The change, to be adopted, has to offer distinct advantages over the old, of course; it has to be worth making the effort. Reinvesting. But it is not without a struggle from those with vested interest or careers dependent on the old knowledge…

There are many such changes occurring in Medicine. Some are lauded and universally appreciated: a new treatment for cancer, say, or a fresh insight into the cause of a disease. Others, seemingly trivial, go unremarked -or at least unflagged until pointed out. And yet they may represent paradigm shifts in their own right. For example, new ways of looking at the problem of hospital infections and the spread of resistant bacteria. Hand washing and alcohol-containing lotion dispensers situated outside each patient room along the corridor are being universally adopted and are an important component in the containment attempt.

But there is another approach that, now that I think about it, should have been equally obvious. I first read about it being mandated in some UK hospitals and filed it away somewhere as being a good idea. Now it is being considered here in North America, and none too soon:

Hang Up Your Lab Coat (What Not to Wear — for Patient Care) 

It’s so obvious when you stop and think about it, isn’t it? What is worn from room to room, brushing against patients, rubbing on bedclothes, and stained by anything and everything that it touches? The white lab coat, of course! We see them so often in our hospitals, we’ve come to expect them. And we all know who wears them: lab techs shuffling along the halls, doctors hurrying from room to room, senior nurses… its a virtually ubiquitous sight in a hospital. An expectation. And yet, no matter how often and diligently the doctor -or whoever- washes his hands between patients, no matter how devoted to cleanliness, no matter how motivated, if he drags his lab coat -his uniform– from room to room, he’s like a germ duster. A fomite. A Johnny apple-seed for our times. And the admonishment of Bare-below-the-elbows, as the link suggests, makes sense too: it assumes the lab coat has been hung up outside the door. But it’s also one of those things that is clear in retrospect, but almost invisible unless pointed out.

Consider it pointed out.






The Health Care Paradigm

The Middle East has been in the news a lot; the Middle East is the news, with its tentacular failures reaching out to all and sundry, near and far, friend and foe. It sticks like Velcro to anything that has ever passed; it is the spider at the center of a web whose boundaries are still enlarging, still entangling.

At times I am reminded of Health Care -that primitive god appeasable only with sacrifice, but beset with failed diplomacy and feints and posturing. The intentions are laudable but the reality -or the contingencies surrounding that reality- too complex to allow much change. It’s almost as if the assessment were so constrained by circumstance, by need, by good intentions, so shrouded in expectation that no one could see that it was naïve. Unworkable. Even the most optimistic approach is unpalatable to many and dangerous to a few. And in the end, no one, let alone the participants -the victims- are satisfied.

Both situations are subject to similar biases: the ultimate goals are probably unachievable without radical changes –paradigm shifts. Thomas Kuhn in his book The Structure of Scientific Revolutions (where the concept of paradigm shifts -world-view changes- was most forcibly presented) suggested that system changes occur more readily when so many anomalies accumulate in the usual approach it has to be abandoned. Unfortunately, unless another more appropriate theory is ready to jump in and replace the old one, things can drag on inefficiently, often with disastrous results. Be careful what you wish for.

Health Care, like politics in the Middle East, requires a new approach, a new paradigm. When we come home from a long and vexing day, wearing all the unresolved issues it wove, we are comforted by the predictability of our house -the orderliness of a room, say: the vase on the table, the juice in the fridge, the magazine where we left it on the shelf by the couch. It is an oasis tucked away from the world, safe and unchanged. Most of us desperately want -need- the world to be like this: predictable, reassuring, changing little and only within our comfort zones. All therapeutic perhaps, but nonetheless beside the point. Irrelevant. It’s just not how things develop; there is an evolution inherent in issues that is beyond our ken. Our desire for refuge solves little. And yet…  By taking us out of the fray, it may allow us a more dispassionate view of what we left behind. Contrast is sometimes the way out of a paradigm: a sudden light flashing in the dark.

The old way of looking at it has not worked. Our objectives may be noble; our solutions, however, are necessarily coloured by reality. Economics. Politics. For example, in Canada at least, our Health Care motives seem to be laudable: let no one go untreated, unnoticed, uncared for. And yet we know many are. Politicians insist they are pouring more money each year into the system -and no doubt that is the case. But it seems to me that it is akin to bailing a boat with a hole in the bottom; it is doomed to sink. What is needed is a new boat, not a new patch… A new design. A new fabric to make the boat.

And yet, rapid change often begets rapid and usually unanticipated problems. Even new paradigms do not come with guarantees; new clothes -beautiful and desirable ones included- do not always fit. Sometimes one has to measure for need as well as appearance. And measurement is an interesting concept; it entails viewing something in a new way: not how it appears superficially, but rather assessing its components and calibrating them in some consistent and verifiable manner. Not so much the size of the problem -that can be dealt with separately- but the components of the thing measured and the way they aggregate. The way they work. The size of a molecule is one thing, but the way it is put together may more successfully determine the way it interacts with the things with which it is mixed. That may be a better thing to measure… Reality rarely comes uncombined, unmixed, unassembled.

So in the case of Health Care, the situation is often reduced to its ever-increasing expense, its insoluble complexities; or it becomes mired in the mud of one problem or another adding yet another passage to the labyrinth… All, it seems to me, measuring the wrong things: the appearance, the effects, not the way it is put together. We know what we want it to do, not how to make it perform. So in geopolitics as well as in Health Care, maybe we have not yet talked enough to the other side -listened to its opinion, modified the equation. Maybe we’re so intent on what we want to be the answer, we miss the fact that it isn’t. For an equation to work, what appears on one side of the equal sign has to be in balance, in harmony, with what is on the other.

And what, after all this, is my response? Perhaps only the observation that, despite the desperate need, the paradigm has not yet shifted -it is still the same old worn out animal dutifully charged with clearing the pasture. But, more alarmingly, that perhaps we don’t even realize it is just a paradigm… and not the only one.