Ad-monishments

I have a confession to make -and I almost feel like it should be done behind a curtain in a soft, contrite whisper to someone who promises not to tell… It’s not something of which I am particularly proud, nor is it something that might not resolve itself over time -I honestly hope it does- but for now, it is an albatross. What I am so hesitant to disclose is that I don’t like health product ads -especially intimate ones. No, that’s too tame, too polite. They offend me. Some of them, anyway.

It could be my age: increasing frailties with their incessant demands immediately draw my attention to remedies for aching backs, or wobbly knees. Still, that’s old news, and not particularly personal. I can tolerate them, but they are the thin edge of a rather large wedge. Next in line I suppose are the legion, fail-safe bowel aids offered by actors with far more wrinkles than I could possibly fit comfortably on my face. This verges on profiling: not all older people are constipated, although I have to admit that their skin is not the best.

Some ads, despite being personal are more bearable I have to admit. I don’t notice them as much online, for example; one develops a blind spot for things that flash, and focal deafness to pictures that address you personally when the little mouse arrow happens to traverse their otherwise invisible boundaries on the screen.

Ads are far more difficult to ignore on TV, though. They appear suddenly -and purposefully- in the midst of a particularly interesting segment of the program, and unless you are constantly on guard with a thumb hovering over the mute or channel buttons, they are hard to keep subliminal. And yet, to be clear,  it’s not ads per se that I am against; companies have to survive and people have to know there are choices.

No, it’s more subtle than that. My sense is that there are some things that should be kept private, left unsaid. Of course maybe my wish to shade certain problems -certain areas- from public interrogation is merely an idiosyncrasy. Maybe the world has a right to know that there is now an effective treatment for private itch, or off-putting personal odours. Maybe people nowadays feel comfortable sharing these types of things: advocating antifungal creams on their Facebook pages, or Tweeting the ecstasy of their newly discovered intimate online depilatories. But I don’t.

Fortunately, sometimes repetition breeds indifference. I no longer shudder during those bowel commercials, although they do tend to focus my thoughts. I’m a doctor though, eh? I’m supposed to transcend emotions when it comes to the gastrointestinal system -although I hasten to add that the system in which I pretend expertise tends to produce more babies than… well, you know. Perhaps I am more tolerant as well of male hair-removal products nowadays, although I do not understand the need, nor do I personally know anybody who openly aspires to metrosexuality. I am open to face-shaving products, however, and am always on the lookout for improvements that don’t involve adding more blades. My kids have promised to text me if they come across anything.

The line begins to harden when the ads step across gender lines. I’ll admit this is probably a guy thing -an over-fifty me-thing, even- but I struggle with advertisements about stuff I would rather not think about. Maybe I’m just being delicate or old-fashioned; maybe I just haven’t travelled far enough along the information highway; or maybe I’m simply being fussy and curmudgeonly, but I have difficulty with cheery messages about such things as, say, feminine hygiene products (as they have been euphemized to get them on television). And I am annoyed when I am forced to see female incontinence clothes being modelled on the screen as if they were summer shorts. Forgive me, but it strikes me that these issues should be prime topics at the next health care visit, not vaunted, not bannered for all and sundry, not foisted upon them unawares. Unchosen. That someone can actually skate, or dance wearing retention panties is probably a plus, but come on… There are treatments that preserve dignity and don’t involve diapers -even other non-surgical approaches- that the companies would rather obfuscate.

Now I realize that industry needs to publicize its brands, and they even seem to travel a parallel road to public health at times. The inference -the message- is often: ‘Don’t just complain about your problem; try our product.’ And then the disclaimer: ‘This product may not be right for you… Ask your doctor.’ But as one of them, I would still wonder why she had come to ask my opinion about her pants if she were not also wondering about some other treatment options as well. In fact, she may already have chosen what was best for her -she may be wearing the best brand- but I wouldn’t know.

So that’s why I think I have to get over my ad squeamishness. Get over this Western Medicine scientific approach stuff. Embrace the alternatives. Decondition my antipathies. After all, some day, I might develop a personal problem I’d rather not admit to the health clinic at the Home – an embarrassing stain when I laugh, say, or maybe an undue concern over the stability of my teeth. And at that age, I don’t think I’d go to a surgeon anyway… they’d all be too young to know what they were doing. The stuff I’d see on the little silent television mounted on the wall over the card tables, though -I mean what would I have to lose? Something I could slip on and wear unobtrusively at the next sing along would be just the thing… maybe I could laugh again. Safely.

The Night of the Undead -Condom, that is… (female condom, I mean)

They’re back! Well, sort of… My somewhat sketchy memories of them -professional, you understand- are that they resembled the plastic bags you get at a supermarket… not female condoms (FC1s). They didn’t look at all like condoms! In fact, I still remember the jokes about needing Walmart greeters on entry and theft alarms on exit -this from the women themselves. No one seemed particularly enamoured of the concept: they were apparently made of polyurethane and quite apart from the distracting noise they made during use, they were ungainly not to mention unsightly. To use one at all required unprecedented devotion to the product and a fair amount of lead time…

Ahh, but they’re back; this time with fresh clothes: the new and apparently improved FC2 is made of non-rustling synthetic latex (as reported in the BBC News magazine : http://www.bbc.co.uk/news/magazine-25348410 ). I mean, the concept is a good one: empower the person who would suffer most from a pregnancy -the woman. And the article cites other advantages of the device as well: ‘They can be inserted hours before sex, meaning that there is no distraction at the crucial moment, and they don’t need to be removed immediately afterwards. For women, there is better protection from sexually transmitted infections, since the vulva is partially covered by an outer ring that keeps the device in place.’ All well and good; hard to argue with that… I guess.

Perhaps I am being overly critical, but I begin to sense a car salesman approach to a more professional selection in an article recently published in Lancet Global Health about three new models of the female condom: ‘The Cupid is available in India, South Africa and Brazil. It is vanilla scented and comes in pink or natural colours. It is currently the only model besides the FC2 to have been qualified by the World Health Organization (WHO) for public-sector purchase. A smaller version aimed at the Asian market is in trial.’ I suppose anything you can do to spruce up a classic is worthwhile if it makes it more desirable…

Innovation is what drives industry and no doubt adding variations to something I hadn’t even thought about for years, will appeal to a new and younger audience. A different audience. Several models -or at least their names- tweaked my interest. One, called the Air Condom -apparently available in Columbia- has a little pocket of air somewhere in it to make it easier to insert. And then there’s the Panty Condom (gotta love the name) that ‘is packaged with a special pair of knickers’ to keep it in place. Wow. That’s gotta appeal, eh?

But is merely sprucing up an old idea enough? I can’t help but wonder why the female condom never achieved much success in the first place. Is making a re-usable product -as some have suggested for poor countries- the answer? Or even an answer? I mean, would you hang it on the line to dry..? There must be something vaguely anathema about it -something subtle, perhaps embarrassing: something unsettling in the background. Or maybe it comes from the male partner and his unwillingness to countenance it. Who knows..? It might be as simple and intuitive as the idea that it’s better to Saran-wrap the outside of a stick than the inside of a glass. Anybody’s guess, I suppose.

And yet, whether the female condom ever takes off (no pun intended) I think that all is fair in family planning. Anything that adds a little spice to it, or makes people realize they have options is good. There’s an article in the Huffington Post with an interesting variation on this theme: ‘To Promote Family Planning, Let’s Have More Controversy’ ( http://www.huffingtonpost.com/christopher-purdy/to-promote-family-planning_b_4174943.html ) In other words, if people are talking about it -whether positively or critically- they’re thinking about it. Discussing it …and publically! Even condemnation provokes worthwhile response.

A good example of this is another mention in the Huffington Post of the Gates Foundation awarding grants for ‘Condoms of the Future’: http://www.huffingtonpost.com/2013/11/20/gates-foundation-condom_n_4312699.html Make male condoms interesting; make them exciting; make them up front and used above all. So if men aren’t happy with female condoms, make them happy with the testosterone version. Let men think they’re the ones leading the fashion parade. Let them think they’re in control… As long as family planning is out there and -dare I say- sexy in the community at large, everybody wins. Maybe even a souped up multicoloured twenty-first century retro model like the female condom. Personally, I’d change the name…

What’s in a name… Cancer?

Words are important. Quite aside from meaning, each has its own shade, its own temperature. Rose calls forth a mood, an emotion, an expectation that is quite distinct from, say, daisy. Words are little coloured post cards that tell stories and paint pictures; each word elicits a miniature portrait in the brain. Together, they tell stories, individually they hint at direction: plot.

We must never underestimate words. Strung together, they are greater than the sum of their parts; considered separately, they are the clothes of narrative: the shoes and socks so necessary for travel. Science, however -more specifically Technology- has travelled so quickly along the route, it has left words trailing in its wake. Unable to keep up with the pace, and often frazzled at the pace, words, tired and dishevelled, have often done double duty: the same old articles of apparel keeping up appearances and providing some continuity for those watching breathlessly from the sidelines. A narrative is difficult to follow, let alone understand, if there are no recognizeable links with what went before. Even neologisms build on standard and widely understood words or phonemes: retrologisms, as it were…

I was therefore intrigued -although not altogether surprised- at the e-publication of a paper to be published JAMA Intern Med ( http://dx.doi.org/10.1001/jamainternmed.2013.8405 ) that dealt with how the use of the word ‘cancer’ influenced the way patients made decisions about their treatment options -even when the condition they were asked to consider was pre cancer, not actual cancer. Just that word, in whatever context, was enough to alter their choices. In many instances -especially in medicine- the words we utilize are maladapted, anachronistic and, in fact, misleading…

In the days when cancer was, by and large, only detectable as a fait accompli, who would have thought it necessary to create a word describing a ‘not-quite cancer’, or a ‘not-yet cancer’? And yet there are precedents; although in not quite the same context nor perhaps an entirely appropriate analogy for a sequentially evolving concept, the Inuit of northern Canada have always used different words for different types of snow, for example. To a southerner, snow is snow; it all seems the same to an inexperienced observer, and not worth the picayune divisions. And yet the unique words help identify each type as separate, and behaviourly distinct… Often temporally distinct, as well.

I see this confusion not only among my patients but even with some of the non-specialist doctors who are confronted with a pathology report containing words like adenocarcinoma in situ, or perhaps just carcinoma in situ describing the biopsy of a cervix from a woman sent to my Colposcopy Clinic because of an abnormal pap smear. The cancer (carcinoma) word is there for sure, but some how the suffix in situ -meaning not invasive, or ‘contained’ is missed. And even if it is seen and deciphered, the phrase seems to imply that it is in fact a cancer that has been serendipitiously discovered before it has spread… although it is not! But so emotionally charged is the word -the idea of a cell, a process out of control- that it automatically elicits such a response; it’s almost involuntary: the quick withdrawl of a finger from a flame even before the brain has had time to process the sensation. A triumph of atavism over intellect.

While not necessarily, nor even predictably so, we like to think of cancer as having a precursor. In other words, we like to think there are early stages on its path to malignancy where the cell is not yet out of control and where this identification may allow modification -or elimination- of its otherwise inexorable progress. The explanation often chosen is that in its normal state, a cell is controlled by a series of checks and balances: how it grows and how quickly; how it differentiates and under what circumstances; how it adapts to changing conditions; how and when it dies and under what influences or instructions, and so on. If that control is lost -or even modified- the cell will undergo changes accordingly. And thus, the malignant transformation theory goes, at the beginning of the journey it is under control, and at the end of the road, out of control. So, the trick is to find it as it travels along that route -before it arrives at the other end.

And just as the destination is not the same as the stops along the way, those intermediate steps should not have the same names. If I start in Vancouver and end up in Calgary, why should I call Kelowna, or Banff pre-Calgaries? No, it would be too confusing, not to say misleading. They are what they are… And what they are not is Calgary.

We need different words, new words, words untainted by the whiff of dread, and unsullied by the expectation of disaster. “What’s in a name? That which we call a rose by any other name would smell as sweet.”… Really, Juliet? “The lady doth protest too much, methinks”.

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.