Wednesday, August 24, 2011

A Back to School Basic

The phrase “Back to school,” can elicit a wide range of thoughts. Emotional responses include excitement, nerves, and in the case of my wife a profound “Thank Goodness!” My daughter, about to enter first grade, has a somewhat different opinion. “Can my American Girl go instead?”. No matter what, this is the time of year of making back to school plans and lists. Pencils, erasers, coloring books and computer accessories. Notebooks, crayons, backpacks and brown bag lunches. Scissors, sanitizer and glue sticks. Gym clothes, clean underwear and shoes that fit. Feel like something important is missing? Well if you are a 7th-12th grader without an up to date pertussis (whooping cought) booster, than yes, something important is missing. In fact, this something is critically important – as you may not be allowed to attend school without it.
Last year, the state legislature passed AB354, which mandates an up to date pertussis booster (as part of the Tdap immunization) for all 7th-12th students. Based on this new law and immunization records, an estimated 5,000 students in Marin will need to move the Tdap shot to the top of their back to school list, or else there may just not be a school to go back to. Now, if you or your children are in this group, this requirement likely seems like a hassle, and it is. But, there is a good reason. I’ll take a moment to explain...

Vaccination efforts during the past century have made certain childhood diseases so rare that they seem like remnants of an uncivilized past. Few of us have actually seen a new case of polio or measles, so it’s easy to be lulled into thinking that these ailments are so antiquated they couldn’t possibly cause trouble again. Unfortunately, this is just not true. The diseases that we vaccinate against are not extinct; they are lurking, waiting for enough people to drop their guard. If you think that I am an alarmist, consider these recent outbreaks: polio in Nigeria, measles across the U.S. and whooping cough in Marin County.

We are currently in the midst largest pertussis outbreak in 40 years – with ten deaths in California alone. Nationwide, measles is back – with a confirmed 156 cases in the first half of this year – the most since 1996. These outbreaks should remind us that we aren’t as safe from vaccine preventable diseases as we may think. Pertussis, for instance, is a highly contagious lung infection that can affect both children and adults and classically causes a “whoop” after coughing. In the days before DTP (diptheria-tetanus-pertussis) immunization, pertussis killed thousands of infants every year – often because the cough was so severe that it caused them to start bleeding in the brain. Thankfully, with the advent of widespread vaccination, the number of infections declined 99% between the 1930s and the 1980s and the death rate plummeted to single digits by the 1990s. In the last ten years, however, we’ve seen a resurgence of this infant-killer. Nationwide in 2005, there were over 25,000 cases of pertussis reported to the CDC; 21 of these were in Marin County. There are several explanations for pertussis’ comeback, but mostly it can be blamed on under-immunization. The protection afforded by the pertussis vaccine tends to wear off three to five years after vaccination, thus even children who have received the recommended DTaP series (five shots between the ages of 2 months and 6 years) are at risk for contracting the disease later.  Because of herd immunity (immunity that occurs when the vaccination of part of the community – or herd – provides protection to unvaccinated individuals) many parents think that their children are protected against pertussis (and other diseases) even if they are not fully vaccinated. Unfortunately, the more parents who believe this and exercise the (personal belief) exemption to mandatory vaccination, the more likely it is that herd immunity will fail. This is why a group of pediatricians in Philadelphia have published a manifesto to those who “absolutely” refuse to immunize: “by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children ... We feel such an attitude to be self-centered and unacceptable.” These pediatricians would be appalled with vaccination rates in Marin – according to the California Department of Public Health, the Marin County kindergarten immunization rate is 84.7%, significantly below the state rate of 92.1%. And while we have long suspected that un-immunized children are at greater risk of disease, we now have solid evidence of this. Two papers published in 2009 by a team of researchers from Colorado document significantly increased risk of pertussis (twenty-three fold risk) and varicella (nine-fold) in children whose parents refuse these immunizations.

So, what can we do to ward off a further surge in preventable infectious disease? Well, a great place to start is at the top of that back to school list. Fortunately, efforts are in play to make this as hassle free as possible. The Marin County Department of Health and Human Services is partnering with the Marin County Office of Education, San Rafael Kaiser Permanente, the Marin County School Nurses’ Association and the Marin Medical Reserve Corps to offer five vaccine clinics in school sites around the county just before the start of classes. At these clinics the vaccine will be offered at no cost to Kaiser members and the many students who qualify for free vaccine under federal rules and at a maximum will cost $32. Dates are August 15th, 16th, 17th, 19th and 22nd. For more information and details visit

Meditations on Placebo (Marin IJ)

I’ve had placebo on the mind recently. This preoccupation started at the gym after a discussion with a self-described “Zennie,” who tried to convince me of the benefits of meditation - particularly for priming athletes for peak performance. This woman, herself a practitioner of “muga-mushin,” (Japanese for “no mind, no self”), asserted that an athlete could benefit more from careful visualization than from actual practice. I was skeptical; I have to believe Kobe Bryant’s jumper is better served by physical practice than mental repetition. And this is when I started thinking about the placebo effect - the well-described sugar pill phenomenon in which patients experience significant improvement from sham treatments. It occurred to me that perhaps the mind-body benefits seen with placebos were not all that different than those achieved via meditation. And, I began to wonder, could meditation be used to consciously invoke the placebo effect?

Medical literature has, over and over again, demonstrated the power of placebo. Last year, for instance, a Newsweek cover story examined remarkable placebo treatments for depression – so remarkable that they are making it difficult for drug makers to prove the advantages of new anti-depressant medications. (The placebo response has become so robust in clinical trials that the drugs cannot outperform it.) Similarly, a recent Harvard study of asthmatics found 45% improvement in symptoms with a fake inhaler and 46% improvement with impostor acupuncture – compared to 50% with an actual treatment (albuterol).  Beyond just "tricking the brain to feel better," placebo treatments seem capable of causing actual neurological and physiological (bodily response) changes.

Even more startling was a recent study of patients with irritable bowel syndrome (IBS – a chronic gut condition characterized by pain and bowel irregularities). This study utilized an “open-label” placebo – in other words a placebo treatment without deception. In the investigation, led by Ted J. Kaptchuk and colleagues and published in December of 2010, eighty IBS patients were given either 1] no additional therapy or 2] treatment with what they described to the patients as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes." Self-reported symptom scores were assessed at 0, 11 and 21 days after the initiation of treatment. The results demonstrated significant improvements in symptom severity and relief in the placebo group.

Now, this study was a small one, with possible confounders (such as unreliability in patient symptom reporting) but certainly is provocative and promising. For years, physicians have struggled with placebo treatments – because they assumed that trickery was necessary for them to work. Trickery puts doctors in an uncomfortable position – having to choose between two ethical principles – beneficence (helping the patient) and autonomy (helping them make informed decisions). To freely prescribe placebo without the troublesome concealment component opens up a clear pathway for placebo treatments for many conditions - depression, asthma, chronic pain, IBS, addiction, hypertension, and more.  Now, I should be clear, there are limits to the physiologic possibilities for placebo. We can’t expect mind-over-matter to work with a bleeding limb or widely metastatic cancer.

Nonetheless, the ramifications of the IBS study, if borne out in subsequent studies, are huge - the placebo effect may not require deception at all. Perhaps it’s been mischaracterized for decades and perhaps conscious attempts at self-healing should
be carefully examined and mainstreamed. And this brings me back to meditation. Could meditation function like a placebo treatment for some conditions? I do not see why not. I’m no expert in Buddhism or meditation and I do not meditate (small children in the home would seem to make that nearly impossible). Still, I know there are a lot of different types of medication from a number of religious and spiritual traditions. And for the sake of this topic, I think we can agree that each shares an emphasis on channeling attention and achieving a still, rather than muddied and churning, mind. With that context, here’s some substantiation for meditation. First, and anecdotally, from my gymnasium Zennie…

- She successfully used meditation to limit sweating on a very hot day, reporting that she “was able to not sweat, save for a light sweat film on the face (nothing under the arms or chest.)” This, by the way, is not a recommended approach to dealing with the heat.

-She successfully used meditation to prepare for extreme 24-hour straight sessions on the rowing machine achieving “no pain, total relaxation in the moment and no tension.” This by the way, is not a recommended fitness regimen.

Not sold? Here’s what the medical literature has to say…

-Functional MRI studies by Richard Davidson at University of Wisconsin demonstrate that meditation can have measurable effects on certain regions of the brain (such as in the process of consciously cultivating empathy).

-Other studies suggest that meditation can help young adults cope with stress and can improve information-processing in adults.

-Studies of flu vaccine efficacy suggest that meditation can help boost the body’s immune response.

There is still much research to be done and I suspect that meditation is just one of a number of means of achieving better health through mind-body synching. Exercise, healthy relationships and optimism, for instance, may benefit the body through similar mechanisms. While the methods may vary, the physiologic mechanisms are likely similar. But, more on this another time. For now, I need to get back to the couch for some six-pack abs training - visualizing crunches is so much more comfortable than the real thing!