A Short History of Restraint Use.

Leather Restraint

“The great stumbling-block of the American superintendents is their most unfortunate and unhappy resistance to the abolition of mechanical restraint,” said British asylum superintendent John Charles Bucknill in 1876.

In the mid-19th century, after a long history of poor conditions, England started reforming its insane asylums. Cases like that of James Norris, a former seaman who spent ten years shackled to his bed with an iron harness, lead the reformers to push for the near-total abolition of restraint use. The British believed that in a well-run asylum with properly trained physicians on staff, they would rarely be necessary.

Since the first state-run mental hospital in the United States wasn’t established until 1822, Americans didn’t have the same negative history during the British reformation. Rather than seeing restraints as evidence of mistreatment, American physicians believed that restraints were a valuable tool to keep patients safe. They also believed that patients of a democratic nation were less tolerant of authority, and that the American insane were more violent than their British counterparts.

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Cultural Insensitivity.

A 20 minute seizure is considered life threatening. When Lia Lee was four years old, she suffered a seizure that lasted for nearly two hours.

When Lia had first begun to seize, her father, Nao Kao Lee, quickly realized that this seizure was worse than any Lia had before and called his English-speaking nephew over to call an ambulance, delaying Lia’s arrival to the hospital by a critically long 20 minutes.

When journalist Anne Fadiman asked Nao Kao why he had waited for his nephew and then the ambulance to come and get Lia, rather than running the three blocks to the hospital as he had before.

“If you take her in an ambulance, they would pay more attention to her at the hospital,” he replied.

Cultural sensitivity in medicine has become a very vogue topic. But, unless you work in the medical profession, it’s difficult to understand how catastrophic culturally insensitive medicine can be. Luckily, Fadiman successfully portrays the complications surrounding medicine and culture through the Lee family in her book The Spirit Catches You and You Fall Down for all of us who cannot see them first hand.

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Health and Social Hierarchy: Preschool Edition

(c) Nurse Blog

As every teacher knows (and hates), people start forming social hierarchies in preschool. But the dominant children aren’t just steamrolling the subordinate kids into giving up their toys, they may also be sentencing them to a life time of poor health.

University of British Columbia Neurologist and Child Development Special, Dr. Thomas Boyce, spoke about the “biology of misfortune” at the Harvard School of Public Health yesterday afternoon. Dr. Boyce began studying social hierarchies in children to try and explain why some children have medical charts with just a few pages, while others have charts as thick as phone books.

Socioeconomic status is frequently singled out as the biggest predictor of future health. It’s more influential than age, height, social support, and even smoking habits.  On top of that, health isn’t just related to objective social status, but also subjective social status— where people places themselves in the hierarchy. Suspecting that perceived social status started in childhood, Dr. Boyce decided to dig a little deeper.

Playing short video clips of children playing with one another, Dr. Boyce described the different kinds of hierarchy-establishing behaviour he found, including imitation, displacement, directing behavior, and good old-fashion physical attack.

In one clip, two small children are shown digging, with a third child, a little brown haired girl, first attempting to displace one child digging next to a tree before successfully displacing the second from his digging spot. After she tires of digging and moves on to something else, the child she originally tried to displace, a boy with a head full of blond curls, chases after her, grabbing her around the waist and trying to drag her back to the tree.

Dr. Boyce described this as “another demonstration of nuanced male behavior,” to laughs from the audience. The boy eventually figured out he could get the little girl to keep digging with him if he just asked her.

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Why Do Boys Get All The Circumcision?

Nawal Nour speaking with a Sudanese interpreter (c) Brigham and Women's Hospital

Though infant male circumcision is left to the discretion of parents, female circumcision performed on a minor is completely banned in the United States. This strange kind of sexism was the topic of debate at a Harvard Law School panel discussion today.

Male circumcision has long claimed to be the lesser of the two evils— safer, and with potential health benefits. Unfortunately, those potential health benefits are for people facing an AIDS epidemic, not Americans, and every medical procedure has risks.

“I don’t like seeing the poor little penises bleeding,” said panelist Dr. Nawal Nour, an obstetrician/gynecologist who founded the African Women’s Health Center in Boston. She stopped performing the procedure. Another panelist, Law Professor Sarah Waldeck, said that as a middle-age white woman from the midwest she couldn’t be objective on the issue— in her demographic, circumcision is the norm.

Waldeck’s perspective on male circumcision spoke to her early point about female circumcision— that the cultural aspects have to be taken into account when determining laws if they are going to be effective. Because the people the ban is aimed at view female circumcision as normal, she argued, the law is more likely to provoke backlash than lasting change.

“Getting people to stop circumcising their daughters is as difficult as trying to convince Jewish people to stop circumcising their sons,” Waldeck said. Dr. Nour pointed out that in a traditional Jewish bris, the circumcision is not performed in a hospital, or even by a medical professional.

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And The Women Come Last.

I feel bad for Sandeep Jauhal‘s wife. In his memoir about his medical internship, aptly named Intern, he seems a little indifferent to her. But that’s the point of the medical memoir: to drive home the point that doctors only have time to be doctors. They have to sleep, eat, breathe medicine or they will get crushed. And that is just one of the cliches this memoir falls into.

Intern begins with Jauhal not wanting to be a doctor. He’s just another Average Joe doing PhD work on quantum dots at Berkley when he finds out that his girlfriend has lupus. Cut to the medical research montage that not surprisingly, turns up empty. Strangely, he doesn’t want to go to medical school to save her (which would be no more absurd than thinking he could find the cure for lupus in the research library), he wants to go so that he can help someone. Which is probably a good thing, since the girlfriend disappears from the narrative as soon as his mind is made up.

After medical school, he goes to do his internship in New York, “hoping that in a city of eight million people, I’d be lucky enough to meet someone to fall in love with.” Since he never explained what happened to the lupus-sufferer, this admission is more jarring than sweet.

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A Short History of Thorazine.

Wow. This ad is almost as controversial as the drug it promotes, and that’s a feat. Unlike the other banned ads, this isn’t just showcasing out-dated values— it’s advertising the beginning of a mental health revolution. 

Considered a breakthrough medication, Thorazine secured FDA approval on March 26, 1954 as the first psychiatric medication. Prior to Thorazine’s inception, mental illnesses were treated with psycho- and electroshock therapies and institutionalization. The lobotomy was also popular (its inventor, Egaz Moniz, received the 1941 Nobel Prize in Medicine).

Change came when psychiatry finally crossed paths with the rest of medicine. Following in the footsteps of Paul Ehrlich, a German scientist who discovered a cure for syphilis, researchers all over the world were looking for compounds— “magic bullets”— to cure other diseases that plagued humanity.

Thorazine, generic name Chlorpromazine, was the result of researchers in France trying to find a “magic bullet” for malaria. Instead, they found a sedative thought to be potentially useful in surgery. They also discovered that it produced “a medicinal lobotomy.”

And why do with surgery what you could do with drugs?

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HIV Preferable to Diabetes.

Did you know that doctors are learning how to re-grow body parts? It’s true. Not even just bladders and tracheas (as seen on Grey’s Anatomy), but finger tips and nails too. But are these kind of medical advances really what we should be spending our time on? I mean, we barely know how to feed ourselves.

This was the topic of debate this past Saturday at the Harvard Business School’s 8th Annual Healthcare Conference.

The conference kicked off with a keynote address from Robert Epstein, the Chief Medical Officer at Medco, who trumpeted regenerative medicine as one of the four “amazing innovations in science that hold the promise of true healthcare reform,” along with genetics, epigenetics, and stem cell therapies

But Epstein’s assertion that these breakthroughs will help bend the cost curve down was disputed in the very next panel. Larry Fitzgerald, the chief financial officer of the University of Virginia Medical Center, thinks those types of innovations will bring the cost curve up, because they extend life rather than eliminate disease.

“Instead of having neurological problems at age 80, we’re going to have them at age 95 or 100,” he said during the Health IT panel discussion. “We’re still going to have them.”

And so emerged the topic of the day: instead of sinking our resources into ground-breaking innovation, we should be concentrating on preventative medicine and behavioural changes?

According to the U.S. State Department, chronic diseases such as obesity and diabetes account for seven out of every ten deaths in the U.S. and are projected to cause the majority of deaths worldwide by 2020, outstripping infectious diseases such as malaria and HIV/AIDS.

This topic dominated the global health panel, since treating chronic diseases will be a new challenge to the healthcare non-profits, the majority of which currently address infectious diseases.

“We have patients in Sub-Saharan Africa who say they would rather HIV than diabetes, because they can get treatment for HIV,” said Epidemiologist and panelist Todd Reid.

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