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Vol. 10
Spring 2012
MEDICAL DIALOGUE REVIEW
MEDICAL DIALOGUE REVIEW
A letter from the editors
D
ear MDR Readers,
“Medicine is referred to as a practice- a constantly evolving field involving science and the
humanities. It exists as a a delicate balance of dedication, scientific detachment, and compassion. My painting explores this interplay of science and humanity in medicine. In artwork
throughout history, hands are often used to symbolize different concepts like desire, strength,
and hope. To me, the gloved hands featured in this painting have two meanings. The gesture
of the hands is meant to represent the compassion a doctor must have when caring for his
patients, as hands are the primary tool for healing. The fingers are angled upwards in a hopeful manner, and the palm is angled toward the viewer. Yet, I also wanted the glove to demonstrate a sense of sterility. Just like the gloves on a doctor protect the patient and doctor
from infection, the gloves in this painting block the viewer from seeing the subject’s hands in
detail. There is no differentiation that allows the viewer to deduce whether the hand belongs
to a male or female, old or young. The choice of a simple background was intended to allow
each viewer to come to reach her own conclusions and derive whatever meaning that one can
intuitively sense. “
- Noella Richman
We are extremely proud to present the tenth edition of the Medical Dialogue Review! Ten semesters ago, this journal was conceived and created by a group of students who recognized that the university
needed a forum to discuss issues and developments in medicine, that conversation about medical school
admissions was abundant but discourse about the field of medicine itself was lacking. This journal was set
up to fill that void and provide students with a venue for discussing medicine, both in terms of its evolution as a scientific discipline and its role within a larger societal context.
The Medical Dialogue Review urged the NYU community to explore these issues, to speculate about
what improvements would address any shortcomings, and how we—as aspiring physicians and scholars,
and current citizens of the world—can make a difference. For ten semesters and counting, the Review has
upheld this philosophy, collecting and compiling submissions from students in all corners of the university
about every avenue available for exploration within the field of medicine, and this issue is no exception!
This semester, we have once again received a diverse array of submissions from intellectual young writers
with a passion for medicine and humanity. The articles in this edition cover a plethora of topics within the
field of medicine—some aim to educate readers about the characteristics of certain illnesses, while others
describe the attributes of and the controversies associated with emerging medical treatments. We have
articles that view medicine from various unique lenses, offering the readers of this issue the most diverse
perspective yet. The articles you are about to read cover a wide range of issues all connected by a common
thread – the desire to combine medicinal research with a desire to help humanity.
We invite readers from all disciplines to open the pages of this journal and enter the medical dialogue.
Thank you for your support and continued interest in MDR! We hope that our contents educate you on
various aspects of medicine and encourage you to become an analytical, energetic, and active participant
in ongoing debates within the field of medicine. In reading this journal, be prepared to enter and enjoy a
stimulating dialogue with others about interesting subjects in medicine and society!
Disclaimer:
The content of the Journal of Medical Dialogue Review represents perspectives of students, professionals, or
patients on issues in healthcare. These ideas do not represent the opinions of Medical Dialogue or New York
University. Information that is presented is reviewed for accuracy, but should not be used for medical diagnosis or as a substitute of medical advice. MDR is a New York University student publication. NYU is not
responsible for its content.
MEDICAL DIALOGUE REVIEW
Spring 2012
Sincerely,
The Editors of Medical Dialogue Review
Volume 10
MEDICAL DIALOGUE REVIEW
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In This Issue
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2
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A Letter From the Editors
In This Issue
Evaluation of Transcranial Magnetic Stimulation for the Treatment of Major
Depressive Disorder
By Sabrina Miller
In today’s world, depression is one of the leading causes of illness. Many forms of depression are treatmentresistant, making them especially difficult to manage. One method of alleviating treatment-resistant depression
is transcranial magnetic stimulation (TMS). While many studies conducted on TMS so far have produced mixed
results concerning its effectiveness, it is a step-forward in the treatment of major depressive disorders. TMS is
as effective as the current treatment, electroconvulsive therapy, but with milder side-effects. However, a major
problem with the current research being done on TMS is the lack of significant difference in the results of the
control group versus the group receiving the treatment. Further research is being conducted at this moment that
is optimistic in developing clear differences in the results of these two groups.
Help Them to Help Us: Why sustaining Certain Plant Species is Incumbent on Us
By Gregory Rubinfeld
Many ailments, such as malaria and cancer, are treated using plants or plant derivatives. Even the most common
pain reliever, aspirin, is a plant-derived compound. However, there are several things that we should consider
when we harvest these wonderful natural resources for medical purposes. Overharvesting can lead to extinction
of a valuable plant species. On the other hand, most synthetic version of these plant compounds are not as effective as the naturally produced ones in combatting disease. How can we develop a balance between our need to
preserve these valuable species and our need to harvest them for the improvement of human health?
What Doctors Could Learn From Literature and Art
By Pauline Woo
While many doctors focus many of their intellectual pursuits in scientific areas, there may be great benefits to be
reaped from a greater focus on the arts. Studies and experts have suggested that art and literature help doctors
become better at observing details and can improve problem solving as a whole, skills important in diagnosing
patients. Additional studies have shown that art increases the perceived sensitivity of the doctor making them
seem more approachable and improving bedside manner. Overall, much can be gained through greater implementation of art into the lives of current or prospective doctors.
MEDICAL DIALOGUE REVIEW
Spring 2012
EDITOR-IN-CHIEF
Misha Bhandari
4
The Importance of Extracurricular Activities for
Premedical Students
6
Judgment Call: Novel Treatments Using Gene Therapy
9
On Physician Assisted Suicide
SENIOR EDITORS
Jessica Morgan
Courtney Lamb
By Allison Greene
By Andrew Jarrah
By Benjamin Mormann
18
Wresting Power Into the Hands of Patients
22
Revolutions in Neuroscience: Improving the Mind in
Health and Disease
26
Illness Narrative
29
By Jung-Yun Min
By Kevin Dell’Aquila
By Megan Lin
The Key to Paradoxical Latino Immigrant Health
Outcomes: Disappearing Folk and Traditional Healing
Methods
By Mon Yuck Yu
34
The Emergence and Implementation of EMR systems
and Their Effect on Healthcare
38
Psychoneuroimmunology: A Window into Mind-Body
Medicine?
44
The Importance of Health Literacy in Child Obesity
Prevention
By Mrinal Subbiah
By Omar Akhand
By Raphaelle Oriol
Volume 10
LAYOUT EDITOR
Thanita Pilunthanakul
REVIEWERS
Julia Brothers
Sarah A Choksi
Shaimaa M Saad
Ramsha Jabbar
Alivia C Kandabarow
Ilana Shiff
Ezra Dayan
Jessica Somberg
Yekaterina Rempel
Laura Palazzolo
Hillary C Lee
Sneha Aidasani
Manan S Patel
Ko Eun Choi
Rita Twan
Aransiola Fakorode
Alisa J Liu
Sehrash Shabbir
Johnathan Bruce Chen
Carley Demchuk
Carolyn Chang
Kevin Chu
Zev A Stomel
Noah Smith
Chun Yun Hsu
Sadeea Rahman
Sarah Kalinowski
William Pau
Philip Wong
Christopher Ramirez
Rima B Patel
Ashley Chia
Zain I Memon
CLUB ADVISOR
Stephen Polniaszek
FACULTY SUPPORTERS
Dean Gabrielle Starr
Dean Sally Sanderlin
Dean Brian Paquette
Prof. Andrea McKenzie
Advisor James Mazza
Dr. Kristen McHale
MEDICAL
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Greene
Greene
The Importance of
Extracurricular Activities for
Pre-medical Students
By Allison Greene
Two and a half years ago, in September 2009, President
Obama proposed a nationwide goal to produce ten thousand
new science, technology, engineering, and math (STEM) professionals over the next two years, and ten times that amount over
the next decade. With American students falling behind their
foreign peers in multiple academic areas (Drew 2011), Obama’s
call for more STEM professionals is ambitious, but it is also critical if The United States is to become a powerful competitor in
the global marketplace for innovation. Fortunately for America, the number of college freshmen interested in pursing STEM
majors has increased in recent years (Drew 2011). However,
40% of those students change their majors to liberal arts fields
before they graduate, and when premedical students are included in the count the attrition rate spikes to 60%. These numbers
represent a clear challenge at work against Obama’s long-terms
goals for American education. Less clear are the specific factors
that induce a substantial proportion of young scientists- and
doctors-to-be to reroute the trajectories of their aspirations.
In Drew’s New York Times Article Why Science Majors Change Their Minds (It’s Just So Darn Hard), one college
professor attributes the high attrition rate on “the math-science
death march” – a demanding curriculum of science and math
courses that STEM and premedical students are required to
follow during their early undergraduate years. All premedical students understand the difficulty this curriculum, espe-
“President Obama toured a White House science fair last year.
Younger students have been put under a microscope but college is
where excitement fades” (from Drew 2011)
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cially since it is paired with other classes and responsibilities,
and the tasks of acclimating to college world and juggling (a
smidgen of) a social life. Even for students who take advanced
placement science and math courses in high school, “the
math-science death march” can certainly live up to its name.
It’s no secret that the premedical track is designed to
be difficult. It’s meant to provide a foundation for higher-level
classes and, for better or worse, it also acts as a filter. Students
who struggle to stay afloat amid the concepts or coursework
are weaned out either on their own terms or by the minimum
grade requirements necessary for progression. But not all students who withdraw from the premedical track are deterred
by the difficulty. Some are concerned about their GPAs. On
average, grades in math and science classes are lower than
those of liberal arts classes (Drew 2011). One reason for the
disparity is that STEM exams are often more straightforward
than liberal arts exams so they leave less room for subjective
grading, which can often work in students’ favor. In addition,
most science classes are graded along curves where only a
fixed percentage of students receive “A”s. In Principles of Biology at NYU, for example, that fraction is slightly less than
a quarter. Naturally, curves promote competition between students. Ironically, science and engineering on the professional
level thrive on collaboration. In fact, much of the science exposure premedical students gain through their coursework
bears little resemblance to the careers they strive to pursue.
For all undergraduate students, college is an invitation for exploration. Undergraduates are encouraged to take
classes in a variety of academic areas so they can discover
their interests and ultimately choose a career path that best
suits them. However, the opportunity for exploration is truncated for premedical students by virtue of their hefty course
requirements. Their decision-making process is further complicated by the fact that medicine is generally not taught at
undergraduate institutions. While math and science courses
do prepare students for the MCAT and for courses they will
encounter in medical school, they do not teach students
about the field of medicine per se. Certainly the motivation
and competency required of premedical students prepare
them for their futures as physicians, but the premedical track
is not a preview of medicine. Because this track is so far removed from the field of medicine, premedical students must
take the task of learning about medicine into their own hands.
The best and perhaps the only way for students to learn
how medicine works is to become actively involved in it in some
capacity. Opportunities for undergraduates are limited but they
are extremely meaningful. For instance, students can volunteer
in a hospital and work directly with patients, intern in a professor’s research laboratory, or shadow a physician in a hospital or
private office. In doing so, students can learn how hospitals operate and be exposed to variety of patient populations, understand what research is and how it works, and see what it is like
to be a doctor. When it comes to making career decisions, these
lessons are far more valuable to students than those taught in
their classes because they show them the end results of their
career paths. In fact, without medically related extracurricular
experiences, the average premedical student has no exposure
to medicine outside his or her own experiences as a patient.
Despite the importance of extracurricular activities,
it seems that many NYU premedical students have little or no
knowledge about how to get involved. According to Christopher Bailey, an advisor and contributor for NYU MedPac –a
premedical advising site run by current medical students–
“many undergraduate students are unaware of the necessity
for extracurricular involvement, and of the wealth of opportunities they have as college students in Manhattan.” This is
largely because classes and MCAT preparation, not extracurricular activities, are at the forefront of the premed program.
Since research and volunteering are not actual requirements
for the program, students must be proactive about seeking
opportunities. The problem is that many don’t know where
to begin. Finding a doctor to shadow or getting a volunteer
position in a hospital or research lab generally begins with a
Google search and simple email or phone call to a department
at a hospital or university. There are also several student-run
“Because the premedical track is so far removed from the
field of medicine, premedical students must take the task
of learning about medicine into their own hands.”
groups at NYU that are available to advise students about specific volunteer opportunities in Manhattan. If students knew
more about the significance of extracurricular activities and
where to access information, more students would be involved.
On the other hand, there are many students who are
heavily involved in extracurricular activities. Some can balance their time and priorities well, but there are others who
overextend themselves in order to bolster their resumes. The
medical school application process is rigorously competitive,
so these students spend their undergraduate years dabbling in
myriad activities with the misguided belief that they will appear
dedicated or well-rounded to admissions boards. The problem
with this logic is that it misconstrues the purpose of extracurricular involvement. Students who spread themselves across
too many activities cannot truly be dedicated to any of them.
Furthermore, medical schools want applicants who can derive
and discuss meaning from their experiences. The purpose of
extracurricular involvement is not to check off boxes or muster
a large number of volunteering hours. Rather, students should
use the opportunities to learn how medicine works and ulti-
An NYU student who volunteers as a research assistant at an
uptown hospital presents a poster at a medical conference, demonstrating one of the many opportunities undergraduates have to get
involved in the medical field.
mately decide whether or not it is the right career for them.
In Drew’s New York Times Article Why Science Majors Change Their Minds (It’s Just So Darn Hard), he points out
that the high attrition rate among science and math majors in
American universities represents a formidable obstacle hindering the success of Obama’s goal to produce 100,000 new
STEM professionals by 2019. Perhaps the more important
challenge is ensuring that students make well-informed decisions about their careers. “The math-science death march” of
freshman and sophomore year is notoriously difficult, competitive and, for many, discouraging. If science and premedical students use their class performance as the only measure
of their aptitude for success, it’s no wonder so many of them
become disenchanted with medicine. Extracurricular activities offer premedical students opportunities for active learning, the freedom make mistakes without the fear of red ink,
the privilege of working with encouraging professionals, and
the advantage of seeing what the light at the end of the tunnel
looks like for aspiring physicians. Perhaps if extracurricular
involvement were a more integral component of the premedical program, more students would be inclined to stick with it.
REFERENCES
Douliery, Oliver. Photograph. ABACAUSA.com. NYT via
Bloomberg. Web.
Drew, Christopher. “Why Science Majors Change Their Mind
(It’s Just So Darn Hard)” New York Times on the Web. 4 November, 2011.
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About the Author
Allison Greene is a postbaccalaureate student plans to attend medical school and ultimately become a physician. She attended NYU for her undergraduate education where she majored in psychology and conducted an honors
thesis in visual perception and motor planning. Following graduation she was accepted to a doctoral program in school
psychology at Columbia University, but after one semester she decided that medicine would be a better career choice for
her, so she came back downtown to fulfill her premed requirements. When she’s not in class, she enjoys conquering the
New York restaurant scene, traveling, and trapezing.
Judgment Call:
Novel Treatments Using Gene
Therapy
By Andrew Jarrah
“The human genome carries the potential to become the most
effective treatment for curing genetic diseases and acquired injuries.”
Medical diagnosis and treatment are slowly entering a
new field propelled by innovation and research. With time, conventional treatments will be phased for more effective and less
invasive approaches. Genetic therapy has made its way to the
forefront of what is being considered the medicine of tomorrow. Researchers have come to realize that the human genome
itself is one of the most effective treatments against disease prevention and treatment. Injuries which are currently very difficult to treat are the main targets of novel cellular therapies.
One such type of injury is a myocardial infarction
(MI) which is estimated to affect one million Americans each
year. MI coupled with other cardiac stressors such as Coronary
Artery Disease has shown to lead to high rates of ischemia and
Chronic Heart Failure (CHF)1-2. Given the significant economic
and health-related implications of CHF treatment and prevention, researchers have already undertaken the intricate task of
designing genetic therapies to combat these ailments. However,
as their investigations have shown, there are often underlying
and potentially maladaptive repercussions in gene therapies
and should be used only in cases where the full effects of treatment are known. There are often underlying and potentially life
threatening repercussions involved in the use of these therapies.
Understanding gene therapy first involves an understanding of the mechanism by which treatments are carried
out. The methodology behind gene therapies begins with either adeno-associated virus (AAV) or the adenovirus which
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is family of viruses that cause common illnesses like the common cold, pneumonia and bronchitis3. However, gene therapists do not make use of the wild-type vectors; they are constructed into transgenic forms which contain recombinant
DNA (double-stranded for adenovirus and single-stranded
for AAV) which will be therapeutically beneficial to the disease at hand. AAV has become widely popular for genetic
therapies given two integral characteristics: AAV vectors are
Figure 1, the general mechanism by which adenovirus and AAV vectors operate
“Genetic therapies cannot be considered under all
circumstances given that their effects are highly
variable and situation dependent”
non-pathogenic and are incapable of reproduction without a
helper virus, typically adenovirus or herpes simplex. This allows for precise control of the treatment in terms of duration
and concentration. The main drawback to the AAV vector is
size; the virus is rather small which is undoubtedly a positive
from a fiscal perspective but a negative in a therapeutic sense
in that it cannot carry large payloads of genetic information
thus limiting the range of this therapy4. Both adenovirus and
AAV have been used in the heart model with varying results
thus exemplifying the immaturity of vector based gene therapy.
In a current study, a gene based treatment for the repair of cardiomyocytes post-MI involved the upregulation of
stromal-cell-derived factor-1 (SDF-1) in damaged cells via
AAV infection carrying a chemokine-receptor-4 (CXCR4) upregulator along with a cardiomyocyte specific promoter. The
sole ligand of CXCR4 is chemokine-ligand-12 (also known as
SDF-1). This specificity makes it highly attractive as a target
for genetic therapies5-6. The AAV vector was used to upregulate
the number of cell-surface receptors on cardiomyocytes which
in turn increased the concentrations of CXCL12 above physiological levels. Researchers noted that elevated CXCL12 levels
in a murine infarct heart led to increased recruiting of bone
marrow (BM) cells which are highly adaptive to injured tissues.
However, they are quick to suggest that while BM cell homing
did occur, preliminary data indicates that higher concentrations of CXCL12 in adult rat cardiomyocytes induces apoptosis
through apoptotic cytokines such as tumor necrosis factor-α
(TNF-α) . While the positive effects of this therapy need to be
further explored, this example is a prime delineation of the
delicacy of novel therapies. Whereas on one hand, CXCL12 upregulation via increased CXCR4 concentrations has proven to
be effective in inducing BM cell homing and thus cell repair, it
has also been shown to induce TNF-α in a maladaptive format1.
Yet considering the current therapies, it may seem
that gene therapy, no matter how intricate, seems like the
better alternative to conventional treatments. For example,
treatment of hrombolytics, which is considered the standard clinical treatment for ischemia-related injuries caused
by acute occlusion of coronary flow. The treatment functions by dissolving ischemia-inducing thrombi thus reperfusing the occluded artery and restoring flow to the cardiac tissue. Yet as effective as these treatments seem, the drawbacks
are apparent. While waiting for the dissolution of the thrombus, the ischemic tissue is continually undergoing permanent injury. Upon reperfusion, which is necessary yet damaging, lethal reperfusion takes place which induces high
levels of inflammation associated with necrosis and apoptosis7.
In search of a better treatment, researchers studied
the effects of CXCR4 regulation after reperfusion in a myocardial infarction model. Overexpression was facilitated via an
adenovirus vector (at the time, AAV was unavailable) which
was injected into a rat host one week prior to injury. MI was
induced by ligating the left anterior descending (LAD) coro-
Figure 2, CXCR4 infected right, uninfected left; area of infarct is
illustrated in red
Figure 3, CXCR4 upregulation showed increases in both risk and
infarct areas
nary artery and reperfusing for 24 hours. Upon examination of the heart, rats who had received the CXCR4 virus, in
contrast to control animals, showed increases in both infarct
area and decreased fractional shortening (Fig.1). CXCL12,
which was thought to actively recruit stem cells to the site of
ischemia-related injury, was discovered to allow recruitment
of inflammatory cell types and upregulate the production of
TNF-α which subsequently caused the activation of apoptotic
pathways in ischemic tissue1. While the conventional treatment may not be the ideal treatment, genetic therapy in this
instance was shown to be completely maladaptive towards cardiomyocyte recovery and therefore is completely inadvisable.
In the first instance, CXCL12 was shown to play a
beneficial role in its recruiting of BM cells to the site of injury
and in the second, CXCL12 was also shown to increase the inflammation response, initiate further cell death and generally
increase the size of the area at risk (Fig. 2). It would seem that
we have a paradox when it comes to the role of this chemokine but in fact, the answer is quite simple: genetic therapies
cannot be considered under all circumstances given that their
effects are highly variable and situation dependent. The reason
for such high degrees of variability in treating disease is that
conditions such as HF are multi-factorial. There is typically no
single gene or set of genes that can be manipulated in order to
provide an effective treatment in every case. Everything from
the vector used to the concentration of virus and the duration
of the treatment have a strong hand in shaping the outcome8.
Where then do we stand on the debate of gene therapy as a useful therapeutic method? At this point in time, it
is hard to say. The effectiveness of a therapy, as has been delineated, is highly based on intrinsic situational factors, most
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of which we are still unfamiliar with. While research has
been able to provide us the cause-and-effect relationships
of certain therapies, those relationships only hold true under a certain, pre-determined set of circumstances. Little is
known about the systemic consequences of regulating certain
genetic pathways and it is for this reason that genetic therapies have not yet been employed to their full potential. Further research needs to be done before these methods can
safely be used to effectively treat human injury and disease.
However, we should not underestimate the power
and potential of these novel methods. With time, as with most
innovations, progress will enable us to use them in effective
and efficient manners to reduce the health and fiscal related
impacts of disease. Treatments may one day solely consist of
these non-invasive therapies which prove to be effective without the use of synthetic treatments. The human genome carries the potential to become the most effective treatment for
curing genetic diseases and acquired injuries, decreasing the
impact of humanity’s most disabling disorders and conditions.
CXCR4 Gene Transfer on Cardiac Function After Ischemia-Reperfusion Injury.” American Journal Of Pathology 176.4 (2010):
1705-715. Print.
2: Cowie MR, Mosterd A.,Wood DA et al.The epidemiology of
heart failure. European Heart Journal 1997;18:208-15
3: “Clinical Overview (Adenoviruses).” Centers for Disease
Control and Prevention. Centers for Disease Control and Prevention, 27 Dec. 2011. Web. <http://www.cdc.gov/adenovirus/
hcp/clinical-overview.html>.
4: Coura, Renata, and Nance Nardi. “The State of the Art of
Adeno-associated Virus-based Vectors in Gene Therapy.” Virology Journal 4.1 (2007): 99. Print.
5: “Genes and Mapped Phenotypes.” National Center for
Biotechnology Information. U.S. National Library of Medicine.
Web. <http://www.ncbi.nlm.nih.gov/gene/7852>.
6: “Genes and Mapped Phenotypes.” National Center for
Biotechnology Information. U.S. National Library of Medicine.
Web. <http://www.ncbi.nlm.nih.gov/gene/6387>.
7: Yellon D.M., Baxter G.F., Protecting the Ischemic and Reperfused Myocardium in Acute Myocardial Infarction: Distant
Dream or Near Reality?, Heart 2000, 83:381-387.
REFERENCES
1: Chen, J., E. Chemaly, L. Liang, C. Kho, A. Lee, J. Park, P. Altman, A. D. Schecter, R. J. Hajjar, and S. T. Tarzami.“Effects of
About the Author
Andrew Jarrah is a sophomore at NYU originally from Suffolk County, Long Island. He is a declared Biochemistry Major with a minor in Business Studies in CAS. He is currently doing research studying the concentration-dependent
effects of SDF-1 both in vivo and in vitro at Mount Sinai School of Medicine. He is mainly interested in molecular biology
and immunology. Outside the sciences, Andrew enjoys photography, playing the piano, and running (although the latter
proves to be less enjoyment and more torture).
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ON PHYSICIAN ASSISTED
SUICIDE
By Benjamin Mormann
“When a species persists in a changing environment, however, evolutionary adaptations it has
acquired can come to clash with the new environment in novel ways. The emotion we feel when
exposed to death has infiltrated a new realm – one it may or may not belong in. This realm is in
the arena where today’s hot debate over the phenomenon of physician assisted suicide is
contested.”
Nothing moves us quite like death does. As organisms,
we are evolved to survive so that we may reproduce. A key player
in promoting our survival is emotion. Our feelings drop to the
deepest trenches when our loved ones die, we hand over a social
contract to feel protected, and we become uncomfortable when
people commit suicide. Our ability does its job well- people, for
the most part; want to stay alive for themselves and for others.
When a species persists in a changing environment, however,
evolutionary adaptations it has acquired can come to clash with
the new environment in novel ways. The emotion we feel when
exposed to death has infiltrated a new realm-one it may or may
not belong in. This realm is in the arena where today’s hot debate over the phenomenon of physician assisted suicide is contested. In order to produce a fair assessment of the ethicality
of physician assisted suicide, we must look at it as objectively
as possible. We must recognize, then cast aside the aspects of
the debate which pick at our feelings. Further, we must edit the
frame through which we currently view debate, where arguments and support may not, when given a closer look, be reasonably applicable. The material we choose to incorporate into
the new, improved frame must sprout from the roots of our civilization-the same roots that have shaped who we have become.
The American Medical Association defines physician assisted suicide (PAS) as, “when a physician provides a
patient with the medical means and/ or the medical knowledge to commit suicide.” (3) Chronic suffering in patients is
not all too rare. As long as medicine is not complete or perfect, there will be patients who past a certain point, can no further be medically helped. These patients may feel unbearable
amounts of pain, whether it be physical or mental. Most are
aware that they stand no chance of recovery, and some think
of the mounds of money spent on their healthcare, and the
burden they put on their friends and family. The sum of these
reasons and others associated with them may cause a patient to
make a decision that will put him at ease- the decision to end
his life. In PAS, the patient communicates this to his doctor,
who, with the best interest of the patient in mind, prescribes a
lethal dose of medication for the patient to consume himself.
As it can tint the debate, common confusion and
misrepresentation over physician assisted suicide versus a
phenomenon called euthanasia must be cleared up. The case
of infamous Jack Kevorkian (22), who illegally performed euthanasia to a number of his patients throughout his career as
a doctor, remains a disturbing memory to many Americans,
making them skeptical of assisted suicide. Found guilty by the
Michigan jury, Kevorkian was sent to prison for 10-25 years on
convictions of second degree murder, and given a bad name
in the media, coined “Dr. Death”. Our memories of this incident may serve to cloud our thinking as we naturally associate
what Kevorkian did with PAS. We must realize, however, that
euthanasia and PAS are significantly different. The American
Medical Association describes euthanasia as, “the administration of a lethal agent by another person to a patient for the
purpose of relieving the patient’s intolerable and incurable suffering.” (1) The difference between the two is palpable and significant: in physician assisted suicide, the doctor provides the
means to commit suicide for the patient to administer him or
herself, while in euthanasia, the doctor administers the drug to
the patient directly. The manifest line that separates the two is,
as Drexel University puts it, “that in assisted suicide the patient
is in complete control of the process that leads to death because
he/she is the person who performs the act of suicide.”(6) Even
with assurance that the event will occur in this manner, the
question of whether or not it should be allowed is a subject of
hot quarrel today. The American Medical News explains how
PAS is legal in just three American states: Oregon, Washington,
and Montana. (2) Oregon’s legalization of PAS has served as a
bell to other states which either have already followed suit or
now move closer to legalizing the act. In the first two states,
“Death with Dignity” laws have been passed which allow terminally ill, mentally competent patients who are eighteen or older
to die with the assistance of a physician.(4) Montana and Washington effectively legalized PAS just two years ago. Since then,
the fire of the debate has only amplified. If we wish to perform a
thorough examination of this debate to discover truth, we must
begin with square one- the name of the subject being debated.
Physician Assisted Suicide. The last word stings. Most
people would rather not think about it- it summons a particuVolume 10
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lar type of sadness that can make us especially uncomfortable,
and it is denounced in many religions. Many Americans believe
that life is a gift and life is good, so they are disillusioned when
they hear of someone who has ended their own life. Further,
suicide is not normal. We live in a country where a certain degree of normality is required in order to fit in and be a part of
a whole society. Those who stray too far from the norm are out
casted, because the normal people, who compose a majority,
cannot easily identify with the others. As the Stanford Encyclopedia of Philosophy explains, the people in this “normal”
group have an “inability to directly occupy the mental world
of the suicidal.” (20) We just do not understand those who are
suicidal, thus we naturally fear them. Although we may not
look upon these people with esteem, we must recognize that
our distaste may be caused not by our perception of moral corruption or evil in the act but rather by our natural tendencies
to accept that which is normal and push aside that which we
do not understand. Further, physician assisted suicide is likely
entirely different from the idea conjured up when a normal
person thinks of just “suicide”. PAS is intricate, involving a
suffering patient whose condition is often so miserable that a
normal person might even be able to understand their choice
to end their misery. Anyways, those people who still would
not understand such a choice are looking in from the outside,
not experiencing and thus truly understanding the agony that
the patient feels. In each state where laws have been made in
America so far, specific provisions have been included which
limit PAS so that it may be used only by those patients who are
dying already and who are ready to make such fateful decisions.
Looking at physician assisted suicide as just “suicide” gives a
false impression that is unreasonably and unjustly biased.
Such is the case too when physician assisted suicide is
presented as killing or murder. Opponents of PAS believe that
the line must be drawn before we kill or murder anyone. In a
Wall Street Journal study in which doctors were asked whether
they were in favor of, or opposed to physician assisted suicide,
forty-one percent of doctors were opposed, citing a prominent
reason of “assisted suicide is murder.” (11) These words are especially piercing to us. When we hear them uttered, our minds
may jump to images of a burglar shooting an innocent father, or
the famed horror movie character “Freddy” slashing down his
next victim. The prospect of our own or our loved ones’ death
is perhaps the most frightening reality that humans know. So,
when we hear these words be used in the debate over physician
assisted suicide, we react in disapproval- perhaps thinking to
ourselves, “patients can resist treatment if they want, but killing
is just crossing the line.” The words killing and murder, however, may give us inaccurate ideas about what goes on in PAS.
Firstly, in PAS, the patient himself is the one who actually consumes the lethal drug. If the doctors who provide the patients
with the lethal drugs are considered to be killers or murderers,
then so should the cashiers at gun shops. Secondly, the classical ideas we naturally associate with killing and murder look
nothing like what actually happens in PAS. Once again, PAS
occurs in a controlled environment where the patient is experiencing real and unending suffering. The words killing and murder are the secret weapons of those who oppose PAS, because
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although they may be technically accurate, they cause people
to get worked up with ideas which look nothing like what occurs in PAS. Using the words in this way is a classic example of
“baloney” in Carl Sagan’s Baloney detection kit. (19) To give
physician assisted suicide a fair chance, we must recognize
and neglect these dirty tactics which provoke cognitive error.
Some people may argue that PAS is killing or murder because of their religion. The sacred text of Christianity,
the most prominent religion in America, denounces suicide as
a grave sin. From the book of Corinthians in the Holy Bible,
“What? Know ye not that your body is the template of the Holy
Ghost which is in you, which ye have of God, and ye are not your
own? For ye are bought with a price: therefore glorify God in
your body, and in your spirit, which are God’s.” (12) Christians
believe that the human body is the product and property of the
creator- God. For a person to take his or her own life is to destroy divine formations and to go against the will of God. Anyone has every right to believe this if they so choose. But does the
Bible hold the final word? Do we live in a society where religion
and rule are intertwined? In fact, we live in a country where
every citizen is equal and where church and state are separated.
Religions are belief systems, and beliefs held by one person are
equal to the beliefs of another. Suicide happens to be mentioned
in the Bible, but this should not serve to give one side of the debate leverage over the other. Such is consistent with the firmly
grounded ideals of equality and freedom of religion in America.
Truth can be discovered by examining our core American principles to determine if physician assisted suicide fits
in the picture. Civil rights and liberties are two hallmarks of
American political culture associated with the social contractthe idea that we as citizens give up some of our power so that a
government can create a safer, fairer world free of chaos. Civil
rights, expressed as the first ten amendments to the U.S. Constitution, exist because only with their guarantee would the final
states ratify the submitted Constitution- this was effectively part
of the deal of the social contract. Having just been oppressed by
the British government, Americans were very concerned about
the hazards of centralization and arbitrary rule and rightfully
demanded some guarantee of protection from the government
of certain fundamental “rights” that the government could
not lay a hand on. Since their introduction, these rights have
proven to be paramount parts of what it means to be Ameri-
can, as they have been taken into consideration when forming
public policy and been referred to constantly in court rulings
across America. A theme of non-arbitrary governmental rule
emerges form the ten individual rights. We as Americans want
to be self-determining. One matter that is extremely personal
and especially fitting in the category of “self-determination”
is the decision about the continuation or termination of one’s
own life. This is a matter that can be argued to cross the line established in our social contract, as government interference in
such a zone, it seems, would not be constrained within America’s set boundaries. In the words of philosopher Jean Jacques
Rousseau, “the social contract is such that every man has a right
to risk his own life in order to preserve it.” (23) This idea holds
that it is a man’s own choice to do with his body what he like,
as long as he acts in his what he determines to be his best interest. If this means ending his life, then it remains justified.
The issue could also be viewed from a different angle,
however, where the citizen agrees to sacrifice some of his power
for the betterment of society, and is limited by what the institution of authority stipulates as disallowed, as suicide may be on
the list of what is disallowed. John Locke and Thomas Hobbes
were two enlightened philosophers who believed that suicide
should be banned. In Leviathan, Hobbes wrote, “A law of nature, lex naturalis, is a precept, or general rule, found out by reason, by which a man is forbidden to do that which is destructive
of his life, or taketh away the means of preserving the same, and
to omit that by which he thinketh it may be best preserved” (10)
He believed it to be natural and right to do all that one can in
order to live, and immoral to desire to die. Hobbes and Locke
both justified their beliefs off of “natural law.” They may have
failed to make an accurate distinction between the processes in
human societies versus the rest of nature in the world. Humans
do not participate in many processes which are thought of as
“natural”, or existing in nature. We have the principle of a social
contract, which breeds government and man-made laws. This
serves to go against the chaos and selection processes which
would be “natural.” Humans, thus, are open to be in original
situations which deviate from classical “nature”, as we have the
power to modify the world around us. We thus continuously
develop and change our own “nature”. Locke and Hobbes did
not seem to recognize this concept in their published works.
Civil liberties are liberties guaranteed by the government which serve to protect people from other people. James
Madison, in Federalist number 10 of the Federalist Papers
writes of the “tyranny of the majority”, in which he warns that
a whim in a society can threaten those of the minority in disastrous ways. Because of this, he argues, a set of fundamental,
untouchable liberties should be guaranteed to each citizen so
that they may be given a chance to persist unharmed in midst
of a “faction united and actuated by some common impulse of
passion, or of interest, adverse to the rights of other citizens,
or to the permanent and aggregate interests of the community.” (8) Life, liberty, and property, he argued, should always
be safe and beyond reach. We may think of one’s own life as
being their ultimate property, yet a certain legal case views
things differently. In Washington vs. Glucksberg, although
the district court ruled oppositely, the Supreme Court ruled
unanimously that the right to be assisted in committing suicide was not protected by the “due process clause” of the fourteenth amendment. (24) Glucksberg’s argument was grounded
in this clause which forbade the government from “depriving
any person of life, liberty, or property, without due process of
law.” (21) The Supreme Court, however, responded that the
“’right’ to assistance in committing suicide is not a fundamental liberty interest.” Their argument held that assisted suicide
did not fall into the category of, “life, liberty, or property”.
Although we rightfully cherish our rights and liberties, Americans can also have the tendency sometimes to bow
down too much to tradition. The Hippocratic Oath is a major
influence on today’s medical ethics. The argument that PAS
would go completely against the Hippocratic Oath inspired vision of the doctor as the healer and life-giver is true, and brings
up the question of weighing ends versus means. The hole in this
argument, however, is that these ideas are derived from the bigger principle that the doctor exists and acts for the beneficence
of the patient. The overwhelming majority of the time, this beneficence involves promoting health and life. Yet in the small
amount of cases where patients actually believe that they would
be benefited by having their life taken, the beneficence involves
the opposite. In the Wall Street Journal study described previously, a common reason given in support of their response
by the forty-six percent of doctors who were in favor of PAS
was, “I’d want it for me when the need arises”. Also, in a Journal of the American Medical Association (JAMA) report, fiftynine percent of doctors surveyed in Oregon disagreed with a
statement that “writing a lethal prescription for a patient under the Death with Dignity Act [is] immoral and/or unethical.” (7) We must realize that the images conjured up in our
minds of doctors are caused by what the doctor does the majority of the time. Just because an exception to these images presents itself does not mean the doctor’s principle role has been
scathed, or even changed. In the end, the doctor is still acting
in the best interest of the patient- only the means changed. If
the means used stem from the patient’s own choice and action,
and the doctor’s utmost priority is to provide for the beneficence of his patient, then the ends seem to justify the means.
Another argument referencing the Hippocratic Oath
is caused by the fact that we tend to put it up on a pedestal
so that it sits above reach of anyone today, and every last line
becomes glorified. In the oath, the line, “I will not give a lethal
drug to anyone if I am asked, nor will I advise such a plan”, is
often used in the debate on physician assisted suicide. When we
hear this, however, we must remember that times change. The
overall theme may be forever, but some of the specifics written
about in ancient texts seem absurd in today’s world. The bible,
for example, bans divorce, yet between forty to sixty percent of
all new marriages in America today will end in divorce. (25)
Also, Hippocrates, in his famed oath wrote, “[I swear] to hold
him who has taught me this art as equal to my parents and to
live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as
equal to my brothers in male lineage”. These ideas are out of the
question today, as students and their teachers do not share such
close relationships. Hippocrates also wrote, “[I swear] to teach
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[my teacher’s offspring] this art–if they desire to learn it–without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons
of him who has instructed me and to pupils who have signed
the covenant and have taken the oath according to medical law,
but to no one else.” (16) Once again, this has no place in our
society today. What we can do, however, is take away an overall
theme such as, “I promise that when I am a skilled, knowledgeable, and experienced doctor, I will play my part in teaching
the next generation of young doctors”, we just cannot hang on
every word in the oath. The tradition of medical students reciting the Hippocratic Oath at their medical school graduations is
more to vow to be an ethical doctor than it is a promise to follow the every word of Hippocrates. Returning to the line used
to denounce PAS, we must understand that the situations that
some patients become stuck in today were not only inexistent,
but also unimaginable in the times of Hippocrates. Back then,
religion and policy were mingled unlike today, and medical
knowledge that now allows us to know when patients have a
terminal or other irreversible condition was inexistent. Also,
because of vast advances in medicine, patients rarely survived
long enough to be in the situations that suffering patients desiring PAS are in today. (13) This is why fifty-three percent of
respondents in the JAMA report, “would consider obtaining a
physician’s assistance to end their own lives.” If we can realize
that we see a different world than Hippocrates did, then we will
be able to abstain from making the error of being too attached
to our aged sacred texts and thus make the debate more rational.
The fact that we have entered a new kind of world may
not only suggest that we need to take a fresh look at old ideas,
but also suggest the inevitability of an associated necessary
change in policy. Throughout all of American history, changing times have called for changes in how we govern. When big
corporations began forming in America at the turn of the nineteenth century, progressivism emerged as we called upon Teddy
Roosevelt, the “trust buster” to regulate businesses in new ways
so as to maintain market competition that would otherwise be
adversely affected. The call for physician assisted suicide is due
to a changed world too. America is no longer dependent on religion for governance, more rational and empathetic about the
conditions of others, and more advanced and learned in medicine. This is why a new trend in changing PAS policy started in
1994 with Oregon’s “Death with Dignity” Act, why two more
states have since followed suit, why other states are currently
fighting to follow these examples, and why, in the JAMA study,
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“fourteen percent of physicians reported that they had become
more willing to prescribe a lethal medication since 1994.”
In the “Death with Dignity” laws passed so far, numerous stipulations are listed which are purposed at minimizing
the potential for abuse of PAS, such as the minimum age of
eighteen, and the fact that the patient must be deemed mentally competent and terminally ill. Nevertheless, any introduction of new power comes with new abuse even in the presence
of rules to prevent it, as risk can never be completely eliminated. The question, then, becomes: do the potential benefits
of PAS outweigh the potential costs in abuse? This question
can perhaps be explored by looking at other conventions in
the medical world which serve to benefit people yet are subject
to abuse by the doctors who employ them. Morphine, for example is extremely useful in relieving pain, and has allowed an
incredible amount of people worldwide to survive when they
would otherwise not be able to live with such degrees of pain.
The Journal of the American Medical Association, in a different
article on the history of pain management, describes morphine
as, “cheap, reliable, readily available, and with extensive documentation of efficacy—remains the mainstay of cancer pain
treatment today.” (15) It is also abused. Doctors can administer
lethal overdoses to patients. In fact, surveys from numerous institutions including Glasgow University’ Institute of Law and
Ethics in Medicine (14), and the Hospice Patients Alliance (17)
report that from around five to fifteen percent of different doctors in various hospitals admit to having already participated
in PAS. Other drugs and injections are used to “mercy kill” illegally in hospitals today as well. Potential for abuse lives everywhere in any given medical environment- risk is everywhere.
(18) From the U.S. 9th Circuit Court of Appeals, “recognition
of any right creates the possibility of abuse.” (5) In order to give
physician assisted suicide a fair chance, we must recognize this
while still doing all that we can reasonably do to minimize potential for abuse. If it is found that the costs of the abuse will
hurt people more than benefits of the proper use, then PAS
should not be allowed; if the reverse is true, then it should.
Since physician assisted suicide is legal in three states
already, we can observe how it has been running within them
to give us a solid clue about how it will run elsewhere. According to the Journal of the American Medical Association study
on Oregon doctors, “among the [59% of] physicians who were
not morally opposed to writing a lethal prescription, 58% were
at least “a little” concerned about being labeled a ‘Kevorkian’ if
they wrote a lethal prescription, 82% were concerned that writ-
ing a lethal prescription might violate federal Drug Enforcement Agency law, and 65% were concerned that their hospital
might sanction them.” The doctors seemed to be easing into
the change with caution. Less than thirty of the ten thousand
deaths in Oregon in 1999 were due to physician assisted suicide. There seemed to be little harmful costs from abuse of physician assisted suicide. Benefits, on the other hand, were visible.
Besides the few patients who actually took advantage of PAS
by ending their lives, its legalization served as a sort of wake
up call to improve care for terminally ill Oregonians. A telling
sign of this is that, “in 1994, 22% of all deaths in Oregon occurred in persons enrolled in hospice; by 1999, the proportion
had increased to 35%.” The fact that community hospice did
not significantly expand in the years in between suggests that
awareness among physicians of these services increased. Benefits seem to outweigh costs by a substantial margin in Oregon,
so we can predict with a certain degree of confidence that this
will be the case in other areas in America if PAS is legalized.
The point about costs versus benefits is tied to the
argument about the “slippery slope” we could fumble down if
we decide to take the first step of legalizing PAS. We have the
capability to make such arguments for almost anything newwhat separates the legitimate arguments from the “baloney”,
however, is solid evidence, as emphasized in Argumentation:
The Study of Effective Reasoning, 2nd Edition. (26) Dr. Herbert
Hendin, professor in the Department of Psychiatry and Behavioral Sciences at New York Medical College, points out some
evidence: “Over the past two decades, Dutch law and Dutch
medicine have evolved from accepting assisted suicide to accepting euthanasia, and from euthanasia for terminally ill patients to euthanasia for chronically ill individuals.” (9) If we
accept that this could occur in America as well, then we must
move on to question whether the effects of the slippery slope
are positive or negative. Some may argue that the effects are
positive, as they make physician assisted suicide more available
for suffering patients, while others may feel that allowing euthanasia is crossing the line, as it involves the direct “killing”
of a patient by a doctor. America in particular may be especially fearful of euthanasia, as the word triggers memories of
Jack Kevorkian, who was given a bad rap. Sometimes, because
of their condition, patients are unable to administer the lethal
drugs to themselves, so euthanasia could ensure that all patients have access to the opportunity to end their lives. On the
other hand, the doctor himself administering the drug introduces a whole new set of edgy ethical questions, as those who
stand behind the argument of the “slippery slope” may argue.
Some of the debate on physician assisted suicide is,
like parts of any debate, covered in baloney. On a whole, however, the arguments against PAS seemed to be covered in more
depth than the arguments for PAS. Throwing out the words
“killing” and “murder” clouds the rational thinking which is
necessary to discover truth in any debate, and paints a picture
of PAS which is a poor representation of the situations and occurrences associated with PAS. Categorizing PAS as just “suicide” does the same. When we look at what really happens in
physician assisted suicide, we find a suffering patient making
an extremely difficult and intricate decision about his own fate.
These situations are made possible by a changed world, where
old ideas and philosophies may no longer have places. We look
instead to what it means to be an American Citizen. Our civil
rights and liberties give us a certain degree of personal freedom so that we may make of ourselves what we choose. As
we are generally able to determine our own lifestyles as long
as they do not come to harm society, then it seems we should
be able to make the choice of physician assisted suicide, as it
directly regards solely our own lives, and does not serve to
blemish others in society. Although those who are of religions
denouncing any form of suicide may claim otherwise, they
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must learn to live with it, as their beliefs are merely beliefs with
no clout over policy. We increasingly live in a world based off
of progression, knowledge, and reason. Soon, we will realize
that it is time for physician assisted suicide to be legalized.
REFERENCES
1. “AMA - Opinion 2.21 - Euthanasia.” The United Statesn
Medical Association - Physicians, Medical Students & Patients
(AMA). N.p., n.d. Web. 23 Nov. 2010. <http://www.ama-assn.
org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion221.shtml>.
2. “amednews: Physician-assisted suicide legal in Montana,
court rules :: Jan. 18, 2010 ... The United States Medical News.”
The United States Medical Association - Physicians, Medical
Students & Patients (AMA). N.p., n.d. Web. 24 Nov. 2010.
3. “CEJA Report B – A-91 Decisions Near the End of Life.”
American Medical Association. N.p., n.d. Web. 23 Nov. 2010.
4. “Chapter 127 — Powers of Attorney; Advance Directives for
Health Care; Physician Orders for Life-Sustaining Treatment
Registry; Declarations for Mental Health Treatment; Death
with Dignity.” Oregon State Legislature. N.p., n.d. Web. 22 Nov.
2010. <www.leg.state.or.us/ors/127.html>.
5. COMPASSION IN DYING v WASHINGTON. US Court of
Appeals. 6 Mar. 1996.PubMed. Web. <http://www.ncbi.nlm.nih.
gov/pubmed/11648417>.
6. “Euthanasia and Assisted Suicide.” Personal Websites - Office
of Information Resources and Technology. N.p., n.d. Web. 23
Nov. 2010. <http://www.pages.drexel.edu/~cp28/euth1.htm>.
7. Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA,
Delorit MA. Oregon physicians’ attitudes about and experiences with end-of-life care since passage of the Oregon Death
with Dignity Act. JAMA. 2001;285(18):2363-2369.
8. Hamilton, Alexander, James Madison, and John Jay. The Federalist papers; Alexander Hamilton, James Madison, John Jay..
New York: New The United Statesn Library, 1961. Print.
9. Herbert Hendin, The Slippery Slope: The Dutch Example, 35
DUQ. L. REV. 427 (1996)
10. Hobbes, Thomas, and J. C. A. Gaskin. Leviathan . Oxford :
Oxford University Press, 1998. Print.
11. Hobson, Katherine. “ What Doctors Think About Assisted
Suicide, Romance With Patients and Organ-Selling - Health
Blog - WSJ.” WSJ Blogs - WSJ. N.p., n.d. Web. 22 Nov. 2010.
<http://blogs.wsj.com/health/2010/11/11/what-doctors-thinkabout-assisted-suicide-romance-with-patients-and-organselling/>.
12. Holy Bible King James Version, Life Application Study
Bible. Wheaton: Tyndale House Publishers, Inc., 1997. Print.
13. “InternationalTaskForce.org - Frequently Asked Questions.”
InternationalTaskForce.org -- Home Page. N.p., n.d. Web. 24
Nov. 2010. <http://www.internationaltaskforce.org/faq.htm>.
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14. McLean, Sheila, and Alison Britton. Sometimes a Small Victory. Glasgow: Institute of Law and Ethics in Medicine, University of Glasgow, 1996. Print.
15. Meldrum, M. L. “A Capsule History of Pain Management.”
JAMA: The Journal of the American Medical Association 290.18
(2003): 2470-475. Print.
16. “NOVA | Doctors’ Diaries | The Hippocratic Oath: Classical Version | PBS.” PBS: Public Broadcasting Service. N.p., n.d.
Web. 25 Nov. 2010. <http://www.pbs.org/wgbh/nova/doctors/
oath_classical.html>.
17. Panzer, Ron. “When Will Prosecutors Understand that Terminally Ill Patients have been Murdered Before Their Time?.”
Hospice Patients Alliance: Patient Advocates. N.p., n.d. Web. 24
Nov. 2010. <http://www.hospicepatients.org/when-will-prosecutors-act.html>.
18. “Risk Quantification.” University of Illinois at UrbanaChampaign. N.p., n.d. Web. 24 Nov. 2010. <https://netfiles.
uiuc.edu/mragheb/www/NPRE%20457%20CSE%20462%20
Safety%20Analysis%20of%20Nuclear%20Reactor%20Systems/
Risk%20Quantification.pdf>.
19. Sagan, Carl. The demon-haunted world: science as a candle
in the dark. New York: Random House, 1996. Print.
20. “Suicide (Stanford Encyclopedia of Philosophy).” Stanford
Encyclopedia of Philosophy. N.p., n.d. Web. 27 Nov. 2010.
<http://plato.stanford.edu/entries/suicide/>.
21. “The Constitution of the United States of The United States.”
GPO Access Home Page. N.p., n.d. Web. 23 Nov. 2010. <http://
www.gpoaccess.gov/constitution/html/amdt4.html>.
22. “The Kevorkian Verdict.” pbs.org. N.p., n.d. Web. 26 Nov.
2010. <www.pbs.org/wgbh/pages/frontline/kevorkian/>.
23. “The Social Contract or Principles of Political Right by Jean
Jacques Rousseau: 5. The Right of Life and Death.” The Literature Network: Online classic literature, poems, and quotes.
Essays & Summaries. N.p., n.d. Web. 22 Nov. 2010. <http://
www.online-literature.com/rousseau/social-contract-or-principles-/16/>.
24. “Washington v. Glucksberg.” LII | Legal Information
Institute at Cornell Law School. N.p., n.d. Web. 24 Nov. 2010.
<http://www.law.cornell.edu/supct/html/historics/USSC_
CR_0521_0702_ZS.htm
25. Williams, Brian K., Stacey C. Sawyer, and Carl Wahlstrom.
Marriages, families, and intimate relationships: a practical
introduction. Boston, MA: Allyn and Bacon, 2006. Print.
26. Zarefsky, David. Argumentation: the study of effective reasoning. 2nd ed. Chantilly, VA: Teaching Co., 2005. Print.
About the Author
Ben Mormann is a biology major and aspiring physician/scientist in the Presidential Honors Scholars program
of the College of Arts and Sciences. He is a recent recipient of the Chair’s Award in Biology, and the Dean’s Undergraduate Research Grant. Ben enjoys working in Dr. Desplan’s lab, where he uses the fruit fly as a model to study color vision.
He works closely with the manager of the Ambulatory Surgery Center at the NYU Hospital for Joint Diseases to improve
methods of hospital communication, information logging, and both patient and employee education. In addition, he
makes presentations for the hospital which are used in various capacities. He starts on the NYU men’s water polo team
and composes music with his band back in his home state of Maryland.
Help Them to Help Us:
Why Sustaining Certain Plant
Species is Incumbent on Us
By Gregory Rubinfeld
“No disease in history has caused more deaths than malaria and as a result the medical utility of the Cinchona tree is virtually immeasurable.”
Despite our understanding of the vast benefits plants
bring us, including the many salves and medicines they provide, we are exploiting particular species in certain areas by
overharvesting them. If we continue to overharvest in a careless fashion we may ultimately deplete these species. Plants
are not only a current staple of the medical world but are
also a veritable treasure chest of undiscovered medicines and
therapeutic substances. This immense boon for healthcare
can experience a decline if we do not take greater care in our
treatment and harvesting of the medically useful plants. In
this article we discuss a few plants that are of particular interest in the medical field, explore how they are medically
useful, and consider methods for sustaining these plants.
The first plant that will be introduced, the Cinchona
tree, provided us with the primary treatment to the most debilitating disease in human history. The second plants, Voodoo Lilies and Willows, are of particular interest for their intriguing chemical mechanism of action. The third plant that
will be explored, the Madagascar Periwinkle, has incredible
documented results in its various treatments of a wide array
of illnesses. The fourth plant, the African Cherry tree, functions in a detailed gene regulation that results in its ability to
combat cancer cells. The final plant type that is discussed, the
medically useful pulses, introduces a method of sustainability that benefits us while simultaneously benefitting plants.
Since the seventeenth century, extracts from the
bark of the Cinchona tree called quinine have been used to
treat malaria (Griggs et al 2011, page 19). No disease in history has caused more deaths than malaria and as a result the
medical utility of the Cinchona tree is virtually immeasurable.
The ringed structure of quinine effectively combats malaria
by inserting itself into the DNA of the parasite and disrupting replication and transcription (Lexi-Comp 2009). In order
to reduce the amount of Cinchona trees harmed by the extraction of quinine, scientists have synthesized artificial drugs to
work like quinine in order to combat malaria. Unfortunately,
malarial parasites are developing resistance to the artificial
treatments. As a result, doctors are being forced to use natural quinine and the Cinchona trees are being exploited consistently. Consequently, the number of trees in South America
has experienced a marked decline (Griggs et al 2011, page 19).
In an effort to preserve these plants, many organizations have
worked to disperse and grow the trees in many environments.
The British and Dutch established plantations by using Kew
Royal Botanical Gardens as a resource to send seeds to India
and Sri Lanka (Griggs et al 2011, page 19). Even now, scientists
“Because 53 tons of the plant produces only 100 grams
of medically useful drugs, the plant needs extra
protection from the risk of overharvesting.”
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at the Kew Royal Botanical Gardens are experimenting with
chemicals from other plants to find alternative means of treating malaria and reduce our exploitation of the Cinchona trees.
Another plant of medical intrigue is the Voodoo Lily.
The Voodoo Lily contains a hormone known as salicylic acid,
a molecule renowned for its uses in pain relief. Salicylic acid,
in its acetylated form, inhibits the production of prostaglandin
cyclooxygenase, an enzyme that is needed to make prostaglandins. The prostaglandins are molecules that aid in the transmission of pain signals across neural synapses (Jones and Fleming,
2010, page 838). Without the prostaglandins, the pain transmission is effectively blocked. A relative of salicylic acid, a substance called salicin, is found in willow bark (Griggs et al 2011,
page 20). Both Voodoo Lilies and willows have provided scientists with the foundation to create a synthetic pain reliever similar to their salicylic acid and salicin. (Griggs et al 2011, page 20).
That molecule is now known as aspirin. By experimenting in
laboratories to find ways to synthesize similar drugs to the ones
found in the Voodoo Lily and willows, we have not only used
Madagascar Periwinkle
the plants to help us create medical drugs, but also found a way
to obtain the same treatment without having to harm the plants.
Perhaps the most important plant in modern medicine is the Madagascar Periwinkle. The Madagascar Periwinkle
contains over 70 different alkaloids and treats a vast array of
illnesses (Duke 2000). The main alkaloids produced are vinblastine and vincristine. Vinblastine and vincristine act against
cancers by introducing a growth inhibition effect on the cancer
cells that would otherwise grow uncontrollably (Duke 2000).
These two chemicals have revolutionized areas of medicine and
brought about staggering results in the treatment of certain dis-
“To date, the current synthetic vincristine is only about
20% as effective as the natural vincristine from the
Madagascar Periwinkle”.
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eases. The two chemicals, when combined with chemotherapy,
have resulted in 80% remission in Hodgkin’s disease, 99% remission in acute lymphocitic leukemia, 80% remission in Wilm’s
tumor, 70% remission in gestational choricarcinoma, and 50%
remission in Burkitt’s lymphoma (Duke 2000). Because these
“Cherry bark extract significantly suppresses betacatenin transcriptional activity, thus effectively inhibiting
the propagation of colorectal cancer cells.”
plants are so extraordinarily useful in medicine the continued
harvesting of the Madagascar Periwinkle may put them in serious danger of being rapidly depleted. Furthermore, because 53
tons of the plant produces only 100 grams of medically useful
drugs, the plant needs extra protection from the risk of overharvesting (Griggs et al 2011, page 20). In an effort to lessen our
need to harvest the plants in such large quantities for medicines,
much research has been done to synthesize the Madagascar
Periwinkle’s chemicals in the laboratories. To date, the current
synthetic vincristine is only about 20% as effective as the natural vincristine from the Madagascar Periwinkle (Duke 2000).
Finding a careful balance to benefit from a plant’s
medicinal value without decimating the population of certain
species proves to be difficult at times. As a particular case in
point, overharvesting of the African Cherry tree for its drug
potential against cancer is becoming an increasing concern. In
fact, the African Cherry tree has become Africa’s most intensively exported medicinal plant item by volume (Ogutu 2006).
The extracts of the tree combats cancer by manipulating specific transcriptional activity, gene regulation and the inducing of apoptosis. The transcription factor known as β-catenin
promotes expression of several genes such as cyclin D1, which
is essential to the development and progression of colorectal
tumorigenesis. Cherry bark extract significantly suppresses
β-catenin transcriptional activity, thus effectively inhibiting the
propagation of colorectal cancer cells. Furthermore, the bark
extracts induces apoptosis in prostate cancer cells by increasing the expression of the NAG-1 gene. The cherry bark extract
trans-activates the NAG-1 promoter, which in turn increases
the expression of the NAG-1 gene which then increases the
production of the NAG-1 protein. This protein induces apoptosis, signaled cell-death, in certain cancer cells (Yamaguchi and
Liggett 2006). With the increase in demand for the medically potent bark, the tree is being overharvested and the survival of entire populations is being threatened (Griggs et al 2011, page 20).
Protecting plants of medical utility is by extension a
method of protecting ourselves by keeping sources of cures and
treatments within existence. The Tailed Pepper plant is a good
example of people helping the plants to better help themselves.
The plant is used to relieve fever, asthma sunstroke, rheumatism,
genitourinary infections, a variety of intestinal disorders and
much more (Griggs et al 2011, page 26). In order to mitigate the
amount of the plant being harvested, Asian countries stopped
using the plants for spices and now use it only for medicine
(Griggs et al 2011, page 26). By harvesting the plant for strictly
medical purposes, a greater degree of care and discretion s being
shown in the treatment of these plants. This method may seem
to be inconvenient for farmers who wish to turn greater profits
or for scientists and doctors that wish to have an endless supply of effective drugs to study and prescribe. However, in other
cases, methods for sustainability do not involve a compromise
but are rather beneficial in practice as well as in their outcomes.
By planting more Liquorice plants and Bredsoy plants, we
can increase the soil fertility for other plants while benefitting
from the medical utility of Liquorice and Bredsoy themselves.
Liqourice and Bredsoy are Pulses, or edible legumes,
that have special bacteria in their roots that fix the nitrogen in
soil and make it available for other plants (Griggs et al 2011,
page 30). These plants are not only good for increasing soil
fertility and benefitting other plants in their proximity but
are also medically useful in their own right. Bredsoy contains
various essential amino acids and is used as a treatment to
protein malnutrition (Griggs et al 2011, page 31). Liquorice
has been used in both Eastern and Western medicine to treat
a variety of illnesses including the common cold, liver disease,
and respiratory tract infections (Ehrlich 2010). By increasing the growth of these plants we are not only continuing to
provide ourselves with medical caches but are also promoting the growth of other plants by making the soil more fertile.
Though some methods of preserving medically useful plants may seem to call for restraint and the reduction of
harvesting, these efforts are well worth the outcome of the sustained plants species. By helping to sustain the medically useful
plants by manual seed dispersal, creating reserves, synthesizing
alternatives to the chemicals they contain, or simply minimizing the amount of harvesting, we are ensuring the survival of
species that provide us with treatments for many different medical ailments. Alternatively, if we show no restraint and harvest
the plants to gather an excess of medical drugs immediately, we
may come to exhaust invaluable resources that can treat many
diseases now, and, in all likelihood, even more in the future.
REFERENCES
Duke, James A., and James A. Duke. Handbook of Medicinal
Herbs. Boca Raton, FL: CRC, 2002. Print.
Griggs, Patricia, Hew D. V. Prendergast, and Naomi Rumball.
Plants + People: An Exhibition of Items from the Economic
Botany Collections in Museum No. 1. London: Royal Botanic
Gardens, 2000. Print.
Jones, Maitland, and Steven A. Fleming. Organic Chemistry.
New York: Norton, 2010. Print.
“Licorice.” University of Maryland Medical Center. Web. 17 Mar.
2012. <http://www.umm.edu/altmed/articles/licorice-000262.
htm>.
Ogutu, Evelyne. “Campaign to Save Threatened African Tree.”
East African Standard (2006). Web.
Photograph. Madasgascar Periwinkle Plant (See By Seeing).
Web. <http://farm4.staticflickr.com/3367/3635337209_41ab228
9be_z.jpg>
“QuiNINE: Drug Information Provided by Lexi-Comp: Merck
Manual Professional.” THE MERCK MANUALS. July 2010.
Web. 16 Mar. 2012. <http://www.merckmanuals.com/professional/lexicomp/quinine.html>.
About the Author
Gregory Rubinfeld is a junior, majoring in English and pursuing a career in medicine. He is spending the upcoming summer in South Africa tracking and working with Great White Sharks. Greg aspires to be a pediatric surgeon and a
novelist. In his free time, he enjoys snowboarding, deep-sea diving, ice-hockey, and writing.
Volume 10
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Min
Min
Wresting Power Into the Hands
of Patients
By Jung-Yun Min
Perhaps it is the very notion of the overhanging
gloom of death that forces the majority of people to think
conservatively, as it is undeniable that every disease has had
its minority scapegoat. Throughout United States history,
the threat of smallpox had the Chinese, the threat of typhoid
had Irish immigrants, and the threat of HIV, had the homosexual community. Despite the initial naming of HIV as
Gay-Related Immune Deficiency (GRID) by mass media, the
homosexual community would appropriate the framing of
HIV/AIDS. Led by the middle class gay elite, the community would galvanize to form a political identity and challenge
the Food and Drug Administration’s regulation of testing
of new drugs thereby changing the doctor-patient relationship in the U.S. This uniquely developed and morally driven
model of care would inspire future health movements, and lead
to the recognition of HIV/AIDS as the pandemic it truly is.
The medicalization of the socio-cultural proclivities
of a very visual, sexually promiscuous group of homosexuals in the early 1980’s was the mechanism of attaching HIV/
AIDS to the gay community. Although homosexuality was
prevalent arguably throughout history, the incidence in 1981 of
rare, opportunistic infections resulted in Pneumocystis pneumonia (PCP) and Karposi’s sarcoma, a rare form of cancer
usually found in elderly men, in relatively young homosexual
and sexually active males. In 1982, the New England Journal of
Medicine associated the outbreak of PCP with the white male,
“fast lane” homosexual lifestyle, despite the Centers for Disease
Control and Prevention’s (CDC) task force finding that 8% of
159 cases were among heterosexuals, one of whom was a woman. The initial framing of HIV and AIDS would further ignore
these other cases until the late 1980’s and early 1990’s. Despite
the cornerstone of contemporary biomedicine, the principle
of “one disease, one cause, one cure, ”the medical community was accepting of the immune overload hypothesis which
stated that promiscuous men would constantly contract venereal diseases and take harmful drugs to combat them, severely
compromising their immune systems (Epstein 57). Amyl and
butyl nitrite inhalants, also known as poppers, used to intensify
orgasms, were also proposed as etiology despite no odd cases
of PCP or Karposi’s sarcoma. Perhaps the lifestyle of a very visual, although non-representative group of young men posed
as a perversion to the “heterosexist and sex-phobic institution
[of medicine] that reinforced sexual conformity” and obsessively captured the medical community (Epstein 54). After
all, there was a history of the medicalization of homosexuality
in the field of psychiatry; in 1973, the American Psychologi-
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cal Association (APA) removed homosexuality from its Diagnostic and Statistical Manual of Mental Disorders (DSM) but
replaced it with “ego-dystonic homosexuality” in its third edition in 1980. This term was later removed in the revision in
1987. Aliases and phrases such as “gay bowl syndrome,” “the
gay cancer,” “homosexuality as a risk factor,” and “homosexual
hazard,” combined with propagation by the media of sensationalist images of AIDS patients, served to further establish
the perceived legitimacy of the immune overload hypothesis.
“Perhaps the lifestyle of a very visual, although non-representative group of young men posed as a perversion to
the “heterosexist and sex-phobic institution [of medicine]
that reinforced sexual conformity” and obsessively captured the medical community.”
In July 1983, the CDC reported further cases of Karposi’s sarcoma among Haitians living in the U.S,; none reported a gay lifestyle. In August, the CDC reported two cases of
PCP among hemophiliacs, one of whom was an infant. This
suggested that the etiology of the disease was a viral bloodborne pathogen. However, many proponents of the immune
overload theory persisted, notably Dr. Joseph Sonnabend and
his patients Callen and Berkowitz. They claimed that “deep
down, we know who we are and we know why we’re sick.”
In an odd twist of reasoning, Dr. Sonnabend was concerned
that the gay community could come under attack for spreading the disease and suggested an end to promiscuity. However,
many members of the gay community preferred a viral etiology due to accusations from “various right-wing spokespersons of pursuing a ‘promiscuous’ lifestyle that was in reality
a deathstyle” (Epstein 95). Rejecting sexual freedom that was
essential for a gay identity at the time, which could be interpreted as an admission of wrong-doing, would only lead to a
rise in cases of antigay discrimination in housing, healthcare,
and the workplace. Thus, many individuals turned to science.
HIV is in itself a very interesting virus. By attaching to the CD4 and CCR5 of the host cell via the gp120 receptor, HIV1 enters through endocytosis and inserts its RNA
into the cell. It avoids destruction from the body due to its
high mutation rate, and the fact that its glycoproteins are not
immediately distinguishable from the proteins of the body’s
own cells. There is also recent evidence that if CCR5 receptors are saturated, CCR4 is used by the retrovirus as a docking
site. By use of reverse transcriptase, a complementary strand
of DNA is created and inserted into the DNA of the host cell.
Figure 1
HIV effectively destroys most of CD4+ T helper cells, resulting in a severe decline in the differentiation to B cells. Patients
who then develop AIDS often die of secondary, opportunistic
infections. That HIV was the cause itself, and not an opportunistic virus was not clear until the mid-1980’s. However, in
that short period of debate, Duesberg had caused much damage in influencing AIDS Denialists. He raised much doubt in
pointing out that funding concerns would prevent scientists
studying AIDS from raising questions that HIV caused AIDS,
and how Gallo the “cofounder” as well as the U.S. government
stood to gain much that basis (Epstein 113): the US Government had filed the patent for the commercial antibody test for
HIV even before Gallo’s findings had undergone peer revision.
The upper middle class gay men affluent in Los Angeles and New York also held a role in linking HIV/AIDS to homosexual behavior. However, in doing so, they usurped power
from those who had little at stake in the framing of the disease
and its treatment. Many being physicians, lawyers and activists
themselves, they almost willingly played scapegoats and advocated the public to “be your own expert.” This was in contrast to
the African American response to HIV/AIDS that very much
associated the infection with individual responsibility, and marginalized HIV positive members. Groups such as “ACT UP” and
“Project Inform” placed considerable pressure on the FDA even
when the Reagan would not publicly recognize HIV/AIDS until
the beginning of his second term. With the infection’s increasing
prevalence and the absolute death sentence that came after diagnosis of AIDS, clinical trials became a way to get medication.
Due to the passage of the Kefauver-Harris amendment
in 1962 to the Pure Food and Drug Act in 1906, prompted by the
finding that thalidomide caused birth defects, drug regulation
was very slow and bureaucratic (Epstein 185). A drug had to pass
three phases in order to be approved for widespread commercial use that incorporated larger and larger samples and length-
ier double blind studies with a control placebo group. Although
the use of control groups was the gold standard for proof of
efficacy, this ran counter to the wishes of HIV positive patients
wanting to receive treatment. Having a defined, integrated social group, there was a danger of widespread, group-sanctioned
patient noncompliance: rumors spread that participants were
pooling together drugs so that those in the control group could
get some dosage of medication, and that participants were taking their medication to chemists to see if they had the placebo.
There was also an increase of medical tourism notably by Rock
Hudson who traveled to outside of the US to France for access
to HPA-23, a proposed but ultimately ineffective treatment, at
the time not approved by the FDA. Martin Delaney was also
noted to buy ribovirin in Mexico and give it out to doctors.
Figure 2
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Min
Min
“Although the use of control groups was the gold standard
for proof of efficacy, this ran counter to the wishes of HIV
positive patients wanting to receive treatment.”
Due to negative publicity, the FDA relented somewhat in permitting HPA-23 and other antiviral AIDS drugs
on a “compassionate use” basis and sped up the phase trial
periods for azidothymine (AZT). When Samuel Broder of the
NCI called for University and private scientists to send for any
chemicals that could be used for treatment, Burroughs Wellcome sent AZT, which had been developed twenty years prior
but proven ineffective for cancer treatment. It turned out to be
the most effective drug for HIV/AIDS in 1985. AZT is a reverse transcription inhibitor with strong antiviral activity. Although provided free due to the pressure of activists during its
trial, when AZT was approved by the FDA that was no longer
the case. At a cost of $8,000 to $10,000 a year, it was out of
reach to those without premium health insurance. The company refused to disclose its profit margins for AZT despite the
fact that its development had been funded by federal funds
decades earlier. In 1993, it was found to be highly toxic and
posed a great risk in its ability to cross the blood-brain barrier.
Another group, ATN, circulated a newsletter that
provided the latest information on new drugs and alternative
therapies in such an efficient way that researchers, clinicians
and patients would often simultaneously receive information
(Epstein 194). Already experts in prevention strategies, antibody testing, and antidiscrimination legislation, activists also
further sought to break down barriers between the FDA and
medical researchers. The Community Research Initiative (CRI)
invited patients to participate in the decision making of which
trials it should conduct and the ethics of placebo use. The CRI
was also open to women, deviating from the norm of the white,
homosexual male in HIV/AIDS dialogue. Due to faster trial
systems, various companies held contracts with CRI. In 1989,
after the FDA examined data from the CCC and CRI, it approved aerosolized pentamidine for prophylactic use against
PCP. This was the first time in history that the FDA approved
a drug based on community data (Epstein 218). Due to even
more pressure by “ACT UP” in 1988, the FDA permitted the
import of unapproved AIDS drugs for personal use. Activists
had circumvented much of BigPharma’s earlier attempts to
capitalize on the human loss by debating ethics in science and
protesting the FDA. These actions grounded the epidemic in
a humanistic stance. In 1987, Jesse Helmes, a Republican US
Senator from North Carolina, stated “there is not one single
case of AIDS in this country that can not be traced in origin
to sodomy.” However, by the mid 2000’s he had come to accept
AIDS/HIV, at least in international cases, as a Christian issue.
Since the mid-1990’s, a new viral drug cocktail developed by David Ho allowed for a new generation of HIV positive patients to say “HIV as you know it and HIV as I know
it.” A diagnosis of HIV was no longer a death sentence in the
United States (at least to those who could afford it). By 1993,
via the NIH Revitalization Act which required testing of women and people of color, there was recognition that AIDS/HIV
was not only a white male infection. One may say that affluent gay white men had “hijacked” the disease. However, the
movement proved that grass roots organizations could challenge a national regulatory board, and grounded the disease
in a moral basis, changing the role of the patient in medicine.
In 2010, there were approximately 34 million people living
with HIV and since its discovery, more than 25 million have
died of AIDS (WHO). There is still a sense of AIDS Denialism in Russia, India and China although efforts in the past
decade have served to get governments to respond to the care
of its citizens for global stability and welfare. The issue is that
the disease is still largely framed as persisting in the social
“degenerates:” the IV drug users, the prostitutes, and the gay
communities in other countries. It cannot be said that the initial galvanization will come from the upper middle class gay
community as it did in the US given different socio-cultural
and political environment of those countries. There are also
issues of distribution of medication especially in underdeveloped countries due to a dearth of storage facilities and infrastructure. Misinformation also persists on HIV/AIDS, as well
as interests from conservative Christian groups who advocate
abstinence instead of condom use. However, what can be said
of the homosexual community’s usurpation of HIV/AIDS is
that morality in the form of economic and social justice drives
the continuing research and the need to address the epidemic.
Rowland, Teisha. “Potential of Stem Cells to Cure HIV.”
All Things Stem Cell. Web. <http://www.allthingsstemcell.
com/2009/03/stem-cells-cure-hiv/>
“Silence=Death” Poster. Digital image. Queer Cultural Center.
1986. Web. <http://www.queerculturalcenter.org/Media/AidsDemo/silence2.jpg>.
“Watch Online | The Age Of Aids | FRONTLINE | PBS.” PBS:
Public Broadcasting Service. Web. 7 Dec. 2011. <http://www.pbs.
org/wgbh/pages/frontline/aids/view/>.
World Health Organization (WHO). “HIV/AIDS Fact sheet.”
World Health Organization Media centre. Web. 1 Apr. 2012.
<www.who.int/mediacentre/factsheets/fs360/en/index.html>.
REFERENCES
Epstein, Steven. Impure science: AIDS, activism, and the politics of
knowledge. Berkeley: University of California Press, 1996. Print.
About the Author
Jung-Yun Min is a junior in The Gallatin School of Individualized Study. Her stated concentration is the Neural
and Social Basis of Racism and Fear, although this is slowly changing into the Social Construction of Biological Race. It’ll
probably continue to change, perhaps into something else entirely, and she loves it and also hates it for the anxiety it produces. After Gallatin, she hopes to attend medical school and work in underserved communities. Outside of school, lab,
and volunteering, she eats cupcakes with tea and watches way too many television comedies.
Figure 3
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Volume 10
MEDICAL DIALOGUE REVIEW
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Dell’Aquila
Dell’Aquila
Revolutions in Neuroscience:
Improving the Mind in Health
and Disease
By Kevin Dell’Aquila
“By combining the potency of plasticity with nascent nanotechnology, the
potential for the reversibility of disease can spill over even to the possibility of enhancement of healthy nervous systems.”
Science fiction generally precedes reality. In the time of
H.G. Wells, perhaps no one truly believed that Wells’ vision of a
palm-sized, flat square with a moving and audible image (i.e. a
19th century video iPod) in “The Sleeper Awakes,” would emerge
only 100 years later.8 Yet the exponential rate of scientific development has perhaps caught up with the speed of imagination.
The once distant world of cyborgs, synthetic life, and virtual
reality pervades the present. Science continues to develop previously unimaginable ideas like a human brain that can link
itself to the Internet and even remotely control physical objects
via electrical communication5. It is now self-evident that technological advances will have, and is having, an unparalleled effect on medicine as well as on how we approach the improvement of both diseased and healthy physiological functions.
One especially salient example of this in medicine, inherently fraught with controversy, would be the development
in neurology due to rapidly expanding understandings of neuroscience and applicable technology. A now outdated maxim
for most neurological diseases, such as Alzheimer’s or multiple
sclerosis, was that the chance of recovery is slim to nonexistent,
due to the incorrect conviction that neural regeneration is impossible. However, due to many breakthroughs with therapies
such as stem cell grafting, gene manipulation, and nanotechnology, we are now seeing the maxim to be a thing of the past.
One of the most important findings leading to the
new hope for neurology was the discovery that the brain is a
more plastic (structural changes provoked by external stimuli
later in life) organ than anyone could have anticipated, and
that adult neural stem cells can remain dormant or stimulated to grow, throughout life. 2 By combining the potency of
plasticity with nascent nanotechnology, the potential for the
reversibility of disease can spill over even to the possibility of
enhancement of healthy nervous systems. Studies are already
being done assessing the viability of an electro-neural interface that could “enhance the capability of the human brain by
providing instantaneous access to information, increase external or internal memory storage, and increase mathemati-
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Spring 2012
cal capabilities”.5 Any human equipped with these intellectually enhancing mechanisms would clearly have powerful
advantages in today’s merit-based society, advantages especially over those without the same electro-neural interfaces
(the implications of which will be discussed later). Despite
the power nanotechnology might have one day, other more
practical and promising avenues to improvement in neurology include manipulation of biology rather than machinery.
One of the more feasible and popular biological possibilities for neural repair is gene therapy. The controversy behind gene therapy is the use of either adult stem cells or embryonic stem cells, which are manipulated by turning target genes
on or off and then are stimulated to divide. This gene therapy
can be induced either in vivo—directing a curative plasmid
that stimulates growth directly into the adult stem cell of host,
or ex vivo—modifying of stem cells in a culture, then grafting
the modified cells back into the host to divide. Generally the ex
vivo method is more stable than in vivo. And within the ex vivo
method, using embryonic stem cells would be more stable than
adult stem cells, because embryonic cells haven’t yet lost any
differentiation capacity (unlike adult stem cells).3 The problem
with this, however, is that using frozen human embryonic tissue is an understandably disturbing prospect to many people.
It is beneficial then that growth induction techniques for adult
stem cells have improved,3 because it perhaps removes the
need for and controversy of embryonic stem cells altogether.
Using adult stem cells cultured from the host also includes the
added benefit of reducing the risk of autoimmune reactions.
The exact gene therapy technique for CNS diseases like
Alzheimer’s is commonly invasive. Fibroblasts (a type of cell
in connective tissue) have their genome manipulated to promote production of NGF, nerve growth factor, and these NGFsecreting fibroblasts are cultured ex vivo and then grafted back
into the host.3 In a trial called “Progress in Brain Research“ on
the regeneration of cholinergic neurons (type of neurons lost in
Alzheimer’s), rhesus monkeys were given lesions on cholinergic neural regions and then induced with fibroblasts with genes
From the National Institutes of Health website
turned on to produce NGF.3 The control monkeys retained only
25% of cholinergic neurons after lesions, in comparison to 92%
of neural protection in NGF-secreting monkeys, which demonstrates an incredibly efficacy of gene therapy in our primate
cousins.3 In other words, nerve growth factor (NGF) directly
and superlatively stimulates the production of neurons, which
can help treat diseases where neurons are lost, like Alzheimer’s.
Despite invasiveness, NGF inoculation into stem cells
is a rather safe and symptom free option, at least in our close
evolutionary relatives like the rhesus monkey. Both safety and
efficacy demonstrates the potential application of this NGF
inoculation in human Alzheimer’s disease. It is believed NGF
could be clinically useful, “by reducing the extent of cholin-
ergic neuronal loss; or by augmenting neuronal function via
direct NGF-mediated stimulation of cholinergic transmission.”3 Despite the efficacy, it is still not surprising that this
method has not permeated entirely into every day medicine,
because of a few drawbacks. If any of the potential risks of
“pain, weight loss…tumor formation from grafted cells,” were
to occur in humans (although they have never been seen in
trial monkeys) it would be difficult to treat.3 Our current understanding of Alzheimer’s disease, even adult stem cell potential, is incomplete, and ignorance is a fertile field for hindering development due to ideological or ethical reasons.
NGF gene inoculation undeniably demonstrates one
potential for treatment, perhaps even enhancement of the adult
brain (by added neural growth), and a relatively simple biological one. But perhaps the public would be more satisfied with an
equally effective natural alternative, with zero potential for controversy? It seems inescapable that biological treatment of neural degeneration will have to, in some way, feature stem cells.
This is because neurons are ‘postmitotic,’ meaning they are in a
terminal stage of development, and have already divided from
stem cells.4 Furthermore, because dead brain tissue can’t be
replaced by surrounding tissue, as can be done in organs like
epidermis and the liver, the brain tissue can only be replaced
by stem cells that haven’t lost proliferation capacity. Another
study called, “Activity-dependent regulation of neuronal plasticity and self repair” has demonstrated that adult stem cells
can be stimulated not only synthetically from ex vivo grafting
(as we have already seen), but also by more evasive, natural, and
organic alternatives like the simple performance of exercise.4
Exercise, and other stimuli related to immersive activity, basically takes advantage of a principle called “Hebbian plasticity,” which is also more commonly understood in neurosciVolume 10
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Dell’Aquila
Dell’Aquila
ence jargon as the ‘use it or lose it principle.’6 Donald Hebb, who
postulated this theorem, conducted tests on the behavior of rats
in relation to their environment. Hebb’s research had shown
that “rats that he took to his home as pets showed behavioral
improvements over their littermates kept at the laboratory.”4
Later biochemical and molecular analysis reinforced and gave
light to this phenomenon, which demonstrates that this continuous plasticity is derivative of the brain’s interaction with stimuli from a complex environment, and the plasticity and change
in the brain is in reaction to challenges made on networks in
the brain. One example of network molecular interactions that
change in response to the environment, would be the “stress
hormones,” and related physiological regions of the brain.4 Major proponents to stress are the glucocorticoids, which have
been seen to inhibit neurogenesis in the adult hippocampus.4
In other words, because the hippocampus is the site of memory
storage, stress and stressful environments inhibits learning.
If the network for learning can be inhibited, it makes
sense that it can also be stimulated. And it can be partially en-
“So perhaps inoculation of information, not stem cells,
should be the clinical approach of the future.”
hanced, thanks to in part by “a second region in the adult brain
that routinely produces new neurons during adulthood” called
the subgranular zone4. However, as no single feature of the
brain functions in isolation, nor should any region be overemphasized for importance, this subgranular region in the adult
brain that stimulates growth must be one small part of a greater
network of neural regions in order to be stimulated to action.
Simply put, there is no primary neural region or function from
which all others rise; each region of the human brain interacts
in a continuous web with other regions. Exercise (voluntary
cerebellar stimulation) is a clear representation of creating
complex challenges for interacting neural networks, leading to
neurogenesis. This is because exercise stimulates the subgranular zone to create stem cells that proliferate to the hippocampus. Exercise then is seen to indirectly but inexorably lead to
improved memory, neural functioning, and neural lifespan.
The hippocampal region of the brain generates wave
lengths, which oscillate between 5 to 8 Hz as seen on electroencephalogram (a depiction of electrical activity in the brain)4.
This is significant because, “activity in the theta rhythm frequency range can enhance the ability of otherwise weak stimuli
to produce synaptic plasticity in the hippocampus.”4 Exercise
stimulates the brain to produce wave lengths between 5 to 8
Hz, meaning that it can strengthen otherwise weak hippocampal stimuli, and cause proliferation of stem cells to the hippocampal region by reinforcing the stimuli to do so. Exercise also
stimulates an increase in serotonin and norepinephrine levels,
which have been described as the brain’s ‘motor oil,’ keeping the
gears running smoothly so they don’t overtire.6 Even fibroblast
growth factor (FGF) and the nerve growth factor seen in the
rhesus monkey experiment (NGF), are enhanced by activity,
stimulating stem cells to migrate to relevant areas.4 Exercise,
especially because of its NGF stimulation, shows a powerful alternative to invasive approaches. Extrapolating from this infor-
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mation, one can see that because of NGF’s efficacy in preventing
and improving Alzheimer’s, consistent exercise is a potent alternative because it accomplishes the same goal as the ex vivo NGF
inoculation, but naturally. So perhaps inoculation of information, not stem cells, should be the clinical approach of the future.
Regardless of viability of natural alternatives, development for approaches to artificially enhance brain functioning is
currently underway, in ways previously unimaginable. Nanotechnology has presented itself to have almost omnipotent relevance in both understanding and enhancing our current model of the human brain. In a study performed to determine the
viability of establishing a neuron-nanostructure interaction,
“Intact Mammalian Cell Function on Semiconductor Nanowire Arrays: New Perspectives for Cell-Based Biosensing,” a culture of class F-11 human neurons, inducible to maturation by
a molecule called cAMP, demonstrated a viability above 95%
in the presence of nanowires.1 This means that the beneficial
applications of nanowires don’t also include hindrances to any
preexisting cell function. Nanowires, which are exactly what
they sound like, can permeate cell membranes with essentially no effect on cell activity, and they have many applications.1
They have been used to implement direct gene induction, to
deliver intracellular biomolecules with a high degree of control,
and are strong candidates for electrophysiological intracellular
probing, which can allow scientists to visualize cell activity in
the brain.1 All of this may seem quite technical, but the implications are clear; nanowires may lead to almost complete control
and monitoring of cellular function, which may eventually lead
to enhanced performance microscopically and macroscopically.
Carbon nanotubes (CNT), a type of nanowires, are
also potential candidates for promoting growth and activity of
neurons, and transmissions of action potentials, all of which
leads to stimulation efficiency and maximization of neural
strength.2 Using a specific CNT known as Multi-walled CNTs,
allows for controlling, and separating neural signals, as well as
visualizing them.2 It can be seen from the diverse applications
of CNTs, through directing growth and visualizing neural activity, that nanotechnology can soon not only be used in clinical practice to either prevent, compensate, or cure the degeneration caused by various neurologic diseases, but also perhaps
enhance and direct an improved healthy model of the brain.
The improved brain and nervous system sounds unambiguously positive, but there is inevitably a price tag to everything.
What then is the price of the most intrinsic self-improvement?
Both the research behind technology to improve the
nervous system, and the applications proceeding from technology’s development, are steeped with ethical issues. Manipulating the organ that allows us to manipulate anything may lead
us to what neuroscientist Steven Rose calls a “posthuman future,” in which our questionable amount of control creates “a
cyborgian future in which other constraints and freedoms appear.”7 This postulation may not be farfetched; when one pictures the prospect of fusing an organic brain with ubiquitous
“However the more sci-fi prospect of enhancing mathematical prowess, or uploading information from the internet
directly to the brain is now not far out of reach.”
nanowires, it creates an image of an almost cyborg human.
It is common knowledge that neuroscience advancement has opened up the possibility of remote control of prosthetics or interfaces with computers, especially for paralyzed
patients. However the more sci-fi prospect of enhancing mathematical prowess, or uploading information from the internet
ire prospect. But obviously, there will be a financial cost to
the nanotechnology in neurology, and one that not every
one can afford. It wouldn’t be far fetched to imagine that divisions in financial advantages among people could preclude
divisions in intellectual advantages offered by the nanotechnology, which would then reinforce the financial divisions,
because we are living in a merit based society where profit is
inextricable with a profitable mind. Of course, no one has the
answers, but what will always be true is the power of knowledge. Perhaps, if people learned that they themselves held the
key to the continuous fitness of their own mind, as “Activitydependent regulation of neuronal plasticity and self repair”
suggests, no one would find the need for artificial enhancements.4 But then again, quick fixes will always seem preferable
and essential to many. If nothing else, the coming decades will
inevitably reveal discourse between science and every aspect
of life that will be more interesting than any fiction yet written.
REFERENCES
Carbon Nanotubules
directly to the brain is now not far out of reach.5 This potential
future may seem idyllic to some, and dystopian to others, and
regardless of the general consensus of the prospect, perhaps a
deeper concern may be with what some call ‘playing god,’ be it
with controlling stem cells or consciousness, and without unanimous will of the public. But should any of the potential ethical
issues inhibit such revolution that can improve the quality of life
of countless individuals, and perhaps even society as a whole?
With such a complex question, a good scientist always
tries to look for the simplest solution, as Occam’s razor suggests. It could be that the rate of scientific development is increasing at such a rate that if a ‘posthuman future’ is where we
are headed, nothing can stop it. But perhaps we are simply at
a tipping point of civilization and the consensus of the public
may be to hark back to a more organic, natural approach of
medicine and living. Regardless, there are inescapable needs
that can be addressed by growing neuroscience knowledge.
One need applies to the growing population of elderly, who
tend to have a low standard of living due to outliving neurologic potential. Other needs could be political, like the need
for intellectual prowess to find solutions to sustainable ‘green’
energy production—and perhaps this need could be met if the
intellect of a human could be enhanced. A few options for enhancement are readily available to us currently: the manipulation of biology in stem cells and gene therapy, the manipulation of computer systems in nanotechnology, and also the
organic approach of physical activity which accomplishes many
of the goals of the former two pursuits in a simple fashion.4
It is perhaps oversimplification to suggest the personal responsibility of keeping physically fit is the best way to
address the multifarious needs in neurology, which can more
quickly, directly, and efficiently be addressed by the nanow-
1. Berthing, T., S. Bonde, C. B. Sorensen, P. Utko, J. Nygard, and
K. L. Martinez. “Intact Mammalian Cell Function on Semiconductor Nanowire Arrays: New Perspectives for Cell-Based
Biosensing.” Small 7.5 (2011): 640-47. Print.
2. Chen, Chang-Hsiao. “Hydrophilic Modification of Neural
Microelectrode Arrays Based on Multi-walled Carbon Nanotubes.” Nanotechnology 21.48 (2010): 485-501. Print.
3. Conner, James, Armin Blesch, David Smith, David A. Merrill, and H. L. Vahlsing. Progress in Brain Research. By Mark H.
Tuszynski. New ed. Vol. 138. Amsterdam: Elsevier, 2002. Print.
Plasticity in the Adult Brain: From Genes to Neurotherapy.
4. Gage, F. H. “Activity-dependent Regulation of Neuronal
Plasticity and Self-repair.” Progress in Brain Research. By G.
Kempermann and H. Van Praag. New ed. Vol. 127. Amsterdam:
Elsevier, 2000. 35-44. Print. Functional Neural Transplantation
II: Novel Cell Therapies for CNS Disorders.
5. Kennedy, Philip, Dinal Andreasen, Jess Bartels, Princewill
Ehirim, Hui Mao, Meel Velliste, Thomas Wichmann, and Joe
Wright. “Making the Lifetime Connection between Brain and
Machine for Restoring and Enhancing Function.” Progress of
Brain Research 194 (2011): 1-25. Print.
6. LeDoux, Joseph E. Synaptic Self: How Our Brains Become
Who We Are. New York: Viking, 2002. Print.
7. Rose, Steven P. R. The Future of the Brain: The Promise and
Perils of Tomorrow’s Neuroscience. Oxford: Oxford UP, 2005.
Print.
8. Wells, H. G., Patrick Parrinder, and Andy Sawyer. The Sleeper
Awakes. London: Penguin, 2005. Print
GRAPHICS CITED
“Emerging Ideas in Neural Science.” Emerging Ideas in Neural
Science.Web. 06 Apr. 2012. <http://brainchemist.wordpress.
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Dell’Aquila | Lin
Lin
com/2010/11/07/nanoparticles-iron-containing-multi-walledcarbon-nanotubes-as-destructive-beacons-to-zap-tumors/>.
“Process of Gene Therapy.” Gene Therapy. Web. 06 Apr. 2012.
<http://gene-therapy.yolasite.com/process.php>.
“NIH Fact Sheets - Alzheimer’s Disease.” NIH Research Portfolio
Online Reporting Tools (RePORT). National Institutes of Health.
Web. <http://report.nih.gov/nihfactsheets/ViewFactSheet.
aspx?csid=107>.
About the Author
Kevin Dell’Aquila is a freshman in CAS majoring in Neural Science. He is planning on becoming a neurosurgeon
one day as well as doing clinical research. In addition to volunteering, work, and newscasting for NYU’s radio station,
WNYU, he will also soon be conducting research on the hydrogen production of T. Vaginalis in Professor Jane Carlton’s
lab.
ILLNESS NARRATIVE
By Megan Lin
“With biomedicine being grounded in science, it is a common conception to assume illness as
an isolated category; however, illness is in fact, deeply rooted in society. Medical knowledge
and biomedical practice is inseparable from social factors and must be analyzed in parallel with
social and cultural context.”
My friend Allison (name changed for privacy purposes) and I always complain to each other about our various bodily
ailments. The playful exchange of complaints over the years has
forged an exclusive bond between us. While I thought I knew
plenty about her healthcare concerns, it was not until I interviewed her for my Medical Anthropology class that I learned
more about Allison’s illness from a different point of view.
Allison lives with eczema and hypothyroidism.
Allison’s skin lacks a certain barrier that would
usually serve as protection from bacteria. As a result, the
environment can easily irritate her skin. The main problem with eczema is that it is a source of constant discomfort. The skin on her face is almost always painful to the
touch. Also, due to constant itchiness, intense scratching to
affected areas is a common occurrence. Allison often gets
teased for her vigorous scratching, which produces a horrific
sound much like sharp claws grating on bark. Her scratching interferes not only with her daily activities but also her
sleep. Besides frightening her friends, excessive scratching
also causes her skin to bleed, increasing risk for infection.
Allison’s hypothyroidism was caused by her previous hyperthyroidism. It is common for hyperthyroidism to
occur first, followed by gradual progression into hypothy-
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roidism. When suffering from hyperthyroidism, the thyroid
produces an excess of hormones, causing bodily functions to
speed up. When the thyroid becomes overworked and finally
stops functioning, it is an indication that the hyperthyroidism has developed into hypothyroidism. This is when the
thyroid fails to produce enough essential hormones, upsetting
the body’s chemical balance and resulting in an overall slowing down of metabolism. If untreated, further symptoms include weight gain, swelling of the neck and face, constant fatigue, hair loss, and dry skin. The added symptom of dry skin
amplifies the severity of Allison’s eczema. Treatment for Allison’s hypothyroidism consists of a pill taken daily, called Synthroid®. With this daily pill and periodic checkups to an endocrinologist, Allison’s hypothyroidism is now relatively stable.
Intensive studies of anatomy and germ theory in combination with modern technology anchors biomedicine with
what is called an “internalist” approach. This approach puts
heavy emphasis on internalizing effects in regards to diagnosis and treatment. However, sometimes, external factors may
also be significant contributors to the cause. External contributory factors may include habits, lifestyle, and environment.
In Allison’s case, her eczema became very severe after
moving into the city for college. Her allergic reactions to dust
triggered bouts of increased inflammation, also known as “flareups.” Before college, her eczema was restricted to the inside of
the elbow and neck area. After relocating, it had spread to her
entire arm, wrist, and face. With higher levels of pollution, an
urban setting most likely worsened her condition. She claims
that the eczema seems to improve when she returns home to
the suburbs in the summer. In addition to responding to environmental factors, Allison’s eczema also responds to emotional
stress. If her normal lifestyle is in any way disrupted, for example during final exams, the eczema becomes more severe and
uncontrollable. Thus, as proven in Allison’s case, biomedicine’s
“internalist” approach errs in excluding relevant external factors.
Biomedicine is not necessarily the best choice of action
in many instances today. Although biomedicine is omnipresent and easily accessible, many people tend to take a pluralistic
approach– dealing with illnesses by making strategic choices
depending on their ailments. Allison did the same by choosing
to try Chinese medicine to treat her eczema. This “medical pluralism,” the option to switch back and forth between different
methods of treatment, allows patients the opportunity to sample different sources of medication to effectively treat disease.
Allison believes the crucial advantage of using Chinese medicine is the absence of severe side effects. This is
based on the logic that plant based medicines are gentler on
the body than aggressive Western pharmaceuticals. However,
Allison only chose to practice medical pluralism depending on
the ailment. For example, Allison was willing to try Chinese
herbal medicine for her skin but not for her thyroid, since the
thyroid was already stabilized by Western medicine. Western
medication delivered precisely what Allison wanted to receive:
it provided her body with the hormones her thyroid failed
to produce, effectively treating her symptoms without harming the rest of her body. Thus, in the case of hypothyroidism,
Western medicine trumped Chinese medicine. On the other
hand, in the case of her eczema, she felt the need to explore her
choices. This was because Western medicine was not the most
effective for her eczema, and at some points was even harmful.
A dermatologist had once prescribed her a steroid
cream for her eczema. Patients with eczema have such dry
skin that typical moisturizers are inadequate for penetrating
the outer layers of skin. Steroid creams are able to both penetrate and heal the wounds underneath, thus precipitating the
effectiveness of standard moisturizers. Unfortunately, Allison
was not informed exactly when to stop applying the steroid
cream. Steroid creams yield instant and potent results, but the
side-effects are severe and permanent. After long-term use,
the steroid cream caused skin atrophy and also accelerated
aging. When another dermatologist warned her to cease application of the steroid cream, she had already been using it
consistently for a year and was unable to reverse its damage.
Wary of the harmful effects of Western medicine on
her skin and hoping to control flare-ups due to stress, seasonal, and environmental factors, she turned to Chinese
medicine. A local Chinese herbalist recommended her several herbal concoctions. She described one as a sandy brown
powder that was placed directly in her mouth, followed by
water to dissolve. Another was a dark powder brewed into a
hot, black soup. Both were bitter and taken twice daily. She
recalled that they may have worked temporarily, but it was
by no means a cure. As a result, she discontinued use due to
lack of drastic results. After attempting alternative methods
of treatment for her skin, Allison returned to Western medicine in hopes of finding a treatment less severe than the previously used steroid cream. Milder creams, EpiCeram® and
CeraVe® moisturizing lotion seem to ameliorate symptoms
most of the time without lasting side effects, but efforts to
maintain flare-ups due to external factors remains a challenge.
With biomedicine being grounded in science, it is a
common conception to assume illness as an isolated category;
however, illness is in fact, deeply rooted in society. Medical
knowledge and biomedical practice is inseparable from soVolume 10
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Yu
cially, living with eczema has social consequences as well. Allison often feels self-conscious about the appearance of her eczema in public, which affects her daily activity in various ways.
Eczema appears wrinkly, “like old people skin,” and Allison feels
especially insecure about wearing T-shirts and shorts in fear of
exposing unsightliness on her arms and legs. For the same reason, she refuses to put her hair up because it exposes her “wrinkly
and gross looking” neck. Although she wishes she had a smooth
neck, she copes with this issue by always leaving her hair down.
Since the primary mission of biomedicine is to
detect named entities, the successful labeling of Allison’s
health condition as “hypothyroidism” and “eczema,” would
be the end of the story in biomedical tradition. But of
course, the story does not end at the diagnosis. Her illness
is inextricably embedded in the context of her life, which, as
shown, is certain to have unavoidable social consequences.
REFERENCES
cial factors and must be analyzed in parallel with social and
cultural context. In middle school, Allison remembered being frequently fatigued and having trouble concentrating.
The symptoms sometimes even caused mild depression. Unbeknownst to her, it was the onset of her thyroid condition.
Because of her hindered self-expression, she was not very
social at the time. Her mother merely assumed she was tired
from schoolwork or dismissed it as typical pubescent moodiness. After discovering her diagnosis, Allison began to fear
the possibility of losing her emotional control. She said, “It
could make you depressed for no reason and that’s scary.”
Eczema is clearly not an isolated medical issue either.
Similar to how her thyroid problem initially impacted her so-
Chinese Herbal Medicine. 2012. Photograph. Great Way to Wellness. Web. 9 Apr. 2012. <http://www.greatwaywellness.com/
blog/wp-content/uploads/2010/12/Chinese-Herbal-Medicine.
jpg>.
Eczema. 2011. Photograph. Therapies 4 All. Web. 9 Apr. 2012.
<http://www.therapies4all.com/image-files/eczema.jpg>.
Hypothyroidism. 2012. Photograph. World of Generic Drugs.
Web. 9 Apr. 2012. <http://www.world-drugs.net/generic_synthroid_levothyroxine_clip_image004.jpg>.
Lock, Margaret M., and Vinh-Kim Nguyen. An Anthropology of
Biomedicine. Chichester, West Sussex: Wiley-Blackwell, 2010.
Print.
About the Author
Megan Lin is on the Pre-Med track, majoring in Anthropology. She discovered that medical anthropology, which
examines the influence of culture and social factors on health/health care, is often overlooked in our society and needs
attention. She hopes to become a doctor who is not only medically competent but socially competent, understanding
the patient beyond the level of just symptoms and diagnosis.
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The Key to Paradoxical Latino
Immigrant Health Outcomes:
Disappearing Folk and
Traditional Healing Methods
By Mon Yuck Yu
Revealing the Immigrant Paradox: The Unrealized Truth
of the New World
Boarding the bus, Mr. and Mrs. Gonzalez looked at
each other with promising eyes and held tightly to their eightyear-old daughter’s hand. They were leaving their hometown,
San Pablo, Mexico and crossing the border to New York City
in the United States, fervently hoping that the telltale stories of
American prosperity would someday become their reality. The
Gonzalez’s hoped that in America, their daughter would obtain
an excellent education, enjoy good health, and maintain a strong
Mexican culture. For many immigrants, however, this new
American dream is never realized, and it remains just a dream.
While many United States immigrants aspire to fulfill the American Dream and improve their living situations by
immigrating to the United States and converting to an “American” lifestyle, consistent evidence has shown an emerging phenomenon called the “immigrant health paradox.” Substantial
research illustrates that first-generation immigrants experience
lower mortality rates in adulthood and higher life-expectancy
than do second- or third-generation immigrants (Van Rompay
et al. 2012). This is surprising, as first-generation youth (born
outside the US) often experience challenges of adjusting to new
cultural contexts—moving to new homes, transitioning to new
family structures, and learning new languages—compared to
second-generation youth (born in the US to immigrant parents), who are exempt from pre-migratory anxiety and the challenge of transitioning into a new culture. The lack of acculturative stress of the latter generation should contribute to lower
morbidity rates, but this is not the case. The concept of the immigrant paradox has contributed to the advent of other related
phenomena such as the “Mexican-Birth Paradox,” in which
children of U.S.-born Mexican-American mothers demonstrate significantly lower odds of chronic conditions compared
to non-Hispanic white children (Padilla, Hamilton, & Hummer
2009) and the “Hispanic Paradox,” in which first-generation
Latino immigrants exhibit lower probabilities of reverting to
alcohol and cigarette use as opposed to second-generation Latinos, and also fare better in morbidity rates (Kimbro 2009).
The faulty health outcomes of second- and third-
Figure 1. Rates of psychiatric disorders based on race, generation
status, and country of origin. US-born, non-Latino whites have the highest risk of psychiatric disorders. Immigrants generally have lower rates
of disorders compared to US-born participants. (Source: Alegria et al.
2009)
generation immigrants — mainly immigrant descendents
who are more acculturated to the United States — raise the
question of why there is such an immense difference in health
outcomes between the first and latter generations. There are
two key explanations for this phenomenon: a) only a healthy
selection of Latino immigrants are entering the country, thus
proliferating the genes for healthy descendents (which is highly
unlikely), and b) acculturation effects are reversing expected
health outcomes (the more likely explanation). Acculturation is the cultural and psychological change that immigrants,
refugees, and indigenous peoples experience as they come in
contact with the dominant majority of a new country of residence. As immigrant ethnic groups become more acculturated, they experience changes in culture, customs, and social
institutions (e.g. food, clothing, and language). As individuals
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Yu
become more acculturated, this modification begins to manifest in their psychological and physical well-beings as well.
Researchers have long hypothesized that acculturation
is the dominant culprit for unfavorable health outcomes among
second- and third-generation immigrants. In studying this immigrant paradox, they identify three dominant measures of acculturation: length of residence in the United States, language
use, and psychological acculturation. These measurement factors assume that immigrants grow more acculturated to US
culture if they have lived in the United States for a substantial period of time or if they have adapted to using the American language on a regular basis. Psychological acculturation is
measured on a number of socio-cultural elements defining assimilation, integration, separation, and marginalization, which
can range from family dynamics to personal cultural beliefs.
While cultural and social protective factors such as
social support, religion, and dietary norms often help firstgeneration immigrants avoid unhealthy drinking and smoking
behaviors that are more prominent among their Americanborn counterparts (Acevedo-Garcia & Bates 2008; Kimbro
2009), shifting environmental and social factors moderate the
acculturative effects and contribute to the rising rates of cigarette and alcohol use among latter generations, as well as to the
lack of health insurance available for blue-collar and service
workers (NYC DOHMH Community Health Survey 2008).
This contributes to paradoxical health outcomes among firstgeneration descendents, who are expected to have access to
a better educational system and more advanced healthcare.
“Digging deep into the melting pot culture of the United
States allows us to help piece together the picture of the
American Dream for immigrants of all generations, who regardless of citizenship status and background, are entitled
to accessible healthcare, an indispensible human right.”
The Missing Piece: Traditional Latino Medicine
Social factors such as language and cultural differences, lack of insurance, lack of transportation, lack of knowledge
of available services, and immigration status, can affect health
outcomes and be barriers to obtaining professional medical
care for first-generation immigrants who are less acculturated. In interviews with 96 Latino immigrants, participants
reported that they were received negatively when interacting
with the modern medical system: modern hospitals and clinics
often had long waits, rude staff, inadequate physician-patient
relationships where limited time was spent understanding the
illness and learning about the patient, and expense problems
for those without health insurance (Ransford, Carillo, & Rivera 2010). Instead, these immigrants resorted to alternative,
or rather, native health-seeking behaviors, such as traditional
medicine, folk healing, home remedies, and religious prayer.
Latter generations generally have better access to
healthcare, and therefore, put more reliance on the modern
health care system. Paradoxically, health outcomes for second- and third-generation immigrants, who rely on the modern healthcare system (and non-traditional healing methods)
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Spring 2012
“Paradoxically, health outcomes for second- and thirdgeneration immigrants, who rely on the modern healthcare
system (and non-traditional healing methods) report being
worse off in health outcomes.”
report being worse off in health outcomes. Numerous studies
in this paradoxical relationship often overlook the cultural
piece of the puzzle in their measures of psychological acculturation, which is often difficult to investigate: what if the
health outcomes in the immigrant paradox can be attributed
to the use (or lack thereof) of traditional and folk medicine?
Most studies suggest that the immigrant paradox is
attributed to various immigrant acculturation measures; however, the use of traditional healing therapies, which combines
religious customs with dietary change, may also contribute to
this paradoxical health anomaly, and be a factor in the psychological acculturation scale. It appears that acculturation is
diverting American-born children from healthier, traditional
diets, but these trends can be reversed through social medicine
that focuses on illness-generating social conditions and proper interventions (Waitzkin, Iriat, Estrada, & Lamadrid 2001).
I currently serve as Chief of Staff at a startup nonprofit organization working to improve healthcare access to
underserved communities throughout New York City. The organization is strategically located in the Sunset Park neighborhood and situated at the heart of the Brooklyn Latino population. In my capacity as a volunteer, I have organized a series of
free monthly health screenings for the local Latino community.
Prior to the screening, community members are administered
a questionnaire regarding their medical history and health habits. One of the different survey components is a section asking
about their use of alternative medicine and alternative therapy.
While few respondents have indicated that they use any sort of
‘alternative therapies,’ the word alternative has a different connotation in the conceptualization of native medical practices
that may not be viewed as “alternative” from the perspective of
immigrants coming from areas with strong dietary, herbal, and
humoral systems of medicine. In other words, without further
investigation and more detailed interviews, the native healing
therapies that this rich immigrant population brings with it
is basically unknown if our ethnocentric society conceptualizes alternative medicine in terms of a system that is foreign.
What is Traditional Latino Medicine?
Hispanics perceive disease as organic illness, in which
one’s system has an imbalance of the four humors (sanguine,
choleric, phlemagtic, and melancholic), caused in turn by disproportion in the hot and cold systems of the body. Cold diseases are characterized by vasoconstriction and low metabolic
rates, while hot conditions are characterized by vasodilation
and high metabolic rates. The purpose of folk treatment is to
restore the proper physical and spiritual balance. In Hispanic
barrios (villages or neighborhoods), ninety percent of traditional Latino medicine adherents generally obtain their services
from a hierarchy of lay healers in a system called curanderismo.
Patients who are ill are first referred to a señora or
abuela (literally, an adult woman or a grandmother); if she
cannot treat any particular conditions, they are referred to a
yerbero (herbalist), sobador (massage therapist), or parterna
(mid-wife, who is also qualified to treat conditions among
young children) (Neff). A curandero total (specialist lay healer using different methods of treatment) is the final resource
to which a person would be referred; a curandero either receives the skill through family tradition or is specially trained
later on in life. One common characteristic of all healers is
that they use herbal remedies as a means of treating the conditions. Curanderos, however, are often called upon to treat
special conditions that may result from supernatural causes.
Curanderos in traditional Latino Medicine emphasize
working with the person holistically on three levels: the material, the spiritual, and the mental. True healing is thought to be
effective only if it is integrated with the soul on a divine level.
The curandero will engage in three levels of healing, which
include: the plática, in which the curandero listens to the patient’s stories and identifies the starting point for the healing
process; the limpia, or the beginning of the healing process
of the body, mind, and soul; and the soul retrieval, the process of finding the lost soul. These healing rituals are often
conducted with ceremonies, herbal remedies, potions, and
countermagic. Should conditions become more severe, curan-
deros will then refer patients to see a medical doctor. Patients
who also prefer home-based treatment will also revert to using forms of spiritualism, prayer, or herbal home remedies.
Despite participant denial of using “alternative” medicine, evidence has shown that folk and traditional medicine does
exist among Latino populations in the United States. Spiritualism, for example, an alternative to Catholic religion in Mexico,
has combined ritual healing with herbal cleansing in numerous
southwestern states (Alcorn 1990). Botánicas (ethnic-healing
religious stores selling products used in folk healing, such as
folk medicine, religious candles and statuary, amulets, and other products regarded as magical or as alternative medicine) also
exist in Brooklyn Bushwick and East Harlem (Viladrich 2006).
Many immigrant patients begin with home remedies and other traditional medications, while others seek
conventional Western care, and then convert to native health
remedies once the system has been proven to the ineffective
or inaccessible. These traditional remedies are often manifested through “herbal and home remedies purchased in botánicas and markets, use of folk healers, the use of doctors
and/or medicines from Mexico, and the use of spiritual elements such as a personal prayer” (Ransford, Carrillo, & Rivera 2010). Interestingly enough, whereas personal religiosity
was important to spiritual healing, organizational religiosity
Figure 2. A curanduro healing session in Mexico. (Image Source: http://curanderismoadadaption.blogspot.com/)
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(pp.101-113). New York, NY: Springer
Alcorn, J.B. (1990). Evaluating folk medicine: Stories of herbs,
healing, and healers. Latin America Research Review, 25(1),
259-270.
Alegria, M., Canino, G., Shrout, P., Woo, M., Duan, N., Vila, D.,
…Meng, X.L. (2009). The immigrant paradox: Foreign-born
Latinos have lower rates of psychiatric disorders. Statistical
Modeling, Causal Inference, and Social Science. Retrieved from
http://andrewgelman.com/2009/10/the_immigrant_p/
Kimbro, R.T. (2009). Acculturation in context: Gender, age at
migration, neighborhood ethnicity, and health behaviors. Social
Science Quarterly, 90(5), 1145-1166.
Neff, N. Folk medicine in Hispanics in the Southwestern United
States. Retrieved from www.rice.edu/projects/HispanicHealth/
Courses/mod7/mod7.html
Figure 3. Inside of a botánica in Brooklyn, NY.
(Image Source: http://www.1adventure.com/archives/images/
mexican-botanica-lowres.jpg)
(i.e. church attendance) was not related with medical healing
(Ransford, Carrillo, & Rivera 2010). For first-generation immigrants who have minimal access to the healthcare system,
such holistic traditional systems have been identified to be
just as effective as the modern healthcare system in resolving
some major medical conditions, with immigrants even returning to their home countries to receive this alternate form of
care that is more personalized and more spiritually-focused.
The Need for Medical Citizenship
According to the 2010 Latino Health Profile, in 2010,
30.7 percent of the Hispanic population was uninsured, compared to 11.7 percent of the non-Hispanic White population.
While the percentages of first, second and third generation immigrants among this group are unknown, it is evident that this
group must seek a number of different alternatives to receiving
healthcare, which may include seeking out free clinics, paying
out-of-pocket expenses for necessary doctors’ visits, using home
remedies, or seeking alternative medicine therapists. The lack of
health insurance combined with the lack of knowledge to traditional healing methods may be one psychological acculturation
factor affecting health outcomes among later generations who do
not understand alternative ways of accessing cheaper means of
traditional healing that may have similar levels of effectiveness.
Oftentimes, traditional medicine manifests images
of chiropractors, herbalists, and acupuncturists, and Latino
folk and traditional practices are not primary foci of interest
when examining traditional medicine in the United States.
It is important that community development programs help
improve community health by bringing back folk and traditional medicine into the rich immigrant neighborhoods, and
increase group knowledge of Latin American healing systems in an integrative manner. This might consist of an alliance with local tradespeople to offer store discounts through
a referral system at local clinics, which will increase improve
rates of screening participation, and also enhance access to
resources for self-treatment. Individuals without health insurance will have increased access to already available resources
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Figure 4. Storefront of a botánica in Brooklyn, NY.
(Image Source: http://1.bp.blogspot.com/_B6gyINLrSBg/R5X_Ww2WLBI/AAAAAAAACA8/QSO6Y7PgWKI/s1600/Botanica700.jpg)
in the local community. It can also include the inclusion
of traditional medical systems in medical school curricula.
While numerous patients may practice medical tourism, the practice of traveling to other countries to obtain different types of medical care, United States immigrants should adapt
a new type of medical system to accommodate for the demands
of what are traditionally more personable and accessible ways of
managing personal health – a new concept of medical citizenship
– which may involve setting up neighborhood botánicas with
centers for curanderos, yerberos, sobadores, parternas, accessible to local Latino communities. Churches may also partition
a space for this purpose for worshippers seeking medical care.
Doubtless, the rationalizations for the trending immigrant paradox are not explicable by one faulty factor of the
healthcare system, but are joined by many other factors that
include environmental influences and governmental policies.
Nonetheless, small changes at the grassroots level in light of
macroscopic factors create big results in filling the gaps overlooked by policymakers. Digging deep into the melting pot
culture of the United States allows us to help piece together the
picture of the American Dream for immigrants of all generations, who regardless of citizenship status and background, are
entitled to accessible healthcare, an indispensible human right.
New York City Department of Health and Mental Hygiene.
(2008). New York City Community Health Survey 2008. New
York, NY: Bureau of Epidemiology Services Office of Minority Health. (2012, Feb 6). Hispanic/Latino Profile. Retrieved
from http://minorityhealth.hhs.gov/templates/browse.
aspx?lvl=2&lvlID=54
Padilla, Y.C., Hamilton, E.R., & Hummer, R.A. (2009). Beyond
the epidemiological paradox: The health of Mexican-American
children at age five. Social Science Quarterly, 90(5), 1072-1088.
Ransford, H.E., Carrillo, F.R., & Rivera, Y. (2010). Health careseeking among Latino immigrants: Blocked access, use of traditional medicine, and the role of religion. Journal of Healthcare
for the Poor and Underserved, 21(3), 862-78.
Van Rompay, M.I., McKeown, N.M., Castaneda-Sceppa, C., Falcon, L.M., Ordovas, J.M., & Tucker, K.L. (2012). Acculturation
and sociocultural influences on dietary intake and health status
among Puerto Rican adults in Massachusetts. Journal of the
Academy of Nutrition and Dietics, 112(1), 64-74.
Viladrich, A. (2006). Botánicas in America’s backyard: Uncovering the world of Latino healer’s herb-healing practices in New
York City. Hum Organ, 65(4), 407-419.
Waitzkin, H, Iriat, C., Estrada, A., & Lamadrid, S. (2001). Social
medicine then and now: Lessons from Latin America. American Journal of Public Health, 91(10), 1592-1601.
About the Author
Mon Yuck Yu is an Anthropology major, who aspires to work among community nonprofit organizations to battle
predominant public health issues. Mon Yuck currently works as Research Assistant at Dr. Selcuk Sirin’s Applied Psychology Laboratory in the Steinhardt School, studying the effects of the immigrant paradox on health, education, and mental
health outcomes, among others. She has worked in leadership positions in service organizations and non-profits, such
as the American Red Cross and the Chinese-American Planning Council. She also serves as Chief of Staff at a start-up
nonprofit organization called the Academy of Medical & Public Health Services (AMPHS). Part of her duties at AMPHS
include organizing and managing staff members, ensuring staff satisfaction and staff engagement, forming community partnerships, and overseeing a vast array of projects. As an impact-driven social entrepreneur, she has successfully
increased the organization’s volunteer capacity and led a number of venture initiatives that have received over $20,000
in funding. She also co-founded software company Cortex Systems International, Inc. and currently serves as project
manager for a medical ethics software, which is expected to launch in August 2012.
REFERENCES
Acevedo-Garcia, D. & Bates, L.M. (2008). Latino health paradoxes: Empirical evidence, explanations, future research, and
implications. In H. Rodriguez, R. Saenz, & C. Menjivar (Eds.),
Latinas/os in the United States: Changing the face of América,
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Subbiah
Subbiah
The Emergence and
Implementation of EMR
systems and Their Effect on
Healthcare
By Mrinal Subbiah
“Incentives of up to $44,000 could be allocated by Medicare and $65,000
by Medicaid on a per-physician basis to help finance many forward-thinking practices’ switch to EMRs.”
As we have advanced through the modern era, specifically the last 25 years or so, we have witnessed the unprecedented meshing of technology into our daily lives. The stiflingly slow and clunky Pentium Processors of old are relics in
the face of sleek desktops and portable netbooks which process
information at blinding speeds. Only within the last 15 years
has the home phone been replaced by the earliest cell phones,
garish contraptions with no other functionalities than checking
the time and making a phone call. But these too underwent a
metamorphosis, and so the smartphone came to be. As a result
of these innovations, we have attained the power to run entire
businesses, disseminate immense quantities of information and
connect on a global level–all with the swipe of a finger or a wayward click of the mouse. Daily, we accomplish much because of
technological progress. As such, 21st century living is primarily
defined by vastly improved networking capabilities, general ease
of use and ultimately, swift efficiency. Nowhere else is this phenomenon more evident than in the health sector, an occupational society who’s success is contingent upon new technological
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innovations. With the meteoric rise of EMR (Electronic Medical Record) systems, hi-technology once again spurs effectual
change, this time in the daily lives of doctors and their patients.
Before the advent of Electronic Medical Records, there
existed the traditional method of collecting patient histories
and diagnostics–the paper based system, a largely inefficient
means of collecting data. The institution called for physicians to
meander through endless pages of disarrayed notes and figures
that often cannot sufficiently express trends and correlations
within a patient’s medical history. Furthermore, large health
institutions like hospitals frequently divert large sums of space,
money and human capital into devising, maintaining, and effectively retrieving these histories. Since several state laws require medical practices to maintain patient records for at least
7 years, this organizational problem compounds yearly even
though a patient may visit on average only once or twice yearly
(1). This ultimately slows down the workflow within a hospital.
Accordingly, accountability is almost absent in this system. The
possibility of “lost information” looms large, as patient histories
are ferried from one department to another within a hospital.
Non-qualified personnel, namely volunteers can view these
records without ever being reprimanded, as they commonly
come in contact with such documents. The biggest flaw in the
system, though is that of minimal “interoperability,” a term that
describes the ease with which records are transferrable from
one practice or even from one specialist to another. A very real
and probable scenario exists in which an entire family moves
from say, a practice in Chicago to a general hospital in New
“In three separate criterions used to measure patientphysician relationship strength, namely organizational
skills, verbal and nonverbal skills, and computer mastery
skills, the introduction of EMR caused the physicians to
perform poorly in all three.”
York City and likewise needs their histories transferred. Using
the paper-based method, this would either be accomplished by
fax, or by the patient actually transferring the files themselves,
which can lead to the possibility of non-transfer of vital patient
information through misplacement or miscommunication.
In addition to the clearly faulty nature of paper record systems, there existed further motivation by the Federal
Government to make the switch to EMRs. As offered in the
provisions of the aptly titled subsection of Obama’s American
Recovery and Reinvestment Act, the HITECH Act (Health
Information Technology for Economic and Clinical Health),
incentives of up to 44,000$ could be allocated by Medicare
and 65,000$ by Medicaid on a per-physician basis to help finance many forward-thinking practices’ switch to EMRs.
Those practices that exhibited “meaningful use,” could even
apply for further funding. Furthermore, the incentive packages are a time-dependent deal and will slowly trickle down
by 2015, at which point financial penalties will be issued to
by the Federal Government upon those practices whom have
failed to make the required change (2). Recognizing the potential benefits of the system and the government assistance
they would receive, in 2009 43.9% of physicians confessed to
using partial or complete EMRs at their practice, as reported
in a study conducted by Paul C. Beatty under the Division
of Health Care Statistics. That number is only growing. (3)
“In 2009 43.9% of physicians confessed to using partial
or complete EMRs at their practice.”
Preliminary reports given by physicians implementing
EMRs have praised the ease-of-use of and the various utilities
that are provided with the system. Nearly all such systems are
equipped with the ability to create organized and readable electronic notes during a physician’s patient encounter, but the really impressive functions are many systems’ ability to show list
views in which data is grouped into sets, rather than disparate
encounters and depending on the type of data, can be expressed
as graphical time series (line graphs, bar graphs etc.). If a patient needs a prescription, a urine analysis, or has trouble with
billing, then most systems have e-Prescription, e-Lab, and eFinance modules, which send orders directly to and can receive
instantaneous feedback from pharmacies, labs and insurance
companies. Most systems can also migrate old patient records
as well as add new paper records (from a non-EMR practice)
into a system if those records are scanned and digitized. These
EMRs are also very flexible as they allow for patients and physicians to remotely view their patient histories using a username
and password scheme (4). Some practices are even adopting the
use of Dragon NaturallySpeaking, a voice-to-text recognition
software used extensively by Microsoft in their Windows packages (5). The greatest achievement thus far, which is still a work
in progress, is EMRs’ effective tackling of “interoperability.”
Currently, patient history sharing within the same EMR service
provider is painless, as all the information is digitally sent and
received by cooperating practices. In fact, this idea has been
extended by the Federal Government, which has expressed a
desire in implementing exchange capabilities across all EMRs
and has even mandated a homogenization in abbreviations
for prescriptions, diagnosis, and lab tests. It is a preemptive
measure in hopes of a proposed nationwide EMR network (6).
A study performed by David Joos of Vanderbilt University on the effects of EMR implementation at a chosen
clinic showed that in the areas of work speed, accuracy, efficiency, accessibility of system and communication with the
patient, an average of 62% of interviewed clinicians thought
that a newly implemented EMR system helped. Over 80% of
all clinicians interviewed in the same study agreed that an
EMR improves overall administration of healthcare using features like electronic messaging. (7) Another study performed
at Oregon Health Sciences University by Phillip D. Marshall
had similar findings, with 45% of clinicians seeing improvements in clinician-patient interaction with EMR implementation, 51% not really caring either way and 4% of physicians
claiming that EMRs were detrimental to their clinic. (8)
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Subbiah
Subbiah
Although EMRs offer great innovation, there is an
onerous and obvious problem, one that stretches back to the
time of Hippocrates of Kos and is paramount in nearly all
medicine: the patient-physician interaction. An almost immediate consequence of EMR implementation and usage
would be a subversion of many traditional methods of medical diagnosis, as seen in Dr. Pauline W. Chen’s anecdotal
reminiscence of her first EMR-fueled patient encounter: “[A]
s I settled in to see my first clinic patient, I realized I had no
idea where to sit. The new computer was perched atop a desk
in one corner of the room; the patient sat on the exam table
on the other side of the room. In order to use the computer,
I had to turn my back to the patient as I spoke to him. I tried
to compensate by sitting on a rolling stool but soon found
myself spending more time spinning and wheeling back and
forth between patient and computer than I did sitting still and
listening. And when my patient did talk, his story came only
in spurts because every time I turned my back to him to type,
the room fell silent…My vision of an interaction marked by
the seamless flow of conversation and capture of information
vanished. Instead, I was spinning my wheels. Literally.” (9)
The learning curve for those new to Electronic Medical Records
is unbelievably steep, especially for those entrenched in long
established techniques of medical administration. Practices
that are essentially not tech-savvy would flounder under such
inefficiencies, placing the doctor and the patient at a distance
from one another by means of a computer, and as such, this
poses a very real threat to the success of the EMR. Further in
the article, another concern is brought to head in the difficulties
involved in “replicating the narrative aspect of a patient’s illness and the nuances of a patient’s illness course,” if every other
moment the clinician has to type into or debug the system.
In a recent joint study between UCLA and Indiana
University of Medicine on the effect of computers on patientphysician interactions, it was shown that in three separate
criterions used to measure patient-physician relationship
strength, namely organizational skills, verbal and nonverbal skills, and computer mastery skills, the introduction of
EMR caused the physicians to perform poorly in all three.
The main concerns were that the physician fumbled with the
EMR software and accordingly did not make frequent eye
contact with the patient and often even ignored what the patient said. Both parties seemed frustrated by the end of the
examination. Two further problems also endanger the utility
of EMR systems. As a solely digital form of data, patient records are at the whim and wills of a machine. If there is no
power, there are no records and because EMRs usually operate
through the internet, security may not always be absolute. (10)
Among EMR’s shortcomings and triumphs exists
an infinitely clear message: the paper-based patient history is
quickly becoming obsolete. Continuing with a paper system
not only endangers workflow, time and efficiency (aspects often
vital to speedy patient healthcare), but also the overall personal
security of administrators and patients alike. Inefficiency to efficiency. That’s the way technology works and that’s why innovation like the EMR works. As with any change, though, there
must be a letting-go of the former customs. In the deepest sense
EMRs are challenging the core of medical tradition. It’s revolutionizing how medicine can and will be performed and the onthe-job skills prospective M.D.s will require to be successful, so
that physicians can improve accountability, sustainability and
service. At the same time the system switch is leaving doctors
less connected with their patients and this relationship is, arguably, the key facet of almost all health care. Medical practitioners of the older generation are even being threatened by
the emergence of EMR because they simply can’t keep up. Undoubtedly, the single most important question on every physicians mind, taking into account the government incentives, the
problems it would introduce and the solutions it offers, would
probably be: “Was EMR worth it?” As aspiring MDs of the latest generation, we absolutely must consider its implications.
REFERENCES
1. Kasprak, John. “Patient Access To Medical Records.” OLR Research Report. Web. 3 Mar. 2012. <http://www.cga.ct.gov/2006/
rpt/2006-r-0599.htm>.
6. Dunlop, Laura. “Electronic Health Records: Interoperability
Challenges Patients’ Right to Privacy.” Schidler J. L. Communications and Technology. Web. 11 Mar. 2012. <http://digital.
law.washington.edu/dspacelaw/bitstream/handle/1773.1/400/
vol3_no4_art16.pdf?sequence=1>.
7. Joos, David. “An Electronic Medical Record in Primary Care:
Impact on Satisfaction, Work Efficiency and Clinic Processes”.
PubMed Central. Web. 11 Mar. 2012. <http://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1839545/>.
8. Marshall, Phillip. “The Effects of an Electronic Medical Record on Patient Care:Clinician Attitudes in a Large
HMO.” PubMed Central. Web. 11 Mar. 2012. <http://www.
ncbi.nlm.nih.gov/pmc/articles/PMC2232329/pdf/procamiasymp00005-0186.pdf>.
9. Chen, Pauline. “An Unforeseen Complication of Electronic
Medical Records.” The New York Times.Web. 11 Mar. 2012.
<http://www.nytimes.com/2010/04/22/health/22chen.html?_
r=1&pagewanted=print>.
10. Frankel, Richard. “Effects of Exam-Room Computing on
Clinician–Patient Communication: A Longitudinal Qualitative”
Study. PubMed. Web. 11 Mar. 2012. <http://www.ncbi.nlm.nih.
gov/pubmed/16050873>.
2. Athena Healthcare. “Whitepaper.” A Summary of The HITECH Act. Web. 11 Mar. 2012. Pages 2-5. <http://www.athenahealth.com/_doc/pdf/HITECH_Fact_Sheet_Whitepaper.pdf>.
3. Beatty, Paul. “ Electronic Medical Record/Electronic Health
Record Use by Office-based Physicians: United States, 2008 and
Preliminary 2009.” Web. 11 Mar. 2012. <http://www.cdc.gov/
nchs/data/hestat/emr_ehr/emr_ehr.pdf>.
4. “Enable Healthcare Inc.” Enable Healthcare Inc. Web. 11 Mar.
2012. <http://www.ehiconnect.com/>.
5. “EHR Dragon Medical Works With.” Dragon Certified EHRs.
Web. 11 Mar. 2012. <http://www.nuance.com/healthcare/services/dragon-CertifiedEHRs/dragon-works.asp>
36
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Spring 2012
Volume 10
MEDICAL DIALOGUE REVIEW
37
Subbiah | Akhand
Akhand
About the Author
Mrinal Subbiah is a sophomore at NYU CAS and is currently pursuing a mathematics major, while taking the
requisite courses for medical school. Mrinal Subbiah wrote his article on EMR systems primarily because his father works
extensively with Information Technologies and because Mrinal felt it necessary that future doctors should be well versed
in such a field. When he is not going to see obscure movies at the IFC, or hanging out with friends he may head over to
the Fitch Lab to wrangle up some worms (C. elegans). He also enjoys burritos at Chipotle with black beans, white rice,
peppers, barbacoa, hot sauce, corn, lettuce, sour cream and cheese. That is all.
Psychoneuroimmunology:
A Window into Mind-Body
Medicine?
By Omar Akhand
“With rapid technological advances being made in the medical field, it seems that the personal,
social, and humanistic aspects of medicine have become marginalized. Perhaps advances in
psychoneuroimmunology will refine our definition of disease and by extension, our medical
practices and services.”
Mind-body medicine often provokes skepticism. At
best, it is regarded as old- fashioned or perhaps more aligned
with Eastern medicine. At worst, it may be ridiculed as the stuff
of folk medicine, conducted by uncertified quack doctors in
the confines of underground clinics or remote villages. From
highly ritualized sessions of meditation, to acupuncture, to
hypnosis; there persist many quasi-spiritual practices, which
are claimed to have healing powers as well as several recovery stories attesting to the role of spirituality in relieving fatal conditions. A majority of medical research and treatment
options are focused on delivery of cures in the form of vaccines, drugs, or antibiotics and therefore less investigation has
been conducted to better understand the ways in which mental states impact the immune system. While western medicine may not be willing to accept mind-body medicine as an
alternative, perhaps it may draw upon its principles or tenets
in order to improve patient health, care, and satisfaction.
Stories of recovery resulting from alternative treatments are often puzzling and mysterious since little investigation concerning alternative methods has been conducted. Be
it divine intervention or highly improbable turn of events, energy flow through anatomical meridian lines, or the placebo
effect, explanations of such methods are controversial. One
such controversial recovery story involves the very miracle
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MEDICAL DIALOGUE REVIEW
Spring 2012
that had been used cited in the beautification of the late Pope
John Paul II. Sister Marie Simon-Pierre is a French nun who
suffered from Parkinson’s disease or perhaps a similar neurological disease.5 Her condition had confined her to her bed
but that had changed after she and members of her community prayed for the intercession of Pope John Paul II.5 After
her “complete and lasting cure,” she had returned to working
in a maternity hospital run by her order in Paris.5 While it is
uncertain weather whether Sister Simon-Pierre had suffered
from Parkinson’s, a diagnosis cannot be confirmed without an
autopsy and there currently exists no cure for the condition.
Although the example of Sister Simon-Pierre is one
of popular media, there are several accounts of recoveries, especially spontaneous remissions from cancer, which have no
medical explanation, yet are attributed by some doctors to improvements in mental health, increase in optimism, or cathartic experiences.6 Are such seemingly miraculous recoveries
and much of alternative medicine to remain unaccounted for?
“[f]or this is the great error of our day that the
physicians separate the soul from the body.”
Over the course of the last two decades of research,
an emergent field of science, psychoneuroimmunology (PNI),
Table 1 and Figure 21
has shed light on the ways in which psychological states and
the nervous system affect immunity to disease. While this area
of research does not seek to justify any practices or explain any
miracles, it does incorporate many disciplines in order to offer
perspective on the ways in which the two most adaptive systems
of the human body, the central nervous system and the immune
system, interact. Perhaps advances in pyschoneuropharmacology will create a window for us to better understand mind-body
medicine as well as seemingly inexplicable case studies, currently subject to mystification and attribution of divine causality.
Quantitative evidence for such interactions between
the brain and the immune system were first produced by Dr.
Robert Ader and Dr. Nicholas Cohen, who are considered the
fathers of psychoneuropharmacology, coining the name of the
field. Their publication in 1975 demonstrated that immunosuppression can be behaviorally conditioned (tThink Pavlov’s dog
except with rats where the bell is replaced with sweet water and
the meat is replaced by a toxic agent).1 In their experiments,
they provide saccharin-laced water to rats as a neutral stimulus
which had a distinctive taste. This stimulus would be followed
by an administration of cyclophosphamide (CY), the unconditioned stimulus (US) thirty minutes later for all conditioned
rats. This chemical is a toxic agent which causes temporary gastrointestinal upset and immunosuppression and was sufficient
in producing taste aversion to the saccharin water alone after
one pairing, conditioning the neutral stimulus. Three days later,
all rats, conditioned and non-conditioned, were given injections of SRBC, an antigen, followed by either the CS alone, plain
water with the US, or nothing thirty minutes later. This antigen
was administered to provoke an immune response (antibody
production). Six days after the antigen presentation, antibody
titers were taken of all rats. Both non-conditioned rats and conditioned rats that were not presented with the CS before antigen
presentation demonstrated high titers (immune response). No
antibody was detected in conditioned rats that were presented
with CY (toxin) alone, during antigen presentation. Furthermore, conditioned rats presented with the CS (saccharin-water)
during antigen administration “were significantly immunosuppressed.” These results suggested that the laced water, which
had been conditioned to an unpleasant and stressful stimulus
(the toxin or US) was capable of impairing the immune systems of rats without the administration of the toxin. They interpreted these measurements to suggest that such immunological
impairments may have rendered the rats “more vulnerable to
the superimposition of latent pathogens that may have existed
in the environment,” which was supposedly why several rats,
especially those who drank more of the laced water, had died.1
These experiments, designed and conducted by
Ader and Cohen, were the breakthrough that spurred the
growth of PNI as a science and not just a collection of weak
observations. This experiment, which has been reproduced,
demonstrated that taste signals, mediated through the nervous system, affected immune function. Dr. Ader and Cohen went on to postulate in their groundbreaking book,
Psychoneuroimmunology (1981), that the brain and immune system act as a single integrated unit of defense.
Research during the three decades or so following this
initial finding has pointed to the hypothalamus-pituitary-adrenal (HPA) axis, often referred to as the body’s “stress circuit”
as a major system for nervous system-immune system interactions.2 This circuit responds best to stress activity, usually experienced and loosely defined as “a negative emotional state that
“If physicians were to aspire to improved standards in
which their patients are to thrive and defeat their adversities, then they would need to build relationships, engage
in conversation, and immerse themselves within various
communities. In this manner, a physician will heal beyond
simply the alleviation of symptoms.”
Volume 10
MEDICAL DIALOGUE REVIEW
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Akhand
Akhand
is the appraisal of certain situational and psychological factors”
for instance, threats, harm, or challenges.4 Stressful signals,
from environmental threats like a predator for instance, are received by the hypothalamus from various circuits in the brain.
The hypothalamus responds by secreting corticotrophin-releasing hormone (CRH).4 This hormone stimulates the secretion
of adrenocorticotropic hormone (ACTH) in the anterior lobe
of the pituitary gland.4 ACTH is then transported through the
cardiovascular system to the andrenal cortices of the kidneys,
stimulating the secretion of glucocorticoid hormones as well as
epinephrine and norepinephrine into the body’s circulation.4
At this point in the pathway, effects are incredibly globalized, complex, and subject to active research. Glucocorticoids
suppress the synthesis of proinflammatory cytokines which
normally induce inflammatory reactions aiding recovery from
infection.2 Circulating catecholemines like norepinephrine
and epinephrine also modulate activity of different lymphoid
cells affecting lymphocyte traffic, circulation, proliferation, and
cytokine production.4 These hormones as well as inflammatory responses have feedback effects in the brain, controlling
motivation and emotion, and producing characteristic stress
response behaviors like sickness behavior and pain response.4, 6
The HPA axis may have evolved to modify behavior
and physiological conditions in response to stress cues. While
temporary stress or acute stress may be useful for survival,
chronic stress may impair the immune system by creating immunoregulatory dysfunctions and deviations from homeostatic ideals.4 Several immune-based dysfunctions resulting from
excessive stress include susceptibility to infections, allergic diseases, and asthma.4 Stress is also suspected to play a role in the
morbidity and mortality of cancer, HIV disease, and inflammatory bowel disease.4 Further compounding the problems arising from stress are the issues resulting from an overactive sympathetic nervous system during chronic stress.4 Increased heart
rate, blood pressure, catecholamine secretion, and platelet aggregation may also explain the associations between stress, immune dysfunction, and cardiovascular disease.4 Chronic stress
may also have behavioral and psychological consequences that
further impair health, for example, poor diet, lack of exercise,
substance abuse, poor sleep, and decreased quality of life.4
With the evidence mounting in support of mindbody interactions through such systems like the stress circuit
(HPA axis), why haven’t our treatment and practices adapted
to this new perspective. With rapid technological advances
being made in the medical field, it seems that the personal,
social, and humanistic aspects of medicine have become
marginalized. Perhaps advances in psychoneuroimmunology will refine our definition of disease and by extension, our
medical practices and services. American psychiatrist, George
Libman Engel calls for a biopsychosocial model of disease
which recognizes the importance of psychosocial contributors to illness and calls for a multidimensional approach to
diagnosis and treatment.3 Such diseases like type two diabetes are perfect examples of conditions that require assessment
and attention of cultural, social, and psychological factors.
Perhaps the greatest advance we may make in medicine is to revert to an ancient concept. The father of medicine,
Hippocrates, predicted “[f]or this is the great error of our day
that the physicians separate the soul from the body.” If merely
promoting survival were the sole purpose of medicine, than
an empirical approach would suffice; where doctors would
inspect their patient’s like a car engine, prescribing a change
in engine oil or maybe a wheel realignment. But if physicians
were to aspire to improved standards in which their patients
are to thrive and defeat their adversities, then they would need
to build relationships, engage in conversation, and immerse
themselves within various communities. In this manner, a
physician will heal beyond simply the alleviation of symptoms.
2. Azar, Beth. “A new take on psychoneuroimmunology.”
American Psychological Association. 2001. Vol 32, No. 11, pp. 34.
3. G.L. Engel. “The need for a new medical model: a challenge
for biomedicine.” Science. 196 (1977), pp. 129-136.
4. Marshall Jr., Gailen D. “The adverse effects of psychological
stress on immunoregulatory balance: applications to human
inflammatory diseases.” Immunology and allergy clinics of North
America. 2011. Volume 31, Issue 1, pp. 133-140.
5. “Q&A: John Paul II’s beatification”. BBC News. 2011-04-29.
Retrieved 2011-04-29.
6. Sala, Sergio Della. “Tall tales about the mind and brain: separating fact from fiction.” New York: Oxford University Press,
2007. 440-459. Print.
7. Ronald Glaser and Janice K. Kiecolt-Glase. “Stress-induced
immune dysfunction: implications for health.” Nature Reviews:
Immunology. 2005, vol. 5, pp. 243-251.
REFERENCES
1. Ader, Robert; Cohen, Nicholas. “Behaviorally Conditioned
Immunosuppression.” Psychosomatic Medicine. 1975, vol. 37,
no. 4, pp. 333-340
Figure 17 | Stress-associated modulation of
the
hormone response by the central nervous
system.
Experiencing a stressful situation, as perceived by the brain, results in the stimulation
of the hypothalamic–pituitary–adrenal (HPA)
axis and the sympathetic–adrenal–medullary
(SAM) axis. The production of adrenocorticotropic hormone by the pituitary gland results
in the production of glucocorticoid hormones.
The SAM axis can be activated by stimulation
of the adrenal medulla to produce the catecholamines adrenaline and noradrenaline, as well
as by ‘hard-wiring’, through sympathetic-nervous-system innervation of lymphoid organs.
Leukocytes have receptors for stress hormones that are produced by the pituitary and
adrenal glands and can be modulated by the
binding of these hormones to their respective
receptors. In addition, noradrenaline produced
at nerve endings can also modulate immunecell function by binding its receptor at the
surface of cells within lymphoid organs. These
interactions are bidirectional in that cytokines
produced by immune cells can modulate the
activity of the hypothalamus. APC, antigenpresenting cell; IL-1, interleukin-1; NK, natural
killer.7
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About the Author
Omar Akhand is a pre-med sophomore at NYU’s CAS, majoring in neuroscience. His interest in neuroscience
stems from an inclination to understand life and the universe mechanistically and materialistically. He is an honors track
neuroscience student participating in research at the LeDoux laboratory concerning defense (fear) conditioning in rats.
He aspires to become a neurosurgeon or a neurologist. Aside from being a student he is also a basketball wizard, burrito connoisseur, and a guitarist/rockstar. These titles are self-proclaimed and are usually held in contention or dismissed
by those who know him. Omar invites any discussions, questions, or conversations and may be contacted by email at
[email protected].
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Woo
Woo
What Doctors Could Learn from
Literature and Art
By Pauline Woo
“When it comes to enhancing the skill set required to diagnose and treat
illnesses, studying literature and art is an invaluable and usually
overlooked method of doing so.”
Doctors are often called healers, but in my opinion,
the term “diagnostician” offers a more accurate description
of their profession. Doctors are healers in the sense that they
are essentially the gateway between sick patients and recovery.
Technically, the medicine administered to patients is what heals
them—a doctor’s task is to determine what types of medicine—
be it drugs or chemotherapy or some other form of treatment—
are required for a particular patient. The ability to recognize
a specific illness or illnesses is what essentially distinguishes
these medical professionals from the rest of society; therefore,
becoming better at diagnosing patients would result in a more
effective doctor. As medical schools’ intense focus on the sciences reveals, administrators and professors – the people training the next generation of doctors – believe this is accomplished
almost exclusively through biology, chemistry, and the like.
I am not in any way disputing the overwhelming importance of science in a doctor’s education. Without it, doctors would not be doctors. But when it comes to enhancing
the skill set required to diagnose and treat illnesses, studying literature and art is an invaluable and usually overlooked
method of doing so. As Dr. Sandu Charan Panda notes, medicine is “not an exact science. It is an applied science, and its
practice an art.” Literature and art are essentially concerned
with the observance of details to convey an indescribable idea
or emotion related to humanity. By studying this ‘direct’ approach to human nature and sentiment, medical professionals may learn to view people’s mental and physical ailments as
a single entity. Dr. Kenneth Heaton, a vocal advocate for the
increased role of literature in medicine, strongly recommends
Shakespeare’s works for doctors, claiming that their examples
of ways in which emotions could literally affect the body could
enable his peers to more quickly and effectively treat their
patients (Bates). A paper in The Lancet, a prestigious medical journal, acknowledges that, despite the lack of substantial
scientific studies establishing a relationship between literature
and medicine, existing evidence is constant in supporting it. It
is worth noting that, although the relationship is not without
its skeptics, there have been no studies or reports concluding
that studying English, or similar subjects, has a negative effect
on doctors or pre-med students. The research in The Lancet
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gathers that those who study literature have “an increased sensitivity in dealing with patients and a better ability to recognise [sic] and work through difficult and ambiguous situations
more...efficiently,” supporting Dr. Heaton’s claims (Vannatta).
Considering the fact that the idea of healing has been around
as long as people have been getting injured, it is difficult to
deny its primitive connection to humanity, which is a notion
that must be taken into account by those in such a hands-on
profession as a doctor (Panda). There is a reason it is considered romantic to quote poetry or Romeo and Juliet – Shakespeare could put what men or women feel into words in a way
no one else could. Great poets and authors were great because
they could access human emotion and understand it enough
to express it through words. If the popular TV show House
teaches its viewers anything, it is that understanding human
nature can go a very long way when it comes to treating people.
Then there are the empirical contributions to be
gained from studying literature and art. In one experiment,
students from Harvard Medical and Dental Schools in Years
1 and 2 were either enrolled or not in an art-based diagnosis
course, with interesting results: those who took the class had
improved capacities “to make accurate observations of...physical findings” (Naghshineh). Similar findings resulted from an
earlier experiment, run by Dr. Joel Katz along with several other doctors, in which older medical students were divided into
two groups, one of which utilized art to sharpen observational
skills (Shapiro). In the words of Dr. Katz, the students in the art
course were being taught to be “visually literate” (CBC News).
“Considering the fact that the idea of healing has been
around as long as people have been getting injured, it
is difficult to deny its primitive connection to humanity,
which is a notion that must be taken into account by
those in such a hands-on profession as a doctor.”
One of the main reasons pre-med, pre-law, or students
in general avoid humanities majors is because, in the words of
my uncle, “it isn’t practical,” and according to several of my fellow
students, pre-med and not, science majors have an edge when
taking the Medical College Admission Test, commonly known
as the MCATs. However, data from the Association of American
Medical Colleges, which administers the test, reveals that that
is not necessarily the case. In 2009, English majors scored less
than half of a point less than Chemistry majors in the Physical
Sciences section, the same in Biological Sciences, and 1.3 points
higher in Verbal Reasoning (AAMC). They also scored higher
in all three sections than Biology majors, and the composite
scores of English majors were higher than those of Biochemistry, Chemistry, Microbiology, and Biology majors (AAMC).
Clearly, studying literature is not an impractical decision. Declaring my own major, I initially did feel that I was
sacrificing a better chance of scoring higher on my MCATs or
getting a head start in med school, but I quickly realized that
English is very useful outside of my English classes. Being able
to appreciate T.S. Eliot’s poems or understand Shakespeare are
not the only skills English majors graduate with; in order to
do either of those things, one must have the abilities to interpret, deduce, distinguish important details from a sea of unimportant ones – analyzing literature is one of the best ways,
I believe, to hone those skills. Table 1 supports this opinion.
Yet, while pre-health requirements are equal to, if not
greater than, those of the average major at most colleges, of the
more than seven science and math classes, medical schools usually require only one English class, making that one course seem
like an afterthought rather than a subject to be appreciated in the
context of medicine. Literature or art classes, if taken seriously,
could amplify the skills learned from science courses. Overall,
it is for this reason that students hoping to become doctors
should be encouraged, not to shift their main point of focus, but
to expand it, to the humanities, specifically literature and art.
REFERENCES
Association of American Medical Colleges. Average MCAT
Scores by Selected Majors, Table 1. (2010). American Institute of
Physics Statistical Research Center. Retrieved March 27, 2012 <http://www.aip.org/statistics/trends/reports/mcat2009.
pdf>.
Bates C. (2011). “Is this a symptom I see before me? Reading
Shakespeare helps doctors understand patients’ mental state.”
The Daily Mail. Retrieved on February 29, 2012 <http://www.
dailymail.co.uk/health/article-2065646/Reading-Shakespearehelps-doctors-understand-patients-mental-state.html>.
CBC News. “Art classes improve diagnostic skills of medical students.” (2008). CBC News. Retrieved on March 3, 2012
<http://www.cbc.ca/news/arts/artdesign/story/2008/08/18/artmedicine.html?ref=rss>.
Miksanek T. (2009). “Seven Reasons Why Doctors Write.”
Literature, Arts, and Medicine Blog. Retrieved on February 29,
2012 <http://medhum.med.nyu.edu/blog/?p=151>.
Naghshineh S, et al. (2008). Formal art observation training
improves medical students’ visual diagnostic skills. Journal of
General Internal Medicine. 23(7): 991-997. 3 Mar. 2012.
Panda SC. (2006). “Medicine: Science or Art?” Mens Sans
Monographs. 4(1): 127-138. 3 Mar. 2012 <http://www.msmonographs.org/article.asp?issn=09731229;year=2006;volume=4;issu
e=1;spage=127;epage=138;aulast=Panda.>
Photograph. Metrolic. Web. <http://www.metrolic.com/wpcontent/uploads/2010/12/dr_house.jpg>.
Portrait of W. Shakespeare. Digital image. The Complete Works
of William Shakespeare. Web. <http://shakespeare.mit.edu>.
Shapiro J, Rucker L, nd Beck J. (2006). Training the clinical eye
and mind: using the arts to develop medical students’ observational and pattern recognition skills. Medical Education. 40(3):
263-268. 3 Mar. 2012.
Table 1. Average MCAT Scores by Selected Majors, 2009 (AAMC).
Vannatta J, Schleiffer R, and Crow S. (2005). “Literature helps:
listening to the narrative of medicine.” The Lancet. 365(9475):
1919-1920. 25 Feb. 2012.
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Oriol
About the Author
Pauline Woo is a pre-med sophomore in the College of Arts and Sciences majoring in English. She plans to go
on to medical school after graduating, and hopes to become an Emergency Room doctor. Biology is her favorite science,
and T.S. Eliot is her favorite writer. She is currently studying abroad in NYU London, and loving it.
The Importance of Health
Literacy in Child Obesity
Prevention
By Raphaelle Oriol
“By using measures to identify parents with low health literacy,
interventions can potentially correct modifiable child obesogenic
behaviors, and reduce obesity.”
The obesity epidemic in the United States undoubtedly threatens the lives of American children. Rates of obesity are
increasing rapidly despite efforts to promote healthy lifestyles.
Currently, over 30% of children in the US are either overweight
or obese, where juvenile obesity in 1970 was less than 5%. 2
While healthcare professionals once worried that overweight
and obese children would become overweight and obese adults,
now their concerns have accelerated because of the risk of developing cardiac disease, hypertension, and elevated lipid levels;
58% of overweight school kids have at least one modifiable risk
factor for cardiac disease and have three times the risk of hypertension and twice the risk for elevated lipid levels. 16 Currently,
two relationships have been deduced in the recent development
of child obesity prevention: there is a correlation between low
parental health literacy and numeracy skills, and poor child
dietary behaviors and health outcomes; simplifying health
information for parents is key in minimizing child obesity.
One study reveals the importance of understanding the
intersection of culture, language, and literacy in order to better
understand health literacy’s role concerning health disparities
in child obesity.1 Since low-literacy individuals are concentrated
in culturally diverse groups, especially those with populations
of limited English proficiency, it is crucial to acknowledge racial
and ethnic minority groups because 45% of low-literate Americans are members of minority groups. These members of minority groups are often wary of Western medical practices, and
there is a wide gap between the health care of the members of minority groups and that of Whites.1 (See Appendix A) Considering health literacy, cultural competence, and linguistic compe-
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tence, this study concludes that minorities may not understand
health information within the constraints of Western medicine.
A parent’s age, income, race, and educational status with respect to literacy explains why rates of obesity are
highest among children of lower socioeconomic and minority communities.4 (See Appendix A) For example, MexicanAmericans and African-American children aged 4 and 5 are
most obese in the US.7 Income, geography, and culture influence parents’ perceptions of weight and lifestyle choices, which
can cause obesogenic behaviors and obesity outcomes.7 Perceptions that can lead to obesity outcomes include the notion
that formula is better than breast milk, babies need more than
milk or formula to feel full, and sugary drinks are acceptable.
While the connection between literacy as influenced
by race and child obesity is valid, there is a more direct relationship between mothers’ literacy and potential child obesity. The American Medical Association (AMA) as defines
health literacy: “a constellation of skills, including the ability to perform basic reading and numerical tasks required to
function in the health care environment.” 5 Parents with low
health literacy lack the necessary reading and numeracy skills
that enable them to properly interpret health information.
A study shows that mothers with better reading skills
are more likely to breastfeed their children because they tend to
be more informed about the proven benefits of breastfeeding.6
Therefore, their children are half as likely to become obese because babies who are breastfed longer tend to drink sugary drinks
less often than babies who were not breastfed and introduced
to artificial juices.14 Kids with at least a year of breastfeeding
who eschew such drinks are 60% less likely to become obese.14
Another factor that affects a baby’s future health is
a parent’s self-efficacy, which is confidence in his or her capabilities to achieve a desired result.13 In conjunction with
low-literacy, a parent may experience low self-efficacy and
feel discouraged. Low self-efficacy can lead to an inability to
breastfeed appropriately, make healthy lifestyle choices, and
control portion sizes. More importantly, the motivation to
seek and understand health information has a significant influence on communication and relationships with physicians,
decision-making, medical adherence, and health outcomes.17
Despite the unmistakable connection between
health literacy, patient behaviors, and health outcomes, there
has been limited success in deriving interventions based
on such links. The modest interventions generated to reduce obesity underestimate the relative ties between literacy
and health outcomes, and have been ineffective.6 Currently,
most health information is written at a 10th grade reading
level when the average American adult has 8th grade reading skills.18 Before effective interventions targeting health literacy can be created, researchers must first determine literacy and numeracy trends among variant populations so that
they can incorporate their findings into new interventions.
To measure health literacy as a means of designing
adequate interventions, researchers rely on instruments that
test reading recognition, reading comprehension, and numeracy skills. The Rapid Estimate of Adult Literacy in Medicine
(REALM) and the Test of Functional Health Literacy in Adults
(TOFHLA) are the most frequently used generic measures in
assessing health literacy.17 In addition to the REALM and TOFHLA, the Newest Vital Sign (NVS) measure is used to screen
parents. The TOFHLA assesses literacy by ranking subjects
based on their score after subjects answer several fill-in-theblank questions, prompts for interpreting bottle instructions,
and appointment slips; this measure tests reading comprehension and numeracy skills.3 Unlike TOFHLA, REALM assesses
literacy based on a subject’s pronunciation of medical terms
and utilizes a word-recognition list composed of health-related
terms in order of increasing difficulty. Only subjects who score
within 90 to 100% of the total number of words are considered to exceed a ninth-grade reading level and have adequate
literacy.11 One study shows that the NVS reveals a person’s literacy level in less than three minutes by using the nutritional
information on a food label to test the subject’s comprehension.
Even though the NVS is an effective test of literacy, it works in
conjunction with more elaborate measures.15 (See Appendix B)
By using measures to identify parents with low
health literacy, interventions can potentially correct modifiable child obesogenic behaviors, and reduce obesity. Detecting low-literacy populations gives an opportunity to address
pediatric obesity through interventions geared toward improving communication between doctors and patients and
simplifying health materials. In the Green Light Study, which
is funded by the National Institute of Health, researchers have
found that while pediatric clinics serve one in five of the nation’s low-income families who rate highest for low-literacy
and child obesity, many pediatric residents lack sufficient
health communication training. Those at Green Light believe
that improving pediatric residents’ communication abilities
and awareness of low-literate parents will optimize caregivers’ understanding and promote better lifestyle choices and
behaviors; improving physician self-efficacy will result in improved caregiver self-efficacy for positive behavior change.
Because physicians are responsible for educating parents about child health, there is an interconnection among the
capacities of pediatricians and parents, health literacy, and child
health outcomes. Effective literacy-based interventions should
be directed at simplifying health information and improving
communication skills of physicians in order to improve caregiver awareness, behavior, and perceptions of child obesity.
REFERENCES
1. Andrulis, Dennis P., and Cindy Brach. “Integrating Literacy,
Culture, and Language to Improve Health Care Quality for Diverse Populations.” American Journal of Health Behavior (2007):
S122-133. ProQuest Medical Library. Web.
2. Barlow SE. Expert committee recommendations regarding
the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics.
2007;120 Suppl 4:S164- S192.
3. Berkman, Nancy. “Literacy and Health Outcomes, A Systematic Review of the Literature.” Agency for Healthcare Research
and Quality. Print.
4. Center for Disease Control and Prevention. Health, United
States. Table 75. 2007.
5. Committee on Health Literacy. Health literacy: report of the
Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical
Association. Jama. 1999;281:552-7.
6. DeWalt, Darren A., Nancy D. Berkman, Stacey Sheridan,
Kathleen N. Lohr, and Michael P. Pigone. “Literacy and Health
Outcomes, A Systematic Review of the Literature.” JGIM
(2004): 1228-239. Web.
7. Fitzgibbon ML, Stolley MR, Dyer AR, VanHorn L, KauferChristoffel K. A community-based obesity prevention program
for minority children: rationale and study design for Hip-Hop
to Health Jr. Prev Med. 2002;34:289-297.
8. Gillman MW, Rifas-Shiman SL, Camargo CA, Jr., et al. Risk
of overweight among adolescents who were breastfed as infants.
Jama. May 16 2001;285(19):2461-2467.
9. Kutner, M., Greenberg, E., Jin, Y., Boyle, B., Hsu, Y., and
Dunleavy, E. Literacy in Everyday Life: Results from the 2003
National Assessment of Adult Literacy. NCES 2007480. 3-32007. US Department of Education.
10. Leunissen RW, Kerkhof GF, Stijnen T, Hokken-Koelega A.
Timing and tempo of first-year rapid growth in relation to cardiovascular and metabolic risk profile in early adulthood. Jama.
Jun 3 2009;301(21):2234-2242.
11. Osborn, Chandra. “Measuring Adult Literacy in Health
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Care: Performance of the Newest Vital Sign.” American Journal
of Health Behavior (2007). ProQuest Medical Library. Web.
NIH, 2010. Web. 12 Jan. 2012. <http://www.ncbi.nlm.nih.gov/
pubmed/20207930>.
12. Pignone MP, Rothman R, Malone R, Bryant B, Horlen C.
The Impact of Literacy on the Effectiveness of a Comprehensive
Diabetes Management Program. Journal of General Internal
Medicine. 2001;16 (Suppl 1):165.
16. Williams CL, Strobino B, Bollella M, Brotanek J. Body size
and cardiovascular risk factors in a preschool population. Prev
Cardiol. 2004;7:116-121.
17. Wolf, M. S., E. A.H. Wilson, D. N. Rapp, K. R. Waite, M. V.
Bocchini, T. C. Davis, and R. E. Rudd. “Literacy and Learning
in Health Care.” Pediatrics 124.Supplement (2009): S275-281.
Print.
13. Porr, Caroline. “Health Literacy as an Empowerment Tool
for Low-Income Mothers.” Fam Community Health 29.4
(2006): 328-35. Print.
14. Seaman, Andrew M. “Sugary Drinks Tied to Breastfed Kids’
Weight.” Reuters (2012). Web.
18. Yin, H. S., M. Johnson, A. L. Mendelsohn, M. A. Abrams, L.
M. Sanders, and B. P. Dreyer. “The Health Literacy of Parents in
the United States: A Nationally Representative Study.” Pediatrics
124.Supplement (2009): S289-298. Print.
15. Shah, Lisa. “Health Literacy Instrument in Family Medicine:
The “Newest Vital Sign” Ease of Use and Correlates.” Pub Med.
Appendix A
Heal Literacy Trends by Demographic
A-2
A-1
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Appendix B
Generic Health Literacy Measures and Findings
B-1
A-3
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B-2
B-3
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Appendix C
Connections Between Individual Capacity, Literacy, and Outcome
C-1
B-4
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Oriol | Miller
Miller
About the Author
Raphaelle Oriol is a sophomore pre-med student studying public health in Steinhardt. He has been working as
a research intern on a childhood obesity prevention study, taking place at Bellevue Hospital. Since becoming an intern,
I have developed a passion in pediatric obesity interventions. I look forward to continue participating in further research
concerning obesity.
Evaluation of Transcranial
Magnetic Stimulation for
the Treatment of Major
Depressive Disorder
TMS Device
By Sabrina Miller
“[Depression]…is currently estimated to be the fourth leading cause of
disease worldwide, and is predicted to rise to second place, behind heart
disease, in fewer than 10 years.”
Major depressive disorder (MDD) is a clinically diagnosed mood disorder that may cause significant distress
or impairment in social and occupational functioning in affected individuals. The hallmark symptoms of depression include depressed mood most of the day nearly every day and/
or a diminished interest or pleasure in activities that were formerly enjoyable for at least two weeks. Additional symptoms
include: feelings of guilt and worthlessness, loss of energy,
difficulty concentrating, and disturbed appetite and sleep patterns (First, Spitzer, Gibbon, & Williams, 2002). Approximately
one of every six individuals will develop clinical depression
throughout his or her lifetime, making it the most prevalent
DSM-IV-TR Axis I disorder. Moreover, it is currently estimated to be the fourth leading cause of disease worldwide, and
is predicted to rise to second place, behind heart disease, in
fewer than 10 years (Mount Sinai School of Medicine, 2011).
The most common form of treatment for MDD currently in use is antidepressant medication. However, roughly
30% to 40% of patients treated with antidepressants will not
experience notable symptom relief, even after trying two different drugs of adequate dose and duration. Complete remission of depressive symptoms is even less common (Warner &
Bobo, 2009). In addition to psychopharmalogical treatments
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for depression, there have been a number of other therapies developed in recent years, such as brain stimulation techniques.
Transcranial magnetic stimulation (TMS) is a recently
developed treatment that uses magnetic pulses that activate
specific areas of the brain associated with depression, such as
the dorsolateral prefrontal cortex (Krishnan & Nestler, 2008).
Although the mechanism by which the therapy functions is still
unknown, it is believed that regulation of neural excitability,
that is, the firing of neurons as a result of stimulation, plays
a key role. Electroencephalograph readings demonstrate that
TMS alters the oscillation of alpha waves across brain tissue.
This cortical oscillatory activity is postulated to maintain connections throughout cortical areas of the outer brain and to the
thalamic structures deep in the brain in order to coordinate
brain activity. This coordination is possible because alpha waves
can synchronize, thereby binding areas of the brain together
in preparation for performing a task. This process is called an
event-related synchronization (Mount Sinai School of Medicine,
2011). TMS may exert its effects by resetting cortical oscillators
and entraining alpha bands together based on the frequency of
its pulses (Thut & Miniussi, 2009). Previous clinical trials on repetitive TMS treatments have been shown to have longer lasting
antidepressant effects and are believed to alter neural plasticity
and foster long-term potentiation, an enhancement in signal
transmission between neurons resulting from synchronous
electrical or magnetic stimulation (Krishnan & Nestler, 2008).
While repetitive transcranial magnetic stimulation has
shown statistically significant effects, the clinical significance of
these effects has been questioned. Previous studies on the device delivered mixed results and often did not adequately mask
the sham conditions (George et al., 2010). However, a series
of recent TMS trials are beginning to show evidence that this
antidepressant treatment does reduce depressive symptoms to
levels that are clinically meaningful. For example, a National
Institutes of Health–sponsored trial of high-intensity rTMS
for at least 3 weeks of daily treatment was significantly more
likely than the sham arm to result in remission in antidepressant medication–free patients with moderate treatment-resistant unipolar major depressive disorder (George et al., 2010).
In this study, the researchers delivered rTMS to the left
prefrontal cortex at 10 Hz for a 4-second train duration with
an intertrain interval of 26 seconds. The total session time was
37.5 minutes, with 3000 pulses per session using a solid-core
coil. The sham rTMS arm was an identical apparatus except
that it contained a metal insert that effectively blocked the magnetic field from the scalp. The somatosensory sensations were
the same in both arms to maintain double-blind conditions.
The primary efficacy outcome was remission in the
intent-to-treat sample (n=190, 92 active, 98 sham), defined as
a Hamilton Rating Scale for Depression (HAM-D) score of less
than 3. The analysis of this outcome revealed a significant effect
of treatment on the proportion of remitters (14.1% active rTMS
and 5.1% sham) (p = .02). Achieving remission was 4.2 times
greater with active rTMS than with sham (95% confidence interval, 1.32-13.24). However, most remitters had low antidepressant treatment resistance. Almost 30% of patients remitted
in the open-label follow-up (30.2% originally active and 29.6%
sham). The secondary efficacy outcome, defined as the number of treatment responders, revealed that there 19 responders
(10.0%) (15% active and 5% sham) in the ITT sample (P = .009).
While this study has added to the growing literature
that demonstrates the rTMS is a statistically significant treatment for major depressive disorder, one may still reasonably
hesitate to conclude that this treatment has had clinically significant results. For example, while the number of remitters was
greater for the active arm than the sham arm, only 13 of 92
participants receiving active treatment achieved remission and
14 of 92 active treatment participants responded. Viewed in an-
“Roughly 30% to 40% of patients treated with antidepressants will not experience notable symptom relief,
even after trying two different drugs of adequate dose
and duration.”
other way, 65 of 92 participants (70.7%) receiving the active arm
did not respond to treatment. Thus, while rTMS may show improvement in symptoms over no treatment at all, this study has
shown that it is effective only 30% of the time. Moreover, it has
demonstrated that remission mostly occurs in patients who had
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Electroconvulsive Therapy
low treatment resistance. In a study of only high treatment-resistant patients, the efficacy of rTMS could dramatically decrease.
Other trials of rTMS have compared this treatment
with other stimulation techniques, such as electroconvulsive
therapy (ECT). For example, a randomized trial of rTMS vs.
ECT was performed on 25 patients (Janicak et al., 2002). Those
assigned to the rTMS arm received 10-20 treatments at 10Hz
with 3000 pulses per session, while those assigned to the ECT
arm received 4-12 treatments of bilateral electroshock. The
primary efficacy outcome was defined as a 50% reduction in
HAM-D scores from baseline and a final score of less than or
equal to 8. This study revealed that there was no significant difference between the two treatment groups. Thus, this 2-4 week
trial has shown that rTMS and ECT have comparable therapeutic effects in patients who have treatment resistant depression.
However, some studies have shown differences in safety measures between the two treatments, especially in terms of
cognitive disturbances (University of Aarhus, 2008). Electroconvulsive therapy, while generally much safer today than in
the past due to the controlled administration of anesthesia, may
still have negative side effects in some patients. The most common adverse events are memory loss and confusion. The most
common adverse event in rTMS is a headache, treatable with aspirin. Moreover, headaches were common complaints for both
the active and sham arms, rather than for the active arm alone
(George et al., 2011). In addition, rTMS allows focal stimulation of the brain, does not inducing epileptic seizures, and does
not require anesthesia (University of Aarhus, 2011). Compared
to ECT, the side effects of rTMS are considerably mild. Therefore, rTMS is generally deemed safer to administer than ECT.
Other trials of TMS have shown detrimental effects on
task performance, such as a simple memory test, rather than
enhancement effects. To explain this phenomenon, researchers have proposed that the inhibition or facilitation of task performance may be based on the relation between TMS pulses
and an individual’s intrinsic alpha frequency (as cited in Mount
Sinai School of Medicine, 2011). The closer the TMS pulse frequencies are to the subject’s own alpha frequency, the better
the performance. Conversely, the farther away the TMS pulse
frequencies are to the subject’s alpha frequency, the worse the
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performance. NeoSync, Inc. has developed such a device that
delivers alternating magnetic fields that correspond to intrinsic
alpha frequencies for each individual participant based on an
EEG reading performed before stimulation. Currently, there
are open trials for this investigational device that are recruiting subjects at several hospitals across the United States. One
of these research locations is Mount Sinai School of Medicine.
This EEG-synchronized TMS (sTMS) device will take
an electroencephalography reading prior to each treatment.
Treatment will consist of inducing intracerebral currents by
delivering a low emission sinusoidal magnetic field set at the
average intrinsic alpha frequency calculated from each participant’s EEG. This magnetic stimulation will be delivered to each
participant using three 1-inch diameter, diametrically magnetized neodymium magnets that rotate with a surface field of
0.64 Tesla. The device is placed over the participant’s scalp so
that the magnets may stimulate the left dorsolateral prefrontal
cortex. The magnetic field will pass unimpeded across the skull
and convert to an electric field in the brain, inducing electrical
activity in neurons located beneath the coil. Treatment will be
standardized at 120% magnetic field intensity at 10 pulses per
second for 4 seconds, with an intertrain interval of 26 seconds.
Treatment sessions will last for 30 minutes with 2400 pulses delivered. The sham control treatment procedure will be identical
to the active control, as the sham device is designed to mimic the
somatosensory experience of the active treatment despite the
absence of alternating magnetic fields. All treatment sites will be
kept blind to the assignment code, and only the manufacturer
knows the assignment (Mount Sinai School of Medicine, 2011).
The researchers of this 6-week study anticipate
that sTMS will have greater treatment efficacy compared to
sham. It is possible that this treatment device will also have
greater efficacy compared to rTMS. However, more research
will need to be conducted to confirm this hypothesis. There
are no adverse effects predicted for sTMS and it is predicted
that sTMS will have similar side effects compared to rTMS.
More research also needs to be done in order to as-
“TMS has shown some preliminary promising results [in
the treatment of depression].”
sess the longitudinal therapeutic effects of TMS in severely depressed patients. While many TMS trials have demonstrated
that this treatment has statistically significant effects for the
duration of the study, few have measured the long-term effects of this treatment. Those study designs that have included
a follow-up evaluation typically only have a follow-up period of
a few weeks, such as the NeoSync trial at Mount Sinai School
of Medicine (2011). Thus, it is not known whether TMS responders continue to respond after several months or years.
While TMS has shown some preliminary promising
results, more research, such as that currently being conducted
as Mount Sinai, needs to be performed. While this treatment
has shown statistically significant results, it is not yet conclusive
that this treatment has a substantial clinical impact. In particular, this clinical impact is not well understood as the time since
treatment increases. Moreover, few studies have compared
TMS to other stimulation treatments, such as ECT, deep brain
stimulation, or vagus nerve stimulation. A study comparing
these therapies would be particularly useful to those evaluating
treatment options for treatment-resistant depressed patients.
At this stage in clinical research on TMS, it is difficult to conclude whether the device has clinical significance in the treatment of major depressive disorder. However, given new trials,
such as EEG-synchronized transcranial magnetic stimulation,
researchers are hopeful that the device might be proven to be
clinically significant as more thorough research is conducted.
If you or anyone you know is interested in participating in the EEG-synchronized transcranial magnetic stimulation
trial for treatment-resistant depression at Mount Sinai School of
Medicine, please contact Dr. James Murrough at (212) 241-7574.
REFERENCES
“Brain Stimulation Therapies.” NIMH ·. Web. <http://www.
nimh.nih.gov/health/topics/brain-stimulation-therapies/brainstimulation-therapies.shtml>.First, M. B., Spitzer, R. L., Gibbon,
M., & Williams, J.B. (2002). Structured Clinical Interview for
DSM-IV- TR Axis I Disorders, Patient Edition (pp. A1-A5). New
York, NY: New York State Psychiatric Institute
netic stimulation versus electroconvulsive therapy for major
depression: preliminary results of a randomized trial. Biological
Psychiatry, 51(8), 659-667.
Krishnan, V., Nestler, E. J. (2008). The molecular neurobiology of depression. Nature, 455(7215), 894-902. doi:10.1038/
nature07455
McIntyre, Will. Electroconvulsive Therapy. Digital image. Photo
Researchers, Inc. Web. 24 Mar. 2012. <http://www.webmd.com/
depression/ss/slideshow-depression-overview>.
Mount Sinai School of Medicine, Psychiatry Department,
Mood and Anxiety Disorders Program. (2011). Evaluation of
low emission NeoSync EEG synchronized TMS technology for
the treatment of major depressive disorder. (MSSM Study No.
HSM#11-01210).
University of Aarhus (2008). The Antidepressant Effect of Repetitive Transcranial Magnetic Stimulation (rTMS) Compared
to ECT. (ClinicalTrials.gov Identifier No. NCT00299403). Available from http://clinicaltrials.gov/ct2/show/ NCT00299403.
Warner, C. H., Bobo, W. V. (2009). Mood disorders. In L.W.
Roberts, J. G. Hoop, & T.W. Heinrich (Eds.), Clinical Psychiatry
Essentials (pp. 181-206). Philadelphia, PA: Lippincott Williams
& Wilkins
George, M. S., Lisanby, S. H., Avery, D., McDonald, W. H.,
Durkalski, V., Pavlicova, M… Sackeim, H. A. (2010). Daily Left
Prefrontal Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder. Archives of General Psychiatry, 67(5),
507-516.
Janicak, P. G., Dowd, S. M., Martis, B., Alam, D., Beedle, D.,
Krasuski, J…Rosen, C. (2001). Repetitive transcranial mag-
About the Author
Sabrina Miller is a senior, graduating this May with a BA in Psychology. She is also a pre-medical student and
plans to apply for medical school for Fall 2014. During her two-year gap, she plans to continue conducting research on
mood disorders at Mount Sinai School of Medicine. The focus of her work has been on treatment for patients with depression and bipolar disorder. She is particularly interested in neuroscience and clinical trials pertaining to brain stimulation treatments. As an aspiring physician, she would like to study psychiatry or neurology and continue doing research in
addition to having a medical practice.
Volume 10
MEDICAL DIALOGUE REVIEW
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