Monday, April 30, 2007

Chasing Placebo's Ghost

Gaining insight into the origins of magical thinking in medicine

Like a ghostly apparition that flirts just beyond the reach of our grasp, the placebo has seemingly evaded capture and clear definition by modern medicine, at least within the context of real world practice.
Paradoxically, the apparently real, yet illusory and mysterious placebo "effect" creates a quandary within modern medicine that beckons for serious consideration. Practitioners, patients, or persons involved one way or another in medical practice need to strive for a deeper, more comprehensive understanding of this phenomenon. Can we define a placebo? How does the placebo impact health and disease? Is it real?
Indeed, there is question whether the placebo as a discreet entity truly exists. There are many studies that find no evidence for any placebo effect and in fact attribute any supposed effects to other natural causes. Other studies allude to psychosomatic placebo influences on the perception of an illness. Still others point to social and cultural origins of placebo "beliefs". In essence, it seems that today, the placebo can be best understood as an general umbrella term. It seems to have become a "catch phrase" that embraces a variety of properties confusing perceived effects with naturally occurring and variable phenomena. Additionally, the highly volatile and subjective world of human emotion and belief add to the mystique of the placebo.
By gaining insight into the realm and impact of the placebo and exploring associated phenomena we can better understand its appropriate place in medicine. In other words, differentiating the placebo effect from other common characteristics of the disease process avoids a reliance on the placebo for imagined therapeutic effects by even well meaning healing practitioners.
Interestingly, after examining over 800 studies related to the placebo effect, researchers at the Institute for Applied Theory and Methodologies in Health Care found that approximately 60% of disease in these cases resolved spontaneously (This percentage may be smaller in veterinary medicine). Known as statistical regression, this is part of the natural variability observed with disease. Therefore as practitioners we need to realize that their are natural factors other than the placebo that influence apparent therapeutic effect. Studies like these are part of an ongoing process of understanding and illustrates the importance of having a broad knowledge of the natural history of disease.
That is, how does a disease proceed with out any intervention at all? Lacking this knowledge, it is easy to see how confounding and confusing factors can influence the interpretation of a given therapeutic effect and how it is perceived by the clinician, not to mention a lay person. In addition, the matter is further complicated if we lack an efficient system by which to critically evaluate our treatments of diseases. As clinicians, we need to be able to discern the difference between what we do and the natural processes and responses of how the body reacts to disease.
In twenty years of practicing veterinary medicine, I have often come across the placebo effect within the realm of the client/pet/doctor relationship. It has manifested in may ways. The very simple act of entering the exam room can have seemingly magical effects on the pet or clients attitude. The placing of hands on the pet, or acknowledging the clients emotions has often bridged a communicative space creating a sense of bonding and trust. This sometimes seems to have an influence on the perceived responses to a given action by the doctor.
These interesting effects made me realize that their is a grey amorphous world, like the fleeting image just beyond ones visual periphery we alluded to earlier that seemed to impact my practice of medicine. A multitude of questions came to mind. What is this thing? Are there powers beyond my senses? Is this a form of magic?
In time, I eventually began to come to some basic realizations. Being of average intelligence, it has been a rather circuitous road, at times perilously close to losing myself to the mystic netherworld of magical thinking. Eventually though, I learned how to ask the right questions and critically think through these often confusing concepts. Broadening my comprehension of the natural sciences and how people interpret them brought about a much more balanced perspective of medicine than I previously held.
Fundamental interactions such as presence, conversation, eye contact, touching and smiling seemed to tangibly influence how well I reached my clients. I came to understand the wonderful impacts and frustrating limitations of what could be reasonably offered to my animal patients and their human charges.
This journey in veterinary clinical medicine has made me realize the wonder and beauty of the world as it truly is. No need for superlatives and imaginary beings; reality is "magical " enough to far exceed our wildest expectations.

Sunday, April 29, 2007

The Song and Dance of the "Extreme Social Hominid" - part 3

The Dance

" That place between your steps as you
dance... that is where the real dance lies."
Pierre Dulane

Ah, the dance! Here we are talking about a quality that has likely, in some form, accompanied all of our hominid lineages and those creatures before them, and so on. This is indeed an ancient skill, and though humankind has put a unique flavor to it, it goes back millions of years.

There are few truly primal, direct ways to reach our primitive cooperative yearnings than the moving pattern. A good dance reaches deep into our essence. It is connected to primordial needs associated with powerful urges of survival, kin ship, and meaning. As mentioned, humankind is the supreme social hominid and has achieved an unsurpassed skill of intraspecies interaction that favors survival in multidimensional ways. For example, movement elements of dance provide venues for sexual discourse or for expressing varying belief systems by reflecting common cognitive patterns and associations. From an evolutionary perspective, this can favor and optimize survival behaviors such as procreation and tribal bonding.

But that is not the point.

Homo sapiens have become a master of creating pattern associations linked to these survival mechanisms. They likely stem from the need to have some control and power over nature and the unknown. Complex associations became outgrowths of these profound origins. For example, evolutionary sociologists researching the origins of religiosity have come up with two plausible theories. Religion may be a by-product of some deeper mechanism for survival, or it could, in itself be a survival mechanism.

These pattern associations did not necessarily have to reflect reality as it was, they just needed to favor the primordial call to survive. Fascinating as these investigations may be, the roots of dance likely grew with concepts related to cooperative behavior and fundamentally predates elaborate religiosity and ritual. That is, dance seems to lie at the core, and like the layers of an onion, is followed by other human societal elements such as budding religious beliefs and cultural tribalism.

Indeed, dance has been called the silent language. It is an immensely effective communicative tool that even today has the power to bridge language and cultural gaps. Because it is a core quality of the extreme social hominid, it transcends many of the cultural barriers that have surfaced across the social history of humankind. It is a quality that harkens back to a time of unwritten rules and small tribal groups.

Dance serves a profound educational purpose. It teaches the art of cooperation and behavioral practice, and to some extent, acts as a primal moral compass. It reflects a mirror image of the society from where it emerges. It blends the cognitive features of humankind with emotionally vivid or primitive reactions. That place where they meet can be considered the dance; the art, the meaning.

This is the point; This is the space between the steps.

Saturday, April 28, 2007

The Song and Dance of the "Extreme Social Hominid": Homo Sapiens' Way- part 2

The Song

Humankind is not the only living organism possessing a strong social quality. The animal kingdom is replete with species rich with social interactions, kin ships, and relationships. Among the common tools utilized is sound in the form of song. In fact, song and rhythm resembling music forms part and parcel of many types of animal communication from Cicadas to Meer Kats.

Interestingly, the enormous repertoire of biological songs including the beautiful staccato warnings and alarms, as well as the entrancing whistles and moans of intraspecies communication all work within a relatively narrow range of combinations and apparent meaning. The rhythm and deportment of discussion within the animal kingdom is fairly straightforward, and with some exceptions, one-dimensional.

Any hominid noise resembling song and dance probably predated language and likely had basic repetitive patterns relating to primitive communication and general survival. What is so interesting with modern man is our ability to combine notes in different ways; to go beyond simple copy or basic meaning. This seems to be a critical precursor to actual human language and song. Therefore, what makes a song so uniquely human is the way it is put together. Humankind discovered a way to burst through the more common threads and formulas of animal communication.

Humankind's cooperative efforts through time may have been one of the root triggers that allowed for the development of an ability to uniquely thread ideas represented in symbols or notes together as language and song in infinite combinations, allowing for multi-dimensional dialogue.

This amazing capacity could have seeds some time in the last 6 million years during a period of severe global climate change, which may have spurred the creation of new primate lineages, one of whom are our distant ancestors.

Intriguing studies in genetics and paleonuerology are discovering tantalizing clues in the form of transforming genes and shifting biochemical function that shed light on the origin of brain structure and function. This amazing information suggests that even though hominids had big brains 600,000 years ago, and though modern man lived up to 200,000 years ago, it was only in the last 50,000 years or so that evidence of art, language, and culture appears in the fossil record. Fascinatingly, this latter development is also associated with the emergence of new genes which reflect a structural neurological change and may have influenced human memory, symbolic thinking, and advanced language.

All this incoming information is beginning to suggest that hominid evolution consisted of several fits and starts separated by periods of little or no change as it was molded by the force of natural selection. Therefore basic elements of language and cognition reach back before the dawn of Homo sapiens. That said, it appears that the Homo sapiens lineage took song and language to infinite and exquisite combinations ( I wonder what the "Geico caveman" would say).

In addition, genetic studies discovered a recently emerged gene, involved with brain size, which appeared only around 5,000 or 6,000 years ago, just as the first human cities appeared. This is a powerful indication that Homo sapiens, even today continues to evolve and change.

As a greater understanding of the making of humankind's song is gathered from these and other studies, we find that our conceptualization of consciousness and intelligence continually changes and expands. The flexibility, plasticity, and sometimes minor cognitive adjustments leading to major cultural shifts of the hominid mind calls to the "extreme social hominid" to be humble as it considers its place in this universe.

Next post: Part 3: The dance

Friday, April 27, 2007

The Song and Dance of the "Extreme Social Hominid": Homo Sapiens' Way - part 1

Imagine if we could go back to those first tentative baby steps of humanities earliest social awakening. There, sparsely scattered throughout the rolling hills of an immense savanah, tiny groups of our ancestral hominid lineage first began to look across the vastness with a novel curiosity forged and steeled by the relentless need to survive.

Mysteries and dangers abounded everywhere. A thin line separated death from a full stomach and these lonely hominids desparately struggled to discern the difference. The need to garner some kind of meaning out of their surroundings was of extreme urgency. Anywhere along the way, this small spark of humanity could have been snuffed out. A severe drought or a great fire at just the wrong moment in time might have forever silenced this upstart mammal to anononimity lost among the cracking and folding of a changing world.

Here with that incessant compulsion to grasp from the world anything useful, anything edible, he found some solace. Together with his close kin he had some small chance to be, to breath. Associations, patterns, and meanings came of these elemental needs. As the eons passed, man stumbled on a way.

Here deeply intertwined within the reflexive autonomic responses and primordial instincts, there began to stir something else. It was a more nuanced yet spectacularly successful means of survival involving complex interactive cooperation and comunication with siblings, cousins, friends, and eventually other more extended groups. Though not particularly a new system as the world of life goes, these early hominid groups put their own spin on these cooperative efforts.

Some 125,000 years ago at first little by little, then later in earnest the "extreme social hominid" slowly coalesced simple grunts and cries to song and meandering steps and gesticulations to dance and gradually became human. The eons moved inoxerably on, as they will, and these humans survived.

On and on, from these humble beginings, ever more complex and nuanced forms of cooperative effort gave way to increasingly elaborate social and cultural constructs. It is important to remember that all of these advances pale in comparision to that far off moment in time, that epiphany, when a small primate raised its hungry gaze across some dry savanah, and as wonder and hunger overcame fear, took that first fateful step.

Among the early cooperative tools our ancestors appeared to use, song and dance seem to be a link from our deep, deep past to who we are today. The very make up and structure of our brains seems to be adapted for this way of being. If you extend this further, the seeds of belief, religiosity, and societal potential may have origins somewhere in this maze of tribal Pleistocene interactions. The glimmerings of a hominid species overtaking the world could be glimpsed through the powerful cohesive bonding song and dance created.

Let us take a moment to consider these two tools so profoundly ingrained into our way of being. Though song and dance are among our most ancient social tools, likely predating even the 30,000 year old cave paintings of southern Europe, they remain prescient and fresh as ever today. They have stayed with us; they are us.

Admittedly, while it is ultimately futile to tease the song and dance forms of cooperative effort completely apart from a more profound societal whole including language, writing, and art; our humble attempt does serve to focus on the unique perspectives of each.

More on the next post.

Thursday, April 26, 2007

Evolutionary Humor

Caveat Emptor; Caveat Bestia-The Saga Continues

A 4/24 press release from the American Veterinary Medical Association (AVMA) states that the FDA investigation regarding the recent pet food contamination recall has expanded to include the quarantine of hog farms in at least five states including California, North Carolina, South Carolina, New York, Utah, and possibly Ohio. In addition, it is possible one poultry farm in Missouri may have been exposed. Unfortunately, it seems Pandora's Box may have been cracked open!

The trigger for this broadened investigation has been the detection of melamine in the urine of hogs fed "salvage pet food" originating from those manufacturers of pet food that have issued recalls due to melamine contamination. The FDA's chief veterinarian Stephen Sundlof could not confirm wether or not any of these hogs entered the human food supply. The FDA and the USDA are presently investigating this possibility noting thousands of hogs could potentially be affected.

In the US, wheat gluten and rice protein concentrate ingredients imported from China have been implicated as primary sources of the melamine contamination. Interestingly, South Africa has issued a pet food recall due to melamine contaminated corn gluten.

To date, all of the contaminated wheat gluten and rice protein concentrate located by the FDA comes from China imported through two different distributors. I am still having trouble wrapping my head around why the US, quite a large exporter of wheat would import wheat gluten back into the states.

In a recent article, I touched on an interesting internet group discussion about this:

"The vast majority of this wheat (US) is human food grade quality and fetches a premium price in the international commodities market. The Chinese wheat harvest, on the other hand, does not meet US or most other international standards for human consumption and can be an attractive cheaper alternative for some pet food companies or their suppliers...The fact that many companies are using cheap and questionable materials is because they can (lack of effective regulatory control) and because they have to (low profit margins and a highly competitive arena)."

There is an interesting take on this at David Goldsteins site HorsesAss.Org regarding the possibility of "economic adulteration".

"Testifying this morning before the House Committee on Energy & Commerce, ChemNutra CEO Steve Miller- the importer of melamine-tainted wheat gluten...explains the theory: We at ChemNutra strongly suspect, at this point, that XuZhou Anying Biologic Technology Development CO. Ltd may have added melamine to the wheat gluten as an "economic adulteration" designed to make inferior wheat gluten appear to have a higher protein content. "

What ever the case may be, there is a problem. What I didn't realize was just how far this might actually go. The AVMA press release adds that the FDA is now testing 100% of wheat gluten, rice protein concentrate, and corn gluten being imported from China. In addition, the testing is now expanding to include corn meal, rice bran, and soy protein as well. The FDA adds that these imported ingredients may be used for human consumption in products such as bread, pasta, baby formula, and pizza dough. Geees!

Though there is no evidence any of these melamine contaminated products have been sent to human food processing facilities "an expanded investigation is the prudent thing to do" the FDA release notes. Indeed!

At the end of the release it is mentioned that "the FDA will be conducting an outreach effort to communicate the need for manufacturers to know their suppliers well." Good advise for all of us.

Wednesday, April 25, 2007

The "Blog"

My intent in starting this blog is simple. I need a place and a forum to vent , rant, discuss, and ponder upon those things that interest me and perhaps a few others.

Frankly, the e-mailings to friends and family of my meandering thoughts have likely strained and stretched their tolerance for the "crazy" buddy or "mad" brother. The tell-tale frozen silence of barren responses to my posts indicates that indeed I'm quite madly shouting into the blowing winds of this little "e-ther" world. Of course, it could be that what I write is really friggin' nuts and my forced audience manages to tolerate me with clenched teeth.....

Why not then just "kick it up a notch" and shout out into the the torrent of the blogoverse. Maybe I'll meet a few bloggers willing to exchange their madness, interests, and thoughts. If nothing else, I now have a little place where these meanderings can perhaps take root and prosper.

Then again, perhaps not.

In the end, I think what matters most is the ride as "they" say.

So, into the torrent we go.......