You wouldn’t have had to watch too many episodes of my old TV show, House, MD, to hear mention of “sexually transmitted disease.” And you wouldn’t have to sit through too many medical school lectures before you heard about a “mosquito-transmitted disease,” like malaria, or a “tick-transmitted disease,” like Lyme disease.

Nowhere, however, would you ever hear about a “compassion-transmitted disease.” Yet, that’s exactly what Ebola virus disease is in humans.

With few exceptions, a person catches Ebola only through an act of compassion toward another person who has the virus.

For example, Thomas Eric Duncan, the man who died from Ebola in Dallas, picked up the virus when he helped a sick, infected woman get to a clinic in Liberia. The doctors and nurses who have contracted Ebola got it while delivering medical care to Ebola patients. Of course, lab technicians and a cleaning crew are part of the medical enterprise, too. And most of the thousands of people in west Africa who have gotten the disease were helping care for a loved one at home, or were performing post-mortem rituals as a token of benevolent love for the deceased.

Sure, there are exceptions to the compassion rule. The first patient to get the disease in any Ebola epidemic acquires it, most likely, from an animal. And perhaps there are a few cases where someone is exposed to infected body fluids while not coming to the aid of a fellow human. But, children excepted, there is no indication that disease is occurring in the current outbreak after only a coldly inadvertent exposure to body fluids.

There are two tragic ironies to the centrality of compassion.

First, for adults, callousness is effectively an excellent vaccine against Ebola virus disease. <sarcasm>So if you’re being a callous jerk, then congratulations, you’re protected from the disease.</sarcasm> It’s fortunate that Ebola is rare in human history, otherwise evolution might have removed compassion from the population.

Second, the entire epidemic could be ended very quickly if everyone in the affected regions immediately and completely discarded their compassion. In that compassionless scenario, any person who had a symptom or sign of Ebola virus disease would be instantly dumped into a well. Human-to-human transmission of the virus would immediately stop, and the epidemic would be over in a month… easy as pie.

The barbarity and utter impossibility of that scenario is an indication of how deeply compassion runs in humans. And maybe that is the inextinguishable good news in this bleak epidemic.

Rejected by the New England Journal of Medicine in 2014.
Co-authored with Stephen S. Tower, MD

Allen et al (1) courageously report a woman who underwent heart transplantation when her cardiomyopathy’s reversible cause – arthroprosthetic cobaltism (APC) from bilateral metal-on-metal hips – went undiagnosed. Endorsing their conclusion that clinicians in cardiac, orthopedic, thyroid, rheumatic, and ophthalmic specialties need improved awareness of this multi-system disorder, we would add neurologists, psychiatrists, and, especially, primary care physicians.

Cobalt causes a full spectrum of neuropsychiatric effects, from anxiety and irritability to life- threatening mood and thought disorders, plus peripheral neuropathy, cranial neuropathy, cognitive decline, and gait disorders (2,3).

Primary care physicians are likely to encounter APC early in its course, when its manifestations – including tinnitus, fatigue, disturbed sleep, nausea, “mental fog,” and headaches – are mild, non-specific, and easily dismissed as simple aging (4,5).

However, because APC is both progressive and reversible, we suggest all physicians adopt a low threshold for checking cobalt levels in at-risk patients, even those without hip complaints and those with metal-on-plastic or metal-on-ceramic hips (3).

(1) Allen LA, Ambardekar AV, Devaraj KM, Maleszewski JJ, Wolfel EE. Missing elements of the history. N Engl J Med. 2014; 370: 559-566.   Pubmed 24499215

(2) Sotos JG, Tower SS. Systemic disease after hip replacement: aeromedical implications of arthroprosthetic cobaltism. Aviation, Space, and Environmental Medicine 2013; 84: 242-245.

(3) Catalani S, Rizzetti MC, Padovani A, Apostoli P. Neurotoxicity of cobalt. Hum Exp Toxicol. 2012; 31: 421-437.

(4) Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am. 2010; 92: 2847-2851.

(5) Leikin JB, Karydes HC, Whiteley PM, Wills BK, Cumpston KL, Jacobs JJ. Outpatient toxicology clinic experience of patients with hip implants. Clin Toxicol (Phila). 2013; 51: 230-236.

First published on on Nov. 22, 2013

[In response to the question: “Do you recommend vitamin supplements for healthy people?”]

Vitamins have a good reputation. Many people think they can do only good, and never harm. Sadly, this is false.

Biologically, the only difference between a vitamin and a medication is that some amount of the vitamin is necessary for life. Once you go above that amount, however, it is better to think of vitamins as pharmaceuticals, endowed with the potential for both benefit and harm.

In short, despite their positive-sounding name, it is better to think of vitamin supplements as medications, with all their attendant risks.

For example, not many years ago, there was enormous enthusiasm for vitamin E’s potential to lower the risk of coronary artery disease, and many physicians began recommending vitamin E supplementation. Later research has shown no such benefit and, rather horrifyingly, has raised suspicions that vitamin E supplements increase the risk of heart failure. Even a vitamin having no known toxic effects at any dose, e.g. vitamin B12, can cause harm by obscuring the diagnosis of a disease.

Possibly excepting women who are contemplating or experiencing pregnancy, any decision about vitamin supplementation should be undertaken with the same deliberation used in recommending a pharmaceutical. Many supposedly healthy people (discussion of the term “healthy” is a topic unto itself) will indeed benefit from vitamin D or other supplements, but it is far safer to rephrase the question “Do you recommend vitamin supplements for healthy people?” as: “Do you recommend pharmaceutical medications for healthy people?”

First published on on Nov. 20, 2013

[In response to the question: “What is the biggest misconception people have about alternative medicine?”]

Defining “alternative medicine” is the chief pitfall in any discussion of the topic. It is a nebulous term.

The National Institutes of Health defines alternative medicine as a “non-mainstream approach [used] in place of conventional medicine” – effectively exiling it to a desert island and emphasizing that it can only be defined by its relation to mainstream medicine. The NIH notes that true alternative medicine is uncommon, because most people combine it with conventional techniques.

More helpful, I think, is viewing alternative medicine as “proto-medicine,” i.e. as techniques that may some day be adopted into conventional medicine if well-conducted clinical trials show a favorable ratio of benefit to harm.

The classic example of an alternative medicine moving into conventional medicine is the heart medicine digitalis. In the 1700s, Dr. William Withering in Shropshire, England heard that a local witch could do something he couldn’t: successfully treat dropsy (which is today called “edema”). Gaining the witch’s cooperation, Withering painstakingly discovered that, among her potion’s dozens of ingredients, the foxglove plant provided the therapeutic effect. He proved this by conducting formal trials of foxglove, whose scientific name is digitalis. All of this took nine years, but Withering, and the unnamed witch, achieved immortality in medical circles, and their work has benefitted untold numbers of patients. Digitalis derivatives remain in use today.

Physicians are (or should be) pragmatic. If something is provably successful, it deserves to be adopted into conventional medicine and to shed its “alternative” label. To make such a jump, a high level of evidence is required. Investing time, energy, or self in an approach that is unsupported by evidence, no matter how “natural” it seems, is an invitation to disappointment, and worse.

First published on on Nov. 19, 2013

[In response to the question: “Should the eligibility age for Medicare be raised?”]

No. Raising Medicare eligibility age across the board would inevitably eliminate healthcare coverage for some people who simply cannot financially afford it. Why would a compassionate nation want to do that?

At the very least, any proposal to increase Medicare’s eligibility age should add means-testing, so that persons who can afford to pay for their healthcare do so.

This will probably be insufficient, however. Healthcare is already so expensive that the percentage of the population older than 65 who can afford to buy insurance is limited (and declining). Means-testing, therefore, may not exclude enough people to appreciably lessen needs for publicly funded healthcare.

Long term, only one strategy makes sense: give people significant financial incentives to eschew unhealthy lifestyles and to adhere to proven plans that reduce disease burden. It would be the healthcare equivalent of good driver discounts in automotive insurance, and, as with driving, it can have huge effects.

Consider, for example, former Vice President Cheney. Had financial incentives kept him from smoking cigarettes from ages 12 to 37, it is quite possible that onset of his heart disease could have been delayed by 10 years. That would have made him age 79 (not 69) when he was faced with the decision to undergo implantation of an expensive heart-assist device – which ultimately required a 5-week hospitalization, most of it in intensive care – and would have made him 81 (not 71) when he needed a heart transplant – too old to be eligible. He might, therefore, have undergone neither of these very expensive procedures, lowering dramatically his consumption of healthcare resources.

Physicians call such deferral of medical problems (and, therefore, costs) “Compression of morbidity” and view it as the ideal for aging. Helping all Americans attain it would be both compassionate and fiscally sound.