Avandia, Tuberculosis, and Terrorism

Yes, I’m really going to pull all this together.

Let’s start with some basic chemistry. All processes are in an equilibrium.


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You never get to 100% in any direction, because freedom and disorder (entropy) are the driving forces of the universe. Not surprisingly, the closer you get to 100%, the more effort you usually have to put in to take the next step. It may not be worth it.

We’ve learned this in medicine. If you read most medical studies, you’ll see something called a “p-value”. This is statistical lingo for how likely it is that your results were due to random chance, instead of whatever you were trying to do/prove. To put it in evangelist Republican terms: pretend someone is flipping a coin, and you’re “p”raying for heads everytime. And 90 out of 100 times, heads comes up. The p-value tells you how likely that result was due to the fact that "coins do that sometimes", versus the fact that your "p"rayers did it.

In medicine, we consider a “p-value” less than 0.05 “significant” Which basically means the chances are 5% or less that the results were just dumb luck rather than reflecting your “intervention”: a drug, a surgery, a diet. Flip it around, and it could mean that about 5% of things we consider “proven” in medicine could be wrong. It’s actually probably less than that, because we REALLY like p-values of <0.1%. style="font-style: italic;">

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Avandia is a drug for diabetes, and studies showed that it lowered blood sugar. It’s now under fire for increasing the risk of a heart attack. DISCLAIMER: I haven’t reviewed these papers recently. It seems that there were some data suggesting this, but it was thought that the benefit against diabetes would outweigh other risks. We MAY have been wrong.

There’s another issue here called surrogate endpoints, and I may address it later, but I don’t have a good example at the moment. Suffice it to say that we are forced to take a statistical chance that things that look good will be bad, and we MAY have lost on this one. I highlight MAY, because I don’t think all of the facts are in, and I dread the coming barrage of ads saying, “Did you take Avandia? Did you have a heart attack? Call me (lawyer) to sue you doctor.” I think FDA approval should insulate MDs, but again, another topic for another day.

Which brings us to tuberculosis. Let’s start with some honesty; when you heard that someone flew in a plane with extremely drug resistant tuberculosis, did you think he would look like this:


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Me neither. But lay off Dr. Gerberding. She taught me (as did Dr. Leonard, who has been on TV), and I have an incredible amount of respect for her as a physician, a scientist, and a politician. Yes, politician -- ask me, and we'll talk, because I got to talk to her about it.

First, I’m not a lawyer, but my understanding is that it is hard for the CDC to detain someone – actually is the job of the public health department of the city/county (though some things have changed since 9/11). Why do I know? As a training physician, we had to work on detaining someone who wanted to go home with TB. This is how you look at it.

Tb is contagious by respiratory particles. They do linger, but if you are NOT coughing, you are rarely infectious, though you still have the disease. From what I have read, Mr. Speaker was not coughing. In fact, sputum that he coughed up has been analyzed for TB, and 3 samples were negative. This is what a smear with TB [AKA acid-fast bacilli(AFB)] looks like:



www.bact.wisc.edu
On this stain, the tuberculosis organisms show up in red.

In a hospital, if you are (-) for AFB on 3 sputums, we take down the respiratory precautions. Is it 100% safe? No. We could, in fact, put everyone with a postivie PPD (that little bubble test on your skin) in quarantine. Or anyone from a country with a lot of TB. Why don’t we?

First of all, 3 negative cough samples suggests a less than 5% chance (estimate) that you are contagious, which, as discussed above, is about as good as we get in medicine. Second, the cost of quarantining the rest of the people, who are unlikely to be infectious, is HUGE. If you look at medicine in general, the money could be better spent. Finally, to take away the freedom of people who are so unlikely to be a problem is NOT (supposed) to be what we do in this country.

Which brings us to terrorism. For further information, read Fareed Zakaria’s piece in NewsWeek (that guy is awesome).

Benjamin Franklin said " The man who trades freedom for security does not deserve, nor will he receive, either.” I agree. But we’ve gone way beyond sacrificing freedom. At the most recent Republican debate, someone asked “What is the most pressing moral issue facing this country today?” Most of the candidates discussed some version of the “sanctity of life”. (I’m going to address this quickly in another post.) Congressman Ron Paul, who is probably more of a Libertarian than a Republican, said "I think it is the acceptance just recently that we now promote preemptive war. I do not believe that’s part of the American tradition." And it's all done in the name of "Homeland Security".

To recap – NOTHING can be 100%. Chemistry can’t. Drugs can’t. Medicine can’t. So guess what – security can’t be either.

Given the field of Republicans who hate gays and a woman’s right to privacy, there are things I like about Mayor Rudy Guiliani. Unfortunately, he is clearly this election cycle’s “fear-monger”. His alleged strength is “National Security”, and his best path to victory is to scare people about “Islamic Terrorists” and “what they want to do to us”.

I’m worried about terrorism, too. I’ll give President Bush some credit – we haven’t been attacked again. I’ll even admit that for security concerns, sometimes it takes a while to find out just what the dangers were. But we’ve probably gone a little overboard. Doubt me? I give you Bill Maher:"Nixon got in trouble for illegally wire-tapping Democratic headquarters. Bush is illegally wire-tapping the entire country."

We need to accept that a free society can never be 100% secure. 9/11 was a wake up call to get serious – as Europe has been for some time. It wasn’t a reason to pursue an isolationist, pre-emptive strategy that destroyed the world’s good-will for us (Senators Clinton, Obama, Edward -- this applies to you, too, despite your desire to seem "strong" on security.) I think we’re probably 99.0% safe. The money and liberty that would need to be sacrificed to get that last 1% would be better applied to re-building the European, Asian, and Islamic worlds’ opinion of us. Or on health care. Your choice.