Mass Torts: State of the Art : Mass Torts Lawyer & Attorney : Vorys, Sater, Seymour & Pease Law Firm : Toxic Torts & Wrongful Death

In "Finding Untainted Jurors in the Age of the Internet" The New York Times examines one of the issues raised by former Enron CEO Jeffrey Skilling in his appeal to the U.S. Supreme Court - whether someone, anyone, can get a fair trial in an age when jurors can download a torrent of information once they get back home from a long day of tedious and vexatious "trial". The article presents no solution but that is, I suspect, because there isn't one.

No one comes to jury duty untainted by life; there are no blank slates to be found among your venire. If they find something relevant online it's just going to be something that confirms what they already believed. Your job then, as always, is to uncover their worldview in voir dire and to thereafter present a narrative that accommodates both their perspective and your facts.

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The New York Times has an alarming article about the rise of gram-negative bacteria as the cause of a staggering amount of morbidity and mortality among hospital patients. The rogues' gallery of gram-negative "wretched beasties" includes Klebsiella pneumoniae, Legionella pneumophila, Pseudomonas aeruginosa, Escherichia coli, Enterobacter cloacae and Helicobacter pylori.

For more on the problem see: "How Can We Stem the Rising Tide of Multidrug-Resistant Gram-Negative Bacilli?" wherein you'll read: "... we know much less about how best to detect and prevent transmission of multidrug-resistent gram-negative bacilli. These organisms are relative newcomers to the healthcare-associated infections arena ..."

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According to "Lung Cancer and Hormone Replacement Therapy: Association in the Vitamins and Lifestyle Study" published in the Journal of Clinical Oncology, long term use of estrogen and progestin (> 10 yrs) produced a 48% increase in lung cancer and typically advanced disease at that. Interestingly, those taking estrogen alone experienced no increase in risk.

The hazard ratio was only 1.48 with a confidence interval from 1.03 to 2.12 meaning the reported result suggests at best a hypothesis for further testing and not a presumed causal relationship.

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Inquiring defense lawyers will be wondering what article(s) plaintiffs' expert Phil Landrigan refereed for JAMA.

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Back in the day, when the war against junk science was being fought in earnest, the U.S. Supreme Court wrote the following about peer review: "submission to the scrutiny of the scientific community is a component of 'good science,' in part because it increases the likelihood that substantive flaws in methodology will be detected". Today of course we know that most research reported as scientific knowledge in the journals is false. Worse yet, it is becoming increasingly apparent that the peer review process has been hijacked and turned instead to the purpose of safeguarding the prevailing dogma so that "truly original findings may be delayed or rejected" while "[p]apers that are scientifically flawed or comprise only modest technical increments often attract undue profile". These recent observations confirm what I've suspected in the two years since deposing a notorious expert witness who once was regularly excluded as a peddler of junk but who is now a referee for a prominent journal: somehow, some way, the barbarians have become the gatekeepers.

The end may be approaching for peer review, however. Of peer review it has recently been written: "Peer review eludes the immune system of science since it has now been accepted by other bureaucracies as intrinsically valid, such that any residual individual decision-making (no matter how effective in real-world terms) is regarded as intrinsically unreliable (self-interested and corrupt). Thus the endemic failures of peer review merely trigger demands for ever more elaborate and widespread peer review." In the blogosphere you"ll find that the frustration of those whose papers have been delayed or sabotaged by referees more intent on preserving the paradigm that supports them than getting closer to the truth is resonating. Good examples of those concerns and a call to end the ability of reviewers to hide behind their anonymity can be found at Marginal Revolution and Seth's Blog.

I for one support the move to disclose the identity of reviewers as well as the content of their reviews. As we noted in an earlier post, experts facing the prospect of having their opinions critically reviewed by their own peers tend to stay much closer to the truth.

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Yesterday in a unanimous opinion (Hertz Corp. v. Friend et al.) the U.S. Supreme Court held that the “nerve center” test will determine the location of a corporation’s “principal place of business” for ascertaining whether a federal court can exercise diversity jurisdiction.

The Supreme Court noted that since Congress codified that a corporation is a resident of the State in which it was incorporated and the State of its “principal place of business” appellate courts have adopted numerous approaches in determining the location of a corporation’s principal place of business. Some courts applied the “nerve center” test for corporations with “far-flung” business activities which focused on the location of the corporation’s decision-makers. Other courts focused more heavily on where a corporation’s actual business activities were located. The number of factors grew as courts combined aspects of the “nerve center” and “business activity” tests to look to a corporation’s “total activities,” sometimes to try to determine what has been described as the corporation’s “center of gravity.”

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In this article in last month’s Envrionmental Health Perspectives, the authors reported an increased incidence of sperm aneuploidy (abnormal numbers of chromosomes) in men exposed at air levels close to the current 1ppm Permissible Exposure Level (PEL) recognized by EPA. The chromosomes studied have previously been associated with birth defects and miscarriages. This study is the first to associate sperm aneuploidy with levels of bezene exposure below the PEL. It may be pointed to as some indication that the current PEL in the United States insufficiently protective against reproductive harm.

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In a paper published last month in Environmental Science and Technology, the authors measured polycyclic aromatic hydrocarbons (PAH) in settled house dust (SHD) in 23 apartments in Austin, TX. Half of the apartments had parking lots sealed with coal tar based parking lot sealcoat and half of them did not. The authors report 530 times more PAH in SHD in the apartments with parking lots sealed with coal tar based sealants than in the other apartments. These findings suggest that coal tar based sealants may play a significant role in household exposures to PAH, notwithstanding the fact that PAH are ubiquitous in urban environments.

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Readers of The Wall Street Journal may recall the saga of the administrative law judge in NYC who sued a family-owned dry-cleaner for $57 million over a lost pair of pants. Dubbed “The Great American Pants Suit” by this WSJ article, the judge’s law suit was touted by some as emblematic of the flaws in our tort system. When the judge’s suit failed to produce a windfall verdict, dry cleaners everywhere presumably breathed a sigh of relief.

Recent word from EPA, however, may give much greater cause for alarm for the dry cleaning industry. Perchloroethylene, “perc,” PCE, TCE, tetrachloroethyene and tetracholorethylene are solvents used in dry cleaning. Approximately 28,000 U.S. dry cleaners use this family of chemicals, which are the only air toxic emitted from the dry cleaning process. PCE has been subject to limited EPA regulation under the Toxic Substances Control Act (TSCA), because it was in use long before TSCA was passed in 1976. However, according to this Columbus Dispatch article, EPA Administrator Lisa Jackson indicated in a speech in Columbus last week that she believes TSCA is “toothless,” and intends to press Congress for increased EPA authority to review chemicals. Among proposed changes in EPA regulation of PCE: classification as a “likely” carcinogen (rather than a “possible” carcinogen), and reduction in airborne limits. Litigation over injuries attributed to PCE and other chlorinated solvents is nothing new, of course. However, if Administrator Jackson’s proposed changes are implemented, exposure claims in general and cancer claims in particular are likely be significantly affected by the ensuing “hindsight bias” engendered by the new state of the art.

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Under current federal incentives for “green” energy sources, developers have been rushing to place wind turbines in many rural areas. Indeed, even before the Obama administration’s current emphasis on renewable energy, wind farm development has grown rather dramatically in the last decade, as shown by this time elapsed map of installed wind capacity.

In a recent ABA Journal article, the author notes that many neighbors of proposed wind farms have been challenging the placement of the giant turbines near their homes. Most such challenges have occurred before local land use authorities or state public utility boards, but some have been filed in court.

Most interesting from the mass tort perspective is this: at least some challenges to wind turbine developments have been based upon the purported human health effects of the turbines. Nearby homeowners claim that the low level sound, vibration and shadow flicker from the spinning turbines cause a host of non-specific complaints, such as sleep disruption, headaches, nausea and fatigue.

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In Hall v. Warren Pumps LLC, et al., the California Court of Appeals, Second Appellate District, Second Division, held last week that manufacturers of pumps and valves who did not manufacture, sell or distribute asbestos insulation applied to their products are not liable under California law for injuries caused by that insulation. In so holding, the Second Appellate District joins the First Appellate District (Taylor v. Elliott Turbomachinery Co., Inc.), and the Second Appellate District, Third Division (Merrill v. Leslie Control, Inc.), both of which reached the same conclusions.

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According to "Clinical and Economic Outcomes Attributable to Health Care-Associated Sepsis and Pneumonia" just published in Archives of Internal Medicine just two types of preventable hospital acquired infections, sepsis and pneumonia, killed an estimated 48,000 Americans in 2006 and added more than $8 billion to the cost of care. The article details the alarming number of infections due to simple lapses in sanitation, from poor hand washing habits to dirty surgical devices, and the spread of so-called "superbugs" which have acquired immunity to common antibiotics.

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At least that may be the case for parasitic worms, also known as helminths. In the review article "Parasitic Helminths: New Weapons against Immunological Disorders" its authors discuss the recent literature supporting the hygiene hypothesis - the idea that the modern hygienic lifestyles of children deprive them of the immune system priming necessary to provide protection later on against diseases like diabetes, allergies, arthritis, Crohn's disease and cancers like Hodgkin's. Later in the article they turn to the evidence showing that one especially unhygienic aspect of an infestation, the helminths laying eggs in your body, is especially good for you.

So what does this have to do with mass torts? Well, a number of ailments attributed to chemicals, diet or drugs may in fact have their roots in our having rather suddenly and dramatically distanced ourselves from the microbiological environment that shaped us over the eons. Thanks to the elucidation of the molecular pathways responsible it may now be possible to identify those plaintiffs whose unmatured immune systems are the real culprits.

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In "Benzene Exposure and Non-Hodgkins Lymphoma: a Meta-Analysis of Epidemiologic Studies" published in the Journal of Occupational and Environmental Medicine the authors looked at 8 cohort and 14 case-control studies of benzene-exposed workers and their risk of developing non-Hodgkins lymphoma (NHL). Whether in the aggregate or looking just at those with the highest reported exposures the summary relative risk estimate remained almost exactly one. The authors conclude that these studies at least do not demonstrate that benzene is a risk factor for NHL

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Pretend you're not a tort lawyer but instead a criminal lawyer. The judge is going to decide whether your client should be committed or set free. Her decision will turn on the likelihood of your client committing an act of violence in the future. You and the prosecutor reach an agreement on the factors to be weighed and a risk assessment is thereafter produced. It shows that your client has a 26% chance of future violent behavior.

Question: How should you frame your case

(a)   there's only a 26% chance that he'll ever commit an act of violence;

(b)   there's a 74% chance that he'll never commit an act of violence; or

(c)   it doesn't make any difference?

If you answered either (a) or (c) you might want to read "The Effect of Framing Actuarial Risk Probabilities on Involuntary Civil Commitment Decisions" just published in the journal Law and Human Behavior.

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It's likely to depend on whether his or her opinion supports, ultimately, the values of each juror. And if the scientific consensus supports the expert's opinion it's likely to have less persuasive effect than you imagine. It's not a matter of your juror rejecting that consensus. Rather, it's a consequence of your juror assuming, perhaps because instances of agreement come readily to mind, that most experts actually support whatever conclusion about the issue would be deduced from that juror's values. That's my take anyway from the new paper (hat tip: The Situationist) "Cultural Cognition of Scientific Consensus" by Dan M. Kahan, Hank Jenkins-Smith and Donald Braman (part of the Cultural Cognition Project.)

At the conclusion of the paper the authors make a recommendation to those tasked with communicating risk that should be heeded equally by trial lawyers. "It is not enough to assure that scientifically sound information - including evidence of what scientists themselves believe - is widely disseminated: cultural cognition strongly motivates individuals - of all worldviews - to recognize such information as sound in a selective pattern that reinforces their cultural predispositions. To overcome this effect, risk communicators must attend to the cultural meaning as well as the scientific content of information". Swap "trial lawyers" for "risk communicators" and you'll get my point.

One last thing. I wonder what role reputation, and by that I mean the reputation of the subject and not that of the expert, plays in such matters. Here's why I ask. I know people who you'd predict from the authors' "hierarchical individualist" vs "egalitarian communitarian" distinction to fall into the "vaccines don't cause autism" camp instead being fervent anti-vaccination zealots. And I've found the reverse to be true as well. What actually seems most determinative is a like-minded group of friends. From my wholly unscientific observations some views about risk seem to spread among a group of friends or social acquaintances more like a virus. A new concern begins to be discussed, is seen as quirky, slowly spreads, then one day comes a tipping point and almost everyone in that group is announcing they won't be having their kids vaccinated (in the other group calls for the water-boarding of Jenny McCarthy are surprisingly typical) and the rest are feeling like Donald Sutherland in "Invasion of the Body Snatchers" (before the end anyway), and trying to change the subject.

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In a case involving lots of infected meat all from the same plant and all infected with the same pathogen cultured from the victims and known (thanks to the deployment of Koch's postulates) to cause the illness in question, well, tracing the source isn't too hard. But that's not how it usually goes.

After an outbreak and after all the food has been tossed and the food areas washed down with Clorox how could you possibly find the source? Thanks to the robust sales data kept by more and more businesses it may be possible to construct a "virtual cohort" and thereafter through the usual epidemiological techniques trace an outbreak all the way back to "cooked beef topside" at a single delicatessen. The method is discussed in "The Use of a New Virtual Cohort Study Design to Investigate an Outbreak of E. coli O157 Linked to a Supermarket Delicatessen".

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In an article just published in Diagnostic Cytopathology, "Podoplanin is a Useful Marker for Identifying Mesothelioma in Malignant Effusions", the authors conclude that calretinin plus podoplanin (part of an immunohistochemical staining panel) would significantly improve the specificity of pleural effusion diagnostics in suspected cases of malignant pleural mesothelioma (MPM). In other words, the suggested technique would do a better job of differentiating MPM from adenocarcinomas of the ovary, lung and breast.

As more and more putative mesothelioma cases have been filed, particularly by women plaintiffs with de minimis or even nonexistant amphibole exposures, battles over diagnosis have become more common. On the other hand, plaintiffs' counsel are now seeking to tie adenocarcinoma of the ovary to asbestos exposure. Perhaps both then are just new new levels in the never ending Whac-A-Mole game that is asbestos litigation.

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Not so much, that is, unless the experts are at risk of being either penalized or outed for saying something scientifically indefensible. Those are some of the findings from "Competition in the Courtroom: When Does Expert Testimony Improve Jurors' Decisions?" just published in the Journal of Empirical Legal Studies.

Essentially what the authors did was to pick a decision that could objectively be determined as correct or incorrect; and in this case it was a mathematical problem. Then they used SAT scores on math as a proxy for deciding who was and who wasn't sophisticated. Then they exposed the test subjects to competing experts who opined as to the real answer to the math problem. They even mixed things up by having some subjects pose as the experts; leaving some to their own rhetorical devices while others were threatened either with "verification" or a monetary fine.

Among the conclusions: "... our experimental results demonstrate that competition between experts, by itself, does not help unsophisticated subjects to make decisions that are comparable to those of sophisticated subjects..." "Indeed, we find that unsophisticated subjects who are exposed to competing experts make significantly worse decisions than do sophisticated subjects." However, "once competition between experts is coupled with [penalties or threat of exposure] unsophisticated subjects achieve such large improvements in their decisions that the gap between their decisions and those of sophisticated subjects closes."

My takeaway is: add an impartial consulting expert to the gatekeeper's arsenal of expert control measures and jury decision-making is likely to improve dramatically.

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Among the conclusions: mycoplasma pneumoniae causes Stevens-Johnson syndrome (SJS) but symptoms were less severe than those cases produced by drugs and biopsy specimens were distinguishable; treatments for vision-related pathologies are available if administered timely; NSAIDs are only weakly associated with SJS and perhaps not at all; the percentage of total body surface affected by SJS/TEN (TEN is toxic epidermal necrolysis) is the best predictor of whether a potentially deadly blood stream infection will occur thus informing and the types of bacteria typically responsible may guide clinicians regarding antibiotic therapy; and, Tamiflu, SJS and you.

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A study of 57,000 California teachers found that those on hormone replacement therapy (HRT) had a 36% lower risk of colon cancer than women who never used HRT. The study followed California teachers for a over a decade. The study, "Menopausal Hormone Therapy Use and Risk of Invasive Colon Cancer: The California Teachers Study" is published this month in the American Journal of Epidemiology.

The effect, and by the way a 36% decrease in one of the leading causes of cancer is a pretty big deal, held whether the women were active or not, obese or not, taking NSAIDs or not, consumers of alcohol or not and was especially strong among women with a family history of colorectal cancer. Interestingly, the protective effect disappeared after 15 years.

So what should a perimenopausal/postmenopausal woman do? Is it just a matter of picking her poison? I've no idea. But until someone figures out how cancer really works it looks like we're stuck in a "damned if you do, damned if you don't" dilemma.

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Hooray!

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Late last night the press began reporting on a press release from the authors of "Soft Drink and Juice Consumption and Risk of Pancreatic Cancer: The Singapore Chinese Health Study". By this afternoon the claim that drinking as few as two soft drinks a week may nearly double the risk of getting one of those "go get your affairs in order" cancers had appeared on nearly every major news site. So what to make of it?

First it's probably wise to read up on the Singapore Chinese Health Study. How was dose (number of soft drinks per week) determined? It looks as though it was done via questionnaire rather than any objective measurements. And how many cases were there? 140; which isn't many thereby pushing the reported hazard ratio of 1.87 to the "slight" end of the range of the scale used to weigh evidence when making causal inferences.

Second let's look at the other claims on which the authors rely to support their causal hypothesis: specifically, a) Increased sugar intake may stimulate tumor growth through effects of insulin; and b) Pancreatic cancer rates increased nearly twofold over the past several decades.

As we reported recently there is indeed evidence tending to show that chronic moderate to high levels of glucose in the blood are associated with an increased risk of pancreatic cancer. Sounds supportive, right? Only if drinking sweetened soda chronically elevates blood sugar levels. And here's an article that says that it doesn't - not in lean men, not in obese men and not even in type 2 diabetic men; and not even at 75 grams of sucrose per day (seven times the purported risk elevating level referenced in today's article under discussion). So maybe it's like the fat follies of the past few decades; eating fat makes you fat, right? Wrong. Similarly, maybe the association between consuming sugar and hyperglycemia isn't so simple. And isn't that doubt furthered by the finding that sugary fruit drinks were NOT associated with pancreatic cancer?

Finally, here's the SEER Stat Fact Sheet for cancer of the pancreas. As noted there are lots of ways to look at trends but from the SEER perspective the upward trend in pancreatic cancer incidence and mortality is quite recent and looks to be driven by an increase among women. Doesn't that suggest smoking? It is after all the most consistently identified causative factor in cancer of the pancreas.

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A meta-analysis of 22 studies found no evidence of a link between benzene and non-Hodgkin's lymphoma (NHL) even at the highest levels of benzene exposures. Sliced and diced three different ways the data all revealed a summary relative risk estimate of almost exactly one every single time.

The study is titled "Benzene Exposure and Non-Hodkin Lymphoma: A Meta-Analysis of Epidemiologic Studies" and will be published in February's Journal of Occupational and Environmental Medicine.

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Reuters Health is reporting on a new study in the Journal of Investigative Dermatology in which British researchers publish the results of their study on Vitamin D deficiency and sunshine. The short version is: you were made to be exposed to sunlight, you can get sick without it but moderation, as in all things, is the key.

There's a lot more of interest in this study available free online at Nature.

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"I think people will really move on this as quickly as possible now" said Dr. Samuel Goldman of the Parkinson's Institute in Sunnyvale, CA according to the LATimes. Goldman was interviewed about a soon to be released study indicating that while other industrial solvents like xylene, toluene and n-hexane were not associated with Parkinson's, trichloroethylene (TCE) was strongly and significantly associated with the malady.

The results are to be presented in April at a meeting of the American Academy of Neurology and so there's not much to assess at the moment save the large grain of salt to be taken with any science that makes its way into the popular media before it lands in a journal. Nevertheless, the finding, if borne out by subsequent population studies, would be significant. Many substances have been blamed for Parkinson's but none with the 5.5 relative risk reported in this, well, press release.

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Yesterday we reported on a new paper in JAMA counseling caution in the face of activist efforts to impose universal sodium salt reduction on the American populace. We reminded our readers that once upon a time activists demonized saturated fats and stampeded the country towards greater consumption of trans fats. Now there's a new study looking at the health outcomes of 384,000 Americans to see whether those who consumed lots of saturated fats were more likely to develop heart disease than those who avoided saturated fats.

Reuter's Health reports that the study,published in the American Journal of Clinical Nutrition, involved the combination and assessment of 21 large studies of people, their diets with regard to the consumption of saturated fat and whether or not they developed heart disease. It turns out there's no demonstrable association between saturated fat and your risk of heart disease. Eat a lot or eat a little, your risk remains the same. Somewhere my late great grandmother, who lived to 102 and who made the best pies and pastries thanks in part to lard, is smiling.

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Yesterday the Illinois Supreme Court issued an opinion in which they rejected statutory caps on non-economic damages in medical malpractice actions as unconstitutional under the state’s constitution. This isn’t entirely surprising as the Illinois Supreme Court had previously held in Best v. Taylor Machine Works, 179 Ill. 2d 367 (1997) that Section 2-115.1 which provided for caps on non-economic damages in all cases were unconstitutional as they violated the special legislation clause which was intended “to prevent arbitrary legislative classifications that discriminate in favor of a select group without a sound, reasonable basis.” In Best, the court also noted that although the legislature may limit certain types of damages, such as damages recoverable in statutory causes of action, the limitation on damages in section 2–1115.1 violated the separation of powers clause.

Following its holding in Best, the Illinois high court found that the caps in the medical malpractice statute was an unconstitutional legislative remittitur that violates separation of powers. According the court, under the statute the trial court is “required to override the jury’s deliberative process and reduce any non-economic damages in excess of the statutory cap, irrespective of the particular facts and circumstances, and without the plaintiff’s consent. Section 2–1706.5 thus violates the separation of powers clause because it ‘unduly encroaches upon the fundamentally judicial prerogative of determining whether a jury’s assessment of damages is excessive within the meaning of the law.’ Best, 179 Ill. 2d at 414. Section 2–1706.5, like section 2–1115.1, effects an unconstitutional legislative remittitur.”

The Court continued that “[t]he separation of powers clause prohibits one branch of government from exercising “powers properly belonging to another.” Ill. Const. 1970, art. II, §1. Thus, the inquiry under the separation of powers clause is not whether the damages cap is rationally related to a legitimate government interest but, rather, whether the legislature, through its adoption of the damages cap, is exercising powers properly belonging to the judiciary. In other words, does the statute unduly encroach on the judiciary’s ‘sphere of authority’….”
 

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By now you know that the Mayor of New York wants less sodium salt in your diet. You also know that the New England Journal of Medicine published an article in January claiming that if conservative assumptions about the health benefits of reduced salt intake are correct and would be true across the entire population then laws reducing salt intake would save "194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health costs annually . Sounds like a law we ought to adopt tomorrow, right?

In this month's JAMA Dr. Michael H. Alderman of the Department of Epidemiology and Population Health at Albert Einstein College of Medicine has authored "Reducing Dietary Sodium: the Case for Caution". Alderman does a great job of setting out the positions of both the advocates and the skeptics of mass sodium restriction but then he points out the iron law of unintended consequences. "Multiple randomized clinical trials (RCTs) have established that reduction of sodium intake sufficient to lower blood pressure also increases sympathetic nerve activity, decreases insulin sensitivity, activates the renin angiotensin system, and stimulates aldosterone secretion. The health effects of sodium restriction will be the net of these conflicting effects."

Rather than the "rash route" of "universal sodium reduction" Alderman counsels a more cautious approach involving "rigorous, large-scale, population-based randomized clinical trials". He recognizes that a definitive answer would likely take years but, should it turn out that the supposed benefits don't materialize or the harm done to supposedly few people by universal sodium restriction turn out to be harm done to many many people, a lot of money and maybe lives, will have been saved.

A sensible recommendation given the track record of "consumer advocacy groups" - e.g. switching our diet to a starch pyramid and soon thereafter effecting the substitution of trans fats for traditional saturated fats. Maybe this time we can look before we leap.

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It very well might, according to "Diabetes Mellitus Type 2 - An Independant Risk Factor for Cancer?" More alarming is the finding that significant risk of cancer is incurred even at blood glucose levels simply on the high side of "normal". A doubling of the risk for the following cancers has been found among those with type 2 diabetes: colorectal, breast, endometrial, renal, liver and pancreatic.

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That metaphors help us communicate new ideas by casting them in the terms of something similar yet familiar is well known. But did you know that your body not only tends to act out metaphors (e.g. leaning into the future) but also to impose them on the brain (shifting one's judgment about the personality of someone based on whether the perceiver's hands are cold or warm)? Well, it's true, and I was writing up a summary of the recent work when I came across an excellent article by Natalie Angier in The New York Times that does it better than I could. You can find it here: Abstract Thoughts? The Body Takes Them Literally

There's a mind/body debate in there that can wait for another day but in the meantime be conscious of the unconscious impact of metaphors.

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Tomorrow, February 4, is World Cancer Day and the International Union Against Cancer (UICC) is calling for greater awareness of the contribution of infectious disease to cancer cases around the world. "Cancer can be prevented too" is the theme of the effort. According to the press release the campaign is backed by a new scientific report: Protection Against Cancer Causing Infections which focuses on the nine known infections that can lead to cancer.

There's already a highly effective vaccine against human papillomavirus that prevents cervical cancer, a dreadful disease that took the life of one of my law school classmates within a year of her graduation, though it's still not widely given for a variety of reasons associated with culture and values. There's also a vaccine to protect against hepatitis B virus which causes a staggering number of cases of liver cancer worldwide yet it too is grossly underutilized. For more on World Cancer Day 2010 try these links: UICC World Cancer Campaign, World Health Organization,  European Hospital and this book: Infections Causing Human Cancer 

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Today The Lancet announced: "it has become clear that several elements of the 1998 paper by Wakefield et al are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were "consecutively referred" and that investigations were "approved" by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record."

Though this final, and finally complete, retraction is based on a determination of ethical lapses on the part of the author the fact remains that the results reported in the article have never been replicated. Nevertheless, contrary to what most lay people might assume published scientific papers aren't retracted just because the "science" within them turns out to be wrong.

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In a 1971 paper that profoundly influenced how scientists and policy makers approached public health issues Abdel Omran set out his theory of "The Epidemiologic Transition". He hypothesized that societies went through three different ages, or phases, that defined their experience with regard to mortality and life expectancy. In the first, the "age of pestilence and famine", life expectancy is low and episodes of widespread death are common. In the second, the "age of receding pandemics", infectious diseases are overcome and life expectancy increases dramatically. Finally, in the third, the "age of degenerative and man-made diseases", diseases of aging and self-inflicted suffering becomes the predominant determinant of mortality. Eventually others, noting the dramatic increase in life expectancy due to the rapid decline in deaths due to heart attack and stroke, posited a fourth age; essentially the same as the original third age but with cardiovascular disease removed from the "degenerative disease" category.

Now in an editorial in this month's JAMA  Dr. Michael Gaziano asserts that we may be entering a fifth phase, or age, of the epidemiologic transition. We are now, he writes, entering the "age of obesity and inactivity" in which ailments due to gluttony and sloth predominate on death certificates. The editorial references two new articles in the same issue purporting to show Americans are fat and getting fatter; especially the children.

But wait a minute. The age of man-made diseases barely materialized. Certainly there have been many many cases of people suffering terribly as a result of some man-made health hazard. Look no further than the cases of mesothelioma among the men who served aboard amosite laden Navy ships. And smoking continues to exact its terrible toll. Yet if you throw all the deaths due to occupational diseases and every last lung cancer/COPD death into the same category you can't get to 10% using worst case estimates. More sober estimates put the percentage of deaths due to man-made diseases at considerably less than one. Nevertheless, this powerful meme - that most of our woes are self-inflicted and due to some failure to live in a natural way - still propels not only mass tort litigation but also much scientific and political thinking.

However, there's more than just AIDS to demonstrate that we never really saw the "disappearance" of infectious diseases. Go to www.pubmed.gov/ and do some searches on helicobacter pylori and humanpapilloma virus and you'll see just how many cancers are now being attributed to just these two organisms. Investigate mollicutes and you'll find that all sorts of microbes are suddenly being found associated with disease and they're only now being found because the technology to identify them is only now being refined.

Finally, remember to read the fascinating journey of Barry Marshall and Robin Warren from authors of an abstract rejected as one of the year's worst to winners of the Nobel Prize in Medicine for the very same work. In the end, the view, supported by the work of one of the world's preeminent public health researchers, that peptic ulcers were caused by that most modern of man-made insults, stress, only gave way to the understanding that the cause was in fact a bacteria when the evidence was irrefutable.

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