The Sacred Drunken Cow

Look at this graph and tell me retail sales don't matter for alcohol consumption.

Look at this graph and tell me retail sales don’t matter for alcohol consumption (source).


Let’s face it: The Finns are in denial about alcohol and public health. Arguments supported by data are regularly dismissed in public discussion and downvoted on internet forums: most recently in the context of the Centre Party’s suggestion that the sale of mid-strength beer be restricted to liqueur stores.

It has been estimated that this very measure would cut alcohol-related deaths by 350 a year.

When mid-strength beer arrived in Swedish and Finnish grocery stores in the 1960s, alcohol consumption and associated illness exploded. When Sweden later reversed this policy, it was a public health victory (pdf).

Unsurprisingly, the brewing industry has cried out against sale restrictions, but so have many citizens. It’s like a fundamental civil right was at stake.

The opponents’ fears include…

  • increase in total alcohol consumption should the Finns begin to visit liqueur stores more frequently (unfounded; empirical evidence says the opposite)
  • increase in imported alcohol (unlikely, since 90% of Finns live within a few kilometers of a liqueur store, but even if realized this would likely be far outweighed by the positive effects)
  • unemployment in breweries and retail trade (probably some, but again – what is a few lost jobs compared to 350 people killed a year, not to mention other costs to society and families)
  • paternalism, slippery slope, prohibition, freedom of speech, #byroslavia, #sovietfinland.

I’m not pushing for prohibition, I like mid-strength beer as much as the other guy. It’s just that I can walk an extra 100 m to get it if that is the price of a healthier nation.

Keppana Alkoon prkl!

The Emperor of All Maladies

The_Emperor_of_all_MaladiesIn my read books list, I’ve begun to mark with a () any that I would specifically recommend to people in the healthcare sector. Siddhartha Mukherjee’s The Emperor of All Maladies clearly deserves that badge.

The book, as the subtitle has it, is “a biography of cancer”. From its earliest occurrences in historical texts to recent breakthroughs in science and therapy, Mukherjee tracks the ”life and times” of malignant disease. The history of oncology is fascinatingly intertwined with the development of healthcare in general: antiseptics, surgery, pharmacology, the whole concept of preventive medicine, the discovery of AIDS and genetics…

But the scope of the book is as much societal as it is biomedical. It turns out, for example, that in the 60s and 70s there were hugely influential lobbying groups against cancer in the U.S. – the reasoning being that ”if we can build an atomic bomb and put a man to the moon, we sure can cure cancer”. Science is never only about science, it’s also about PR and being able to sell one’s story to obtain funding.

Mukherjee portrays in a lively way the individuals who played key roles in discovery of oncological therapies. Many of them ring a bell, having lent their names to syndromes or surgical instruments. And many had colorful, quirky careers. Take William Halsted for example, the guy who mastered radical cancer surgery while high on cocaine.

But the writer also makes it clear that science is more about teamwork than individual accomplishments. The ”genii” of oncology also sometimes turned out to be the biggest brakes on the field’s development, having so fallen in love with their theories as to try to prevent any attempts to prove otherwise. The most inspiring cancer scientists opened new lines of thought for the path dependent science and thus laid way to even greater discoveries than their own.

The chapters that describe the clinical trials and medical innovations are actually the less interesting parts of the book (although well-written and not too technical, they still feel more like the stuff of medical textbooks). What I liked especially is when Mukherjee describes the societal and philosophical impact of cancer and cancer research.

Every chapter opens with 2 or 3 quotes that serve to convey the zeitgeist of the past decades’ cancer scientists. It is sobering to realize how quickly attitudes and dogmas have changed. Among other things, The Emperor of All Maladies is a study of medical misconceptions, from the generations of doctors who followed the Hippocratic and Galenic humoral theories without daring to object to these authorities to the 20th-century surgeons who insisted on overly radical, disfiguring operations and even opposed adjuvant chemotherapies before the concept of staging was developed and the evidence for chemo’s benefits too clear to ignore anymore.

All in all, the history of cancer makes up for an unexpectedly good story. The disease first enters history as a vague unknown threat and during the centuries of research becomes an almost anthropomorphic enemy against whom ”wars” are waged. For a serious scientist whose publication history includes Nature and NEJM, Mukherjee’s writing is sparkling. Consider this sentence for instance:

Society and illness often encounter each other in parallel mirrors, each holding up a Rorschach test for the other.

Anecdotes from the Mukherjee’s own practice are interwoven with historical accounts and serve to show that some dilemmas – e.g. when to abandon hopes of cure and settle for good quality palliative care – are still the same than decades ago. The author’s sometimes very personal experiences from the wards are among the most touching parts of the book.

My only grudge is non-continuity. The events covered by the book span centuries and often the story just leaps suddenly from one era and place to another. Many such transitions make sense thematically (and I can see how abandoning the strictly chronological approach might have served the structure of the book) but some of them are confusing and break the rhythm of the story.

Anyway, one of this year’s highlights for me.

Love triumphs over ignorance

That’s a pompous choice of words, but nothing summarizes better how I feel about the Finnish parliament’s decision to allow same-sex marriage today. I’m happy, happy for myself and for my gay friends to whom I know this is huge thing.

The new law is a historic one, naturally from the equality perspective but also because it was the first “popular initiative” to pass in the parliament.

The opposing front (besides quoting the Bible) has mainly expressed concern over children’s wellbeing in same-sex families. This, as peer-reviewed literature has it, is rubbish.

The Art of Thinking Clearly

The Art of Thinking Clearly is a 2011 pop-sci book by Rolf Dobelli: a catalogue of common cognitive biases that in a systematic manner cause people to act irrationally and often against their best interest. Each bias is introduced in a short chapter with a few entertaining examples and some speculation of its background in evolutionary psychology.

Health professionals are not immune to cognitive errors and the book serves as a healthy reminder about that. Among the many intellectual traps doctors can fall into is action bias: tendency to perform dramatic interventions even when watchful waiting would be better. Availability bias – e.g. overusing a diagnostic or therapeutic procedure just because it’s on top of one’s mind – is well documented, too (when all you have is a hammer… urology edition). Omission bias might manifest in failing to use lifesaving medicines for the fear of their side effects (must be particularly true in the U.S. and other countries where liability cases are easily triggered).

On the other hand, patients and caregivers alike are prone to regression to the mean. If today’s back pain is worse than ever, it is likely to improve by tomorrow for purely statistical reasons, not necessarily because you saw a doctor/chiropractor/homeopath today. Survivorship bias means a few vocal people praising the efficiency of a particular intervention may hide the fact that a thousand others used the same product without help.

Etc.

The Art of Thinking Clearly
is not a scientific treatise or a psychology textbook (but readers hungry for more information will find references in the end). Despite the name, it’s not a handbook to better thinking either, more like a collection of anecdotes.

Still, the book is clever, accessible and fun (a fairly quick read, too), and will hopefully do a small favor to the world by raising awareness of the fallibility of our minds and by culling some bad argumentation.

Winter Is Coming

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After a month of traveling and meeting friends and relatives, I am now back in N, re-adapting to my country GP life. And it’s alright, even surprisingly so. My patients seem to like me and I like them (well, most of them, anyway) and the little town actually begins to feel a little like home.

But I know I won’t stay for ever. Despite many good experiences, I don’t feel like I belong here. At its core, N is a quiet, conservative backwater with an aging population and withering economy – rural to urban transition in progress. I’m a product of the capital city region.

And then again, my roots are here. My grandparents left N decades ago to settle elsewhere, but in the town cemetary, maybe one in ten tombstones still bears my family name. A neurologist I know told me that as a result of centuries of inbreeding, this region is home to some interesting hereditary disorders.

That’s a line of thought probably best not explored too far.

The temperature has dropped below zero but I still carry on with my new hobby: Nordic walking. I primarily used to run but during the fall I’ve found I prefer walking with poles to jogging. To be honest, running always felt like a chore, something I mostly did out of sense of duty. On the other hand, Nordic walking is fun, it lets one work on one’s upper body as well, and walking on asphalt is not half as dull as jogging on asphalt.

I have also begun to record my exercises in Sports Tracker (which brings wicked joy to the spreadsheet-loving part of me). I also tried Endomondo which seemed nice and had more features, but in the end I decided to go with Sports Tracker for its cleaner interface and straightforward functionality.

I took the above photo on a 9 km walk along the edges of the town yesterday. Today when I woke up, the first snow had covered the ground.

“Best buys” to reducing economic impact from non-communicable diseases

bestbuys

From the 2011 report by WHO & World Economic Forum.

Homeopathic Emergency Department


Chuckle of the day. By Mitchell and Webb.