Review: Keep Sharp

 My wife checked out Keep Sharp from the library and it showed up on my Kindle, so I ended up reading it as a palate cleanser.  I remember being impressed with Sanjay Gupta from World War C, so I kept reading despite already knowing many of the topics he discussed from other books. My biggest problem with the book is that it spends a good 20% of the time telling you what he's going to talk about instead of just telling you what he wants to say.

Anyway, there aren't any magic tricks to improved brain health:

• Exercise, especially aerobic exercise
• Good diet (lots of fruits and vegetables, less red meat, and no highly processed foods)
• Sleep well.
• Having a good social life (the best job is that of a concert conductor where you get to lord it over everyone else and everyone has to pay attention to anything you say, my guess is that being a brain surgeon is the next best thing)

At the very least from the above you can tell that Sanjay Gupta isn't a crackpot and isn't selling fancy supplements (in fact, he cautions against them). There's a 10 week program to get people who aren't already exercising and eating well to do so, and there's a section on how Alzheimers might one day be cured, but you need to get diagnosed early if you want a chance to prevent the disease while there's time to do so. (Or, maybe you want to just live healthily anyway)

I enjoyed the book. I did question how someone with 2 jobs and 3 kids manages to get in his hour of exercise every day plus some time to meditate, but hey, it's quite likely he's a much more organized person than I am!

Review: How Medicine Works and When It Doesn't

 How Medicine Works and When It Doesn't is a book by Yale doctor and physician Perry Wilson. It is readable, funny in many parts, and well-written. For instance, he describes a surgeon's interaction with a family of a patient who's undergone surgery:

I remember listening to one of the cardiothoracic surgeons talking to a family after a large aortic arch repair. The patient had done well but was still unconscious, on the breathing machine. The surgeon, an expert by any definition, explained that the surgery was essentially flawless; in a few days, the patient would be up and around, out of the hospital within two weeks. “Thank God,” his wife said. “No, no. You do not thank God,” the surgeon said. “You thank me.” (pg 245)

I laughed out loud reading about it.  The book first describes what is very basic to scientists: correlation is not causation, and bayesian reasoning. He then points out that because of these problems the best way to identify causation is through randomized controlled trials. Even those are subject to errors and occasionally outright fraud.

He points out that even the best studies and the best outcomes from clinical trials of a new drug has to be done on a population statistical level, which means that in many cases, there's a ton of uncertainty as to whether or not a new drug or treatment will help you:

There is no “one thing” that will help you live longer. There are healthy things, and less healthy things, and unhealthy things. People who adopt multiple, broadly healthy lifestyle choices—from what they eat and don’t eat, to how much exercise they get, to the kinds of activities they take part in—live longer. The problem is no one wants to click on an article saying MAKE THESE 30 CHANGES IN YOUR LIFE TO LIVE LONGER. It is not easy to make thirty lifestyle changes. We all want simple solutions to complex problems. (pg 61)

Just as in investing there's no market for "get rich slow" when there are plenty of people touting "get rich quick" solutions. 

What makes medications special is not the fact that they are so incredibly good at saving lives, but that they are easy to use. You can’t change your age, and quitting smoking is tough, but popping a pill is a straightforward action that doesn’t demand too much change in your usual habits. The sobering truth is that drugs operate on the margins—they have an effect, but they aren’t as impactful as we like to think they are.  (pg. 139)

 Wilson even addresses the elephant in the room, which is the American healthcare system, notorious for being inscrutable, heartless, profit-driven, and liable to drive even insured folks into bankruptcy:

there is no industry that pays more money to Congress than the pharmaceutical industry. We may not have the kind of money pharma does, but we do have one thing it doesn’t have: the votes. I have never been a single-issue voter, but if you were to pick a single issue to vote on, I suggest you make it the one that has the most special-interest money thrown at it. That money tells me that the industry is scared—and while Congress members do like their drug money, they like keeping their jobs more. And drug pricing reform is incredibly popular. In a 2021 Kaiser Family Foundation poll, 88 percent of respondents favored allowing the federal government to negotiate what they will pay for specific drugs, including 77 percent of Republicans and 96 percent of Democrats. (pg 183)

Wilson acknowledges the huge amount of wasted money in the system, including on administrators who do not actually provide any healthcare:

In 2019, Healthline crunched the numbers and found that there were ten healthcare administrators for every one doctor in the United States. These administrators do not provide patient care, but they supposedly improve care. Most administrators argue they are making the system more streamlined, more efficient. But there is not much data to support that. The Harvard Business Review looked at the rapid growth of healthcare administration positions and concluded that the only meaningful difference for patients that correlated with increased administrative roles was a reduction in thirty-day hospital readmission from 19 percent to 17.8 percent. HBR also noted that this reduction happened to occur just when the Affordable Care Act imposed penalties on hospitals based on readmission rates.  (pg. 218)

 What about the frequently made statement that our doctors, nurses are overpaid and that's why we have the most expensive medical system in the world? Wilson debunks that too:

About 20 percent of healthcare spending in the United States goes to “physician services,” but physician salaries are only a fraction of that—just 8.6 percent, the lowest percentage of any Western country save Sweden. Since the majority of physicians now work for hospital systems or corporations, that money goes to headquarters and is parceled out from there. In other words, even if you slashed doctor salaries in half, you would save only 4 percent of the Medicare budget. (pg. 220)

Needless to say I found myself highlighting paragraph after paragraph of this book, taking note of new concepts such as NNT. I came away with this book knowing more than when I started it, which means that I recommend it to anyone. 

Long Term Review: Anker Battery/USB Adapter for Resmed AirMini

 I used my new Anker Powerbank with converter cable on this past sailing trip. While not a certified CPAP device, it operated with extreme reliability. Even better, the Katja had USB outlets in the cabin that operated even when the boat was sailing and the generator wasn't running! My routine for the days on the sailboat were to wake up, immediately unplug the battery to the CPAP after syncing it to my phone, and plug the battery into the USB outlet to let it trickle charge. By noon, the battery would be full.

I didn't need to use the battery to power any other devices, but in theory, I could have done so. In addition, I wasn't carrying the dedicated charger that could only be used to charge the Pilot-24. The battery performance was also superior --- at no point did I drain it past 50%, so I could have survived 2 nights on the Anker battery if I needed to.

When traveling to places where I have wall power, I pair this with the Anker 715 Nano II 65w charger.  This saves no weight compared to carrying the dedicated AirMini charger, but unlike the dedicated AirMini charger, the Anker charger can be used to charge any other USB-C compatible device, so it serves two purposes!

This is clearly a superior option to what I was using before and I can recommend it without reservations.

Review: Fenix 7 Pro Sapphire Solar

Through a series of unlikely events, I managed to snare a Fenix 7 Pro Sapphire Solar at an excellent price. Given that I had also gotten a Garmin Edge 840 recently, I no longer felt obliged to get the biggest screen possible, so I went for the 47mm version of the watch, which is smaller while not being as small as the S. It fits perfectly and is lighter. Unlike in the past, where the X series usually has additional features not on the other sizes of watch, for the 7 Pro series all watches have the same feature. The difference is in size, weight and battery life. I did not opt for the Epix series because there were reports that in cycling mode the display would turn itself dim.

The number of new metrics available on the Fenix 7 Pro that didn't exist on the 5X is substantial. First, you get a training readiness metric that you didn't use to get. Unlike in the past Fenixes, this seems actually accurate. I had a stressful trip and it told me that my body was strained and that i should back off from serious activities.

The sleep section is vastly enhanced, now including breath detection, SpO2 (which by default only turns on during sleep to detect sleep apnea), and a body battery metric that does a relatively good job of detecting how much left you are (though you probably shouldn't need an app to tell you that!)

There's a new wrist mounted flashlight on the watch, which works really well, and I've used it often enough that it doesn't feel like a gimmick, which surprised me. What's better about it than using your smartphone as a flashlight is that being mounted on your wrist effectively makes the flashlight hands free, which is a much bigger deal than you might imagine.

Even the heart rate monitor is improved, giving much more accurate than what was on the Fenix 5X, which I considered science fictional. For instance, my HR never rose about 100 during strength training on the Fenix 5X, but with the 7 Pro it regularly registers 140 when lifting. That makes way more sense. One interesting thing is that if you choose to use a separate heart rate monitor and take off your Fenix, the Fenix doesn't carry that data over from your Edge, and instead treats that segment of the day as blank. On the other hand, for road riding using the device as a HRM doesn't seem to burn substantial battery life, so I'm OK with that. In fact, on a bike tour that means the watch substitutes as a HRM and you no longer have to bring a separate one.

What does feel gimmicky is the sapphire solar screen. Over the course of a 10-day sail trip, it felt like it added at most 4 hours of battery life, not substantial enough to make a huge difference. On the other hand, if I was going on a multi-day backpacking trip with no access to charging my suspicion is that this might let me eke out one more day of battery life. Of course, my CPAP battery would probably run out long before this happened.

Unlike the Edge series, the Fenix doesn't store elevation data on maps. This lets me load it up with both European and US maps and still have substantial storage left. As a backup for the Edge 840 I think this is a good device to have.

There's now a snorkel mode but I didn't find out about it until after my trip. I'll remember to use it next time! There's also jet lag advisory and altitude acclimation data and advise that will be substantially useful in the alps or on mountain trips. I've done enough of those trips that I don't really need this, but if you're new to big mountains I think this will be very useful!

There's a "good morning" screen that summarizes how ready you are to train, how well you slept (which might give you anxiety if you're the anxious type), and some encouragement to start your day off with. It was surprisingly good to have on my sailing trip!

All in all, I'm surprised at how much the Fenix 7 Pro has improved over the 5X. Then again, that's 4 generations of devices. I probably should have upgraded earlier but waiting for a lower price is never something I will regret.

New Resmed AirMini Camping Setup

 I've been traveling with the Pilot-24 medical grade certified battery for camping and sailing with my ResMed Air Mini. The battery is fine, but if you ever tried to use the USB output for say, charging your phone you realized it was kinda lame. I came across an online article about using a standard Anker USB power bank with the Resmed Air Mini. The price is right, especially if you don't mind buying used Like New from Amazon, which cuts 30% off the list price.

I got the powerbank and used it on the Haypress trip. The converter cable has an annoying blue light, easily rectified either with tape or by flipping it blue light down. The power bank reports back more than 75% full after the first night, and I charged my phone from 32% to 72% in less than 30 minutes, and got home and discovered that it took another 30Watts to charge back up to full. Anker specifies a 45W charger with this battery but I discovered that it never charged any faster than 30W no matter how empty it was. This is good enough  for sailing. The whole setup is only 10g lighter than my previous setup, but the thing is the AirMini wall-wart is dedicated to only running the AirMini while any powerful USB-C charger can be used for multiple purposes, so net net the whole thing is a win. It's also much cheaper than the Pilot-24, even accounting for the fact that the Pilot-24 can be paid for using FSA money.

Recommended.

Review: Evolution Gone Wrong

 Evolution Gone Wrong is the book about humanity's poorly designed bodies.  This is such a good genre of books, that I could read multiple books like this and not get tired of it. It's the perverse side of the usual self-congratulatory books about how well designed our bodies are.

The book covers diverse topics such as the shape of our jaw and why we have too many teeth for the size of our jaws (answer: the evolutionary path of teeth and jaws are different, and post-agricultural revolution jaws are smaller, since cooked food doesn't require as much chewing and jaw strengthening exercises so our jaws continued shrinking). It covers why humans choke on food (the larynx is lowered so the humans can speak to each other), and myopia:

Children who spend greater chunks of their day outside have a lesser risk of developing myopia than children who spend their days inside. It doesn’t matter how they spend their time outside. The outdoorsy kids in the studies spent as much total time on screens as the indoorsy kids. They didn’t have to be kicking a soccer ball or climbing a tree. Even if they were playing around on their phones, as long as they were doing it outside, they were less likely to become myopic. It is a shocking result given the total buy-in to the eye-strain hypothesis. (kindle loc 865)

What's interesting is the study on sleep, indicating that even Chimpanzies make the bed:

 They sampled 1,844 chimpanzee night beds (take a second to appreciate that large sample size) and discovered that chimps used the same type of tree to build a nest in 73.6% of cases. Interestingly, the preferred tree made up only 9.6% of the trees in the forest. In other words, the sleepy chimps were not grabbing branches at random and knocking out shoddy, makeshift beds. They were being selective about their mattress materials. The sleep researchers also analyzed the properties of the preferred trees. In the article they published in the journal PLOS ONE, they note that the most coveted type of tree was a species of ironwood that “was the stiffest and had the greatest bending strength” of all the options for bedding materials available to the chimps. So chimps go for mattresses with some give, but ones that are also stable and firm. (kindle loc 2380)

One interesting conclusion is that stiff beds don't actually do as well as medium beds for providing good sleep, which is counter intuitive. The author spends a half chapter pointing out that you can tell which parts of the bodies are maladapted for modern living by looking at medical schools. For instance, dentists don't go to medical school because the demand is so high that society puts dentists directly to dental school. The same goes for podiatrists.

 Any anatomical area that needs its own entire branch on the medical tree clearly troubles a great number of people, as we saw with all the problems covered in the first section of the book. (kindle loc 1714)

The final part of the book covers our reproductive dysfunction:

 Dogon women experience, on average, roughly 100 total menstrual cycles in their lifetimes (the mean in the study was 109 and the median was 94) and birth, on average, 8.6 children. Those numbers are strikingly different from what women experience who are not practicing natural fertility. Strassmann estimates, based on data from other researchers, that it is not unusual for modern American women to go through as many as 400 menstrual cycles in their lifetimes. (kindle loc 2568)

An interesting section covers why women menstruate at all. For one thing, the relationship between fetus and the woman's body isn't a completely friendly one:

 Horse and pig fetuses, for example, do not burrow very aggressively into the womb. The membranes surrounding the fetus are several layers of tissue removed from the maternal blood supply. There is still maternal–fetal conflict in those species, but not the same degree of conflict seen in species where the fetus digs in further. Dogs and cats are somewhere in the middle. Their fetal tissues start to invade the maternal tissues but are still distanced somewhat from the maternal blood vessels. In the most aggressive version of placentation, the fetus roots in, like a mole into dirt, and snuggles right up against the blood vessels of the mother. You can probably guess which type of fetuses humans ended up with. We got the uberaggressive model. And again, we see the comparative approach pay off in solving this riddle of why SD evolved. The animals that exhibit SD and menstruation are also the ones with the most invasive fetuses. Some scientists think SD evolved as a preemptive degree of protection against a hyperinvasive fetus. The logic goes that a woman gets ahead of the game and builds in some extra protection before the vampire-fetus arrives so that her unborn child does not completely suck her dry. After all, if you know a vampire is coming to your quaint, remote village, it makes sense to start beefing up the defenses of the village before the little bloodsucker gets there. Get the garlic planted, the stakes sharpened, and the mirrors shined in preparation. (kindle loc 2751)

 There's even a great section on why Asians are more prone to diabetes at the same body weight compared to European-Americans.

All in all, it's a fun book, written with humor, and keeps you engaged while reading. Recommended!

Review: The Genetic Lottery - Why DNA matters for Social Equality

 The Genetic Lottery is a book about the social and research implications of gene studies and research. It sets out to defend gene studies primarily from a scientist and ethics point of view, mostly from the perspective of a researcher whose work has frequently been lumped in with the eugenics movement, which has long cast a shadow over genetics research. Along the way, she provides lots of information and interesting things to think about that I hadn't seen before. For instance:

As of 2019, people of European descent made up only 16 percent of the global population but accounted for nearly 80 percent of GWAS participants. This situation is not improving, despite the falling cost of genotyping. In the last five years, the share of genetics research focused on people of European ancestry has held steady, even as the overall number of genotyped people continues to explode. genetics research does not just disproportionately study White people. It also is disproportionately conducted by White people. The collection and analysis of genetic data from populations of non-European ancestry thus presents a double bind. Without conducting genetic research with the entire global population, there is a danger that genetic knowledge will only benefit people who are already advantaged.(Kindle Loc 1544-1546)

Harden presents the concept of a polygenic index very early on in the book, basically explaining it as an index of a constellation of genes that gives rise to a complex attribute such as height, IQ, and executive function EF.  The important property of these polygenic indices is that they measure composite complex attributes,  so they're difficult to manipulate. So there's a polygenic index for education, and there's one for wealth, and there's one for executive function. What's interesting is how early these genetic effects kick in:

the education polygenic index is correlated with whether children start talking before age 3 and their scores on IQ tests at age 5.12 So, consistent with what was observed in bioannotation and twin studies, polygenic index analyses suggest that, whatever genes are doing to influence educational inequalities, they are doing it early in life—with effects that are apparent before children ever begin school.... General EF is as heritable as eye color or height, more heritable than BMI or pubertal timing.14 (Kindle Loc 2479-2502)

 Harden points out several things about polygenic indices. First of all, they're not comparable between population subgroups. In other words, if you're not white, the studies that are published currently cannot be used to predict anything about you. Secondly, the genes might do something, but the environment matters. For instance, before women were allowed to go to college, the polygenic index for educational attainment was very weak for women (duh!):

For my grandmother’s birth cohort (people who were born in 1939–1940), the polygenic index was more weakly related to educational attainment among women than among men. (These women were in their thirties before my alma mater, the University of Virginia, admitted students without regard to gender, in 1972.) But this gender difference has narrowed over time: as educational opportunities for women increased, the polygenic index has become more strongly associated with women’s educational outcomes. For woman in my birth cohort (people born in 1975-1982), the polygenic index is as strongly associated with education as it is for men. Genetics, ironically, has become a sign of gender equality. (kindle loc 2761)

What this means is that it doesn't matter how heritable something is, if the gene finds itself in an environment where it cannot express itself. So for instance:

 Despite the mythology of the United States as the “land of opportunity,” it has lower social mobility than many other countries; Denmark is an example of a country with high social mobility. The heritability of educational attainment is actually lower in countries with lower social mobility, like the United States and Italy...the heritability of child cognitive ability is lowest for children raised in poverty and highest for children from rich homes—particularly in the US, where social safety nets for poor families are weaker than in other countries (kindle loc 2773-2779)

 She goes on to reveal that wealthy students in the lowest quartile of the educational attainment polygenic index still graduate college at higher rates than students in the highest quartile of polygenic index from the impoverished social classes. What this means is that there's a ton of un-realized human potential amongst the poorest students in the country, and that the genetic influence on education is still outweighed by the effects of poverty.

Harden then goes on to argue that attempting to do intervention in education, etc without the benefits of insights from genetic research is fruitless. For instance, there's an oft-cited study of how babies whose parents speak more words to them do better in school. But that sort of correlation doesn't mean anything. She claims that rolling out expensive educational policy blindly without any sort of understanding of how the genetic influences work is unsustainable and lead to failure. Most educational interventions do in fact fail.

Where Harden falls down, however, is that she states near the end of the book that we do know what works. Universal healthcare, for instance, would eliminate a lot of the immiseration and suffering and poverty that causes poor performance amongst students. Similarly, eliminating hunger amongst children through food-stamps or poverty reduction programs directly help those students. So in the very last chapter of the book she under-mined her entire thesis! It's very clear that the progressive programs that are considered "far-left-wing" in the USA (while being solidly in the center-right in most developed countries) do not need further research in genetics, cohort studies, or eugenics programs in order to be successful. We already know how to do them, we just have never had the poliltical will to do them.

But you know what, I'm going to give Harden credit for this. Very few people (scientists or otherwise), will admit that the problem they're applying for research funding for has already been solved. And her book contains many good examples of how targetted intervention for kids with say, ADHD or other disabilities shouldn't be considered any differently than giving kids with myopia glasses to see better with. So on the whole I still think her book is worth reading.

Review: T - The Story of Testosterone, the Hormone that Dominates and Divides Us

 T is written by Carole Hooven, a Harvard evolutionary biologist. The book is about testosterone, but as a side effect it teaches many incidental things that aren't about the science of hormones and how human development works.

For instance, the first lesson is that in a world with billions of people, any kind of genetic mutation/disease that can happen will happen. The book opens with a woman who was born without androgen receptors. So while she had both X and Y chromosomes, her testes never descended, and so she was born with a vagina but no womb, uterus, or fallopian tubes. Her medical plight was interesting but other than not being able to have children she led a normal life. Hooven then goes on to describe various tripes of people with faulty CAH receptors, so babies who were born (and then socialized) as girls would as puberty develop penises (my jaw dropped when I read about this), testicles, and then develop as men!

The second thing that's clear ot me was how Hooven chose to write about these case studies. She's arguing against what seems like a wave of books, literature, and papers in the various social sciences that being male/masculine is socialized, rather than being directly affective by biology. As a layman, I would think that it's obvious that testosterone and other hormonal differences between boys and girls is what drives behavior, but Hooven bends over backwards to give the anti-biologists the benefit of the doubt and makes their case alongside hers.

Of course, in any battle between a real scientist and a social scientist, it's always true that the real scientist wins, with an overwhelming abundance of evidence on her side. For instance, the ancient Chinese and the not so ancient Italians practiced castration (the Chinese to produce eunuchs who could be trusted with the emperor's harem, and the Italians to produce men whose voices would never break and therefore provide soprano voices in a choir that didn't allow women to join its ranks). The elimination of testes in prepubescent boys (I wince even typing these words) shows that without testosterone, many typically masculine traits never develop in such men, including sexual desire, development of a deeper voice, preference for athleticism and sports, and so on and so forth.

From here, Hooven grants both insight into controversial issues of the day (such as transgender women competing in women's events) and an understanding of child development from childhood to puberty to adulthood. I didn't know, for instance, that men have between 10-20 times the amount of testosterone in women, but also that during puberty that spikes to 30:1 ratio differences between boys and girls. Similarly, I didn't know that a sharp spike in testosterone is also what stops adolescent height growth in men, and the castrati were actually taller than average because they never did get that second spike in testosterone.

There's excellent digression into how testosterone rises and falls in deer, and why if testosterone is such an advantage it's not just stuck in the on position all the time. Similarly, an examination in the society of chimps and how it works and what the analogue of testosterone spikes in human society goes. All of it is not just educational but also entertaining. I loved some quotes, such as Robert Sapolsky's note that because testosterone spikes are really about achieving higher status in society, if you went and injected a bunch of buddhist monks with an excess of testosterone what you might get is an increase in random acts of kindness. Now imagine doing that to a bunch of evangelicals.

There's lots more in the book that I can't possibly add here, including real life interviews of transgender people (and one woman who started testosterone injections for several years and then realized she actually wanted to be a woman and switched back) that are both enlightening and touching.

This is a great book and I learned a lot. It provides a much needed discourse in the current discussion about  gender and masculinity. Highly recommended.

Review: Immune

 Immune is a layman's introduction to immunology. Written by a German science popularizer, it's written in easily understood vernacular and came with lavish color illustrations that I ignored, given that I was reading it on a Kindle paperwhite.

The book explains all the dry stuff you might have garnered from other immunology books or articles about the immune system. For instance, what's the innate immune system? How does it interact with the adaptive immune system? What's a mast cell? What's a T-cell? What's the difference between a Helper-T cell, and a Killer-T cell? How does the immune system know when to turn on and off? What's special about Immune, however, is that he also explores the implications you might not have known or even thought about:

why does the body of a woman not recognize sperm cells as other and kill them right away? Well, it does! This is one of the reasons you need about 200 million sperm cells to fertilize a single egg! Right after sperm is delivered into the vagina, it is confronted with a hostile environment that it has to deal with. The vagina is a pretty acidic and deadly place for visitors, so sperm cells move on as fast as possible to escape it. Most of them gain access to the cervix and uterus within a few minutes. Although here they are greeted by an onslaught of Macrophages and Neutrophils that kill the majority of the friendly visitors that are only trying to do their job. Sperm cells are at least a bit equipped to deal with the hostile immune system (a little like a specialized pathogen if you think about it). They release a number of molecules and substances aimed at suppressing the angry immune cells around them, to buy them a little bit of time. And it may actually be the case that they are able to communicate with the cells that line the uterus, to let them know that they are friendly visitors, which might turn down inflammation. But there is a surprisingly large number of things that are not completely understood yet, in these interactions. In any case, from the millions of sperm cells that entered, only a few hundred enter the fallopian tubes and get a shot at fertilizing the egg. (Kindle Loc 1277)

The analogies used in the explanations are clear and a lot of fun, and Dettmer does a great job also of reminding you that he's simplifying a lot of issues. The explanation of how T-Cells get selected in the Thymus is great, and once again, there's a willingness to expose the implications of your shrinking Thymus:

 Your Thymus basically begins shrinking and withering away when you are a small child. A process that is sped up once you reach puberty. Every year you are alive more and more Thymus cells turn into fat cells or just worthless tissue. The university closes more and more departments and gets worse as you age, until around the ripe age of eighty-five, your T Cell university closes its gates for good. Which is sort of horrible if you like the concept of being alive and healthy. There are other places in the body where T Cells can be educated, but for the most part from this point forward your immune system is more limited than before. Because once your Thymus is gone, you have to get by with the T Cells you have trained up to this point. The absence of the immune cell university is one of the most important reasons why seniors are much weaker and more susceptible to infectious diseases and cancer than younger people. (Kindle Loc 1756)

I also enjoyed the sections on how "immune boosting" is not a good idea, including a depiction of real life experiments that went horribly wrong and a reminder of how little we still know about immunology, including the so-called hygiene hypothesis:

Even in developed countries, a number of studies found that children who grow up in the countryside and especially on farms, surrounded by animals and with much more exposure to the outside, suffer significantly less from immune disorders. So while it doesn’t seem to make a difference if a house is clean or not, it does make a difference if it is surrounded by cows and trees and bushes and if dogs roam freely. So what can you take away from this chapter? Wash your hands at least every time you use the restroom, clean your apartment but don’t try to sterilize it, and clean the tools you use to prepare food properly. But let your kids play in the forest. (Kindle Loc 4170)

 Finally, there's an exploration of in addition the allergies, a discussion of how your immune system plays an active job in suppressing cancer, as well as why we have such a hard time developing anti-viral drugs, whereas it still at least seems somewhat possible to develop newer antibiotics.

The book taught me a lot, and I think it's well worth reading. Recommended.

Review: The Remarkable Life of the Skin

 I read The Remarkable Life of the Skin during a sailing trip in the Caribbean, which made the early chapters on how tanning and melanin work really resonate with me:

Overnight, keratinocytes proliferate rapidly, preparing and protecting our outer barrier for the sunlight and scratches of the coming day. During the day, these cells then selectively switch on genes involved with protection against the sun’s ultraviolet (UV) rays. A 2017 study took this one step further and found, rather remarkably, that midnight feasts could actually cause sunburn.14 If we eat late at night, our skin’s clock assumes that it must be dinner time and consequently pushes back the activation of the morning-UV-protection genes, leaving us more exposed the next day. So while studies are increasingly showing that a lack of sleep is detrimental to our overall physical and mental health, it now seems that our skin also benefits from additional sleep. (page 9)

 The next few chapters describe how amazing the skin is, including how it's carefully acidic for a particular reason:

The acids in sebum also keep the surface of the skin slightly acidic (between a pH of 4.5 and 6), which deters potentially dangerous bacteria, while those that adapt to this environment will be consequently less able to thrive if they manage to get past the skin and infect the alkaline environment of the blood. (pg. 13)

This is followed by chapters on touch, how skin recovers from wounds and activate the immune system, and even how tattoes work:

 The most impressive feature of Meissner corpuscles is that they literally catch us every time we fall. As you hold the key, it actually slips a thousandth of a millimetre a number of times a second. Our Meissner corpuscles can detect this loss and, in a series of rapid reflexes, cause our skin to tighten so that we don’t end up dropping the object. All of this is completely subconscious. (pg. 113)

 We essentially create an infinite infection. So if you sport a tattoo, spare a thought for the little fellows who went into battle thinking they were fighting an infection but were instead fated to spend the rest of their days embedded in your skin-based art. (pg. 176)

There are also entire chapters on skin diseases, including exotic ones like leprosy and river blindness, which I didn't realize was a skin disease as well. The social implications of skin coloring (such as albinism, not just race) are also covered, and in well-written fashion. After reading this book I took Bowen to the pediatrician where she told him his skin was so dry that he needed moisturizer twice a day. The knowledge in the book prepared me to treat her recommendations seriously (eczema is no joke and can lead to infection).  The book was therefore well worth my time.

Review: Why Geese Don't Get Obese

 Why Geese Don't Get Obese is a book on the physiology of animals in comparison to our own, and how our lifestyle as well as our unique features make us susceptible to problems that other creatures don't. It contains many titbits that are really relevant to parents. For instance:

Large numbers of new fat cells are not created—that happens primarily in early life. But if there were twice as many fat cells around to begin with, there would be that many more fat cells with the capacity to become fatter. So, the idea goes, it is especially important not to overfeed young children and toddlers, because this is the time when they can still make additional adipocytes. Overeating, therefore, will cause growth of both the number and the size of fat cells. It is highly probable that overeating in newborns leads to adults with lots of extra adipocytes, just waiting for that next cupcake or scoop of ice cream. (page 28)

This partially explains why obesity runs in families. There are lots of fascinating sections about lung capacity, hormonal responses, and sweat, some of which I didn't know. For instance:

 Although perspiration on our upper lip may taste salty, it is actually less salty than our blood. The water in the perspiration comes from our internal stores of water. Thus, when we perspire heavily on a hot day, we lose both water and salt but proportionately more water than salt. (pg. 45)

The section on marine mammals is great. For instance, I did not know that seals expelled all residual air from their lungs before they dove, which is one reason they don't get decompression sickness by ascending rapidly. It turns out that lungs don't hold much more than about 2 minutes of air, which is insignificant for the length of dives the seals and otters do. Avoiding decompression illness is worth losing those two minutes. 

I enjoyed the book, even though it's short, and the epilogue is even more interesting, as it describes the experiment on geese which required putting them on a treadmill while measuring their oxygen intake.  The diagram is thoroughly entertaining and well worth the time to read. Recommended.

Review: Extreme Medicine

 Extreme Medicine is a book about how exploration transformed medicine and vice-versa, and starts off with the discussion of Robert F Scott's death in Antarctica and tying it to the survival of Anna Bagenholm, one of the first people who'd survived due to deep cold conditions. The author, Kevin Fong is an MD and I have no reason to doubt the accuracy of the book, but upon reflection realized that Robert F Scott had nothing to do with Bagenholm's survival!

The same sequence would happen all through the book in the early chapters, detailing burn victims, and then you hit smack-dab into the section on the ICU, which has a discussion of the original SARS epidemic and but has zero content about  how the various devices in the ICU works and also noted that the SARS epidemic was won by public health, not by heroic interventions in the ICU. Sure, the ICU saved lives, but as the recent SARS-Cov2 virus showed, no amount of ICU intervention will prevent large numbers of death if your public health infrastructure has fallen down.

Hence, you get a great discussion of the invention of ventilators, only to realize (and to his credit Fong acknowledges that) the polio epidemics was only ended by vaccines.

Only the final few chapters have anything to do with exploration --- the one on traveling to Mars and NASA's repeated attempt at artificial gravity does actually seem like inventions designed to facilitate exploration, as well as the solar flare protection plans. But boy, that's 1 chapter in a book that otherwise never ties its content to its title.

Fong is a good presenter (apparently he's  TV personality in the UK), and writes well. The prose is reasonably interesting, but I'd recommend several other medical-related books over this one.

Review: Exercised

 Exercised is an evolutionary biologist's view of the modern invention of exercise. It turns out that Dan Lieberman was the person whose paper inspired the book, Born to Run, which described a tribe of Tarahumara runners in Mexico who run barefoot. But when Lieberman actually visits that tribe, when he interviews everyone, he discovered that most people would say that they didn't race, and definitely did not exercise. When he finally found a racer, he asked the racer about training, and the racer looked nonplused and had to have the concept of training explained to him. It turned out that the Tarahumara race was actually a social ritual, involving kicking a ball, following it, and then kicking it again. The race involved 2 teams, and the team that lapped another team won, so races could go on all night. Lieberman speculates later on in the book that this sport probably evolved out of the need to track animals over long distances while doing persistence hunting.

Lieberman delves into many myths about exercise. The big one (which is the subtitle of the book) is that we were never born to exercise. The hunter-gather tribes live on such an edge of caloric sufficiency that humans who unnecessarily expended energy would have to give up reproduction or other important activities of life, so instead, the human body (and brain!) evolved to do everything as efficiently as possible while expending as little energy as possible. In fact, the average hunter gatherer walks about 20,000 steps a day, which while a lot compared to modern Westernized societies, is only about 10 miles. From this insight, many other aspects of modern ailments and attitudes towards exercise can be deduced. For instance, one reason walking doesn't really result in weight loss is that walking is so efficient that you'd have to well exceed the minimum typically prescribed by health authorities --- you pretty much have to run (an hour or so) or walk tremendous amounts to achieve weight loss.

From this, Lieberman goes on to attack other myths, such as the one about "sitting is the new smoking." It turns out that traditional hunter-gathers do sit a lot. But it's rarely more than 15 minutes at a stretch, and obviously, they're still getting lots of walking in. It's not the sitting that's bad, it's that the time spent sitting in front of a TV or computer monitor is time that isn't spent exercising. Lieberman then explains why exercise is so good for you --- it creates inflammation and then the body hyper-compensates, basically overdoing the repair and eliminating the damaged caused by the exercise and then some. What's important here is that the lack of activity actually induces a mild form of inflammation, which is repaired during recovery from exercise. Because humans evolved in a state where exercise was required to survive, the recovery system never evolved to activate outside of exercise, which is why exercise is so important.

Similarly, Lieberman dismisses the paleo-fitness regime. He points out that the traditional hunter gatherer male is 5'5" and 115 pounds, and that modern gym rats with access to weight machines and dumb-bells and access to all the food they want, have exceeded the strength of most hunter gatherers (not to mention weight!). The metabolic requirements of excess muscle would never have been tolerated in a state of caloric scarcity. He does point out that traditional human society do participate in rituals that look a bit like training: dancing and sports, some of which last long enough to evoke endorphin high and other experiences that athletes have experienced,.

The exploration of aging is also excellent. Lieberman points out that hunter gatherers do live to the traditional 4 score and 10 years, but also have much reduced morbidity compared to modern Westerners. The advances in medicine mostly means that people who might otherwise have died earlier, live about as long as hunter gatherers, but in a state of requiring constant medical support in the form of medicine, surgery, and therapy. He points out that even people who never exercise (e.g., Donald Trump) frequently do live long lives --- it's just that they might have to be on medication, and obviously they're not performing optimally, mentally or physically.

The book is well written and I read it compellingly for not just the health nuggets and advice, but also for the stories about the research on the topic. After I finished I wanted to go back and start it again, and wish I'd waited for the ebook version from the library so I could have highlighted the important passages. Highly recommended.

Switching to Bar Soap

 I'd been using Nivea 3-in-1 shampoo and body wash for myself and the kids through a series of Amazon deals, but then ran out in the middle of the summer. I felt a little guilty about the amount of plastic being thrown away, and read a few articles about the much reduced carbon footprints of bar soaps and decided to try them.

Dove is the default brand at both Costco and Amazon. Each bar lasts about a week, but the book Clean noted that Dove as a PH-neutral soap did not clean as effectively as real soap! So I tried the whole foods branded 360 Soap. The kids love the smell and my wife stole a bar, but the pine tar version left a nasty black residue in the bath tub. Each bar lasts a week as well, but is an awkward shape and doesn't really fit well in the bath.

I remembered using the Grant Petersen approved Grandpa's Pine Tar soap, which is more expensive per ounce than either of the above. The kids didn't love the smell, but after a week of use (each bar lasts two and a half weeks, so you would be willing to pay twice as much per ounce for this soap compared to the whole foods or Dove soap), all eczema was gone, and any residual itchiness they complained about on a regular basis is gone as well. I guess this is the one to get.

Review: Clean

 Clean was on the Smithsonian 20 best science books of the year, and it was written by a doctor who's a staff writer at The Atlantic, so I checked it out of the library. The book begins strongly, with the doctor proclaiming that he hadn't showered for years. Then he gets into the reason behind it, including a fun reading history of soap, as well as the sad lack of regulation behind personal care products:

European Union and Canada have been reviewing ingredients in personal care products for decades. More than 1,500 chemicals are banned or restricted from these products in the European Union, and some 800 are banned or restricted in Canada. California state lawmakers proposed a bill in 2019 that would ban the inclusion of lead, formaldehyde, mercury, asbestos, and many other potentially harmful compounds from personal care products, which, if enacted, would be the first legislation of its kind in the United States. As of this writing, the effort has not yet been successful. (kindle loc 1505)

But the detail isn't there. There's no discussion as to whether not showering or bathing will solve eczema, a common childhood ailment. No studies (double-blinded or not), just loads and loads of anecdotal evidence. We get lots of copy text about how little regulation there is for makeup and other health supplements (which you would know about if you'd even read one other non-fiction book about the topic), but the scientific evidence is sadly lacking. There is a note that Dove is a particularly ineffective soap, which is why it gets to be marketed as mild!

The book then branches out into various other aspects of the hygiene hypothesis and the rise of allergy and asthma:

 In wealthy countries around the world, people now spend more than 90 percent of their lives indoors. Friends and family are not allowed to touch babies unless their hands have been scrubbed or coated in antibacterial gels. The indoor air is lacking in the wealth of bacterial particles that used to temper our immune systems. Our diet is hyperprocessed and cleaned and low in fresh fruits and vegetables—which are naturally loaded with bacteria. An average apple contains 100 million microbes. (kindle loc 1765)

But there's no real detail behind it. There's nothing about whether eating apple skin is good for you, no studies, and definitely no clinical recommendations. The entire book goes on like this, with forays into green space exposure and outdoor exercise vs indoor exercise: 

A number of studies have reported associations between green-space exposure and self-reported health, birth outcomes, and reduced morbidity. A 2018 meta-analysis found statistically significant associations between exposure to green spaces and reduced blood pressure, heart rate, cortisol levels, incidence of type 2 diabetes, and death from cardiovascular disease. Exercising outdoors may also have health benefits you don’t get at the gym. Much work has been done in this area by Diana Bowler and colleagues in the UK, who compared the effects of exercise in “natural” and “synthetic” environments and found that a walk or run outside “may convey greater health benefits than the same activity in a synthetic environment.” (kindle loc 2004)

At least this particular instance had great relevance to me and some literature citations, but the author provides no quantification of the results, and clearly the science here is difficult to do (how do you do a double-blind study of a topic like this one?). I came away with the book vaguely dissatisfied. I cannot sincerely recommend this book.

Review: Temtop M10 Air Quality Monitor

 With the fires raging near us, I broke out all the air purifiers I bought last year during Amazon Prime Day, purchased specifically for such an occasion. But even with 3 air purifiers, you can't cover an entire house, so it's important to figure out where to put them. I researched air quality monitors and eventually settled on the Temtop M10: I didn't need fancy wireless readouts. I just wanted it to display what the current air quality is.

The first sample I received was garbage. It just was stuck at 4, no matter if I could smell smoke, indoors or out. So I returned it to Amazon and got a second sample. This second sample is good, accurately rating HCHO/PM2.5, TVOC, and AQI depending on where it was in the house, whether it was cooking, and matching Purple Air and/or AirNow's readouts.

At $80, it's pretty cheap and of course is now completely sold out on Amazon. The battery lasts for 6 hours, which is enough for you to stick in your pannier/trunk bag/handlebag and go out for a ride and let you know when the air has gone bad enough for you to need to go home. Recommended.

Review: Gut - The Inside Story of Our Body's Most Underrated Organ

Gut is a strange book. The author, Giulia Enders has a fun sense of humor (I guess that's what it takes to be a gastroenterologist):

Japanese researchers fed volunteers luminous substances and X-rayed them while they were doing their business in various positions. They found out two interesting things. First, squatting does indeed lead to a nice, straight intestinal tract, allowing for a direct, easy exit. Second, some people are nice enough to let researchers feed them luminous substances and X-ray them while they have a bowel movement, all in the name of science. Both findings are pretty impressive, I think. (Pg. 19)

The book thereby proceeds in fits and starts, lurching from subject to subject in an unpaced fashion. (How much of it is because Enders is German and this book was translated from German I don't know)

But there are some good tidbits, like:

Of particular interest to those fighting fat is that olive oil also has the potential to help get rid of that spare tire. It blocks an enzyme in fatty tissue—known as fatty acid synthase—that likes to create fat out of spare carbohydrates. And we are not the only ones who benefit from the properties of olive oil—the good bacteria in our gut also appreciate a little pampering. (pg. 53)

Nevertheless, the book is full of practical tips, though because of the translation, some of it seems a little confusing:

One example of bacteria dilution in the home is washing fruit and vegetables. Washing dilutes most soil-dwelling bacteria to such a low concentration that they become harmless to humans. Koreans add a little vinegar to the water to make it slightly acidic and just that bit more uncomfortable for any bacteria. Airing a room is also a dilution technique. If you dilute the bacteria on your plates, cutlery, and cutting board nicely with water, then wipe them over with a kitchen sponge before putting them away, you may as well have licked them clean with your tongue. (Pg. 227)

 Nevertheless, I enjoyed some of the interesting stories, and many of the stories were new to me, such as this one:

A group of South Americans had to learn that through bitter experience. They had the clever idea of taking pregnant women to the South Pole to have their babies. The plan was that the babies born there could stake a claim to any oil future reserves as natives of the region. The babies did not survive. They died soon after birth or on the way back to South America. The South Pole is so cold and germ-free that the infants simply did not get the bacteria they needed to survive. The normal temperatures and bacteria the babies encountered after leaving the Antarctic were enough to kill them. (pg. 240)

Recommended.

Review: The Body - A Guide for Occupants

I've bounced of a number of other Bill Bryson books before, so I approached The Body with low expectations. To my surprise I found myself reading the book in earnest, highlighting passage after passage. Here he is about lifespan:

Many factors determine life span, of course, but it is a fact that men who have been castrated live about as long as women do. In what way exactly testosterone might shorten male lives is not known. Testosterone levels in men fall by about 1 percent a year beginning in their forties, prompting many to take supplements in the hope of boosting their sex drive and energy levels. The evidence that it improves sexual performance or general virility is thin at best; there is much greater evidence that it can lead to an increased risk of heart attack or stroke. (Kindle Loc 2490)

 I remember reading in one of John Medina's books about how hunter-gathers might walk as much as 10 miles a day. Here's Bill Bryson debunking that:

According to The Economist, some American companies have begun offering rewards to employees who log a million steps a year on an activity tracker such as a Fitbit. That seems a pretty ambitious number but actually works out to just 2,740 steps a day, or a little over a mile. Even that, however, seems to be beyond many. “Some workers have reportedly strapped their Fitbits to their dogs to boost their activity scores,” The Economist noted. Modern hunter-gatherers, by contrast, average about nineteen miles of walking and trotting to secure a day’s food, and it is reasonable to assume that our ancient forebears would have done about the same. (Kindle Loc 2968)

 Ok, that's all stuff you already know. But here he is on the puzzle of allergies, and the increasing rate of asthma among children:

An estimated 300 million people in the world have asthma today, about 5 percent of adults and about 15 percent of children in those countries where it is measured carefully, though the proportions vary markedly from region to region and country to country, even from city to city. In China, the city of Guangzhou is highly polluted, while nearby Hong Kong, just an hour away by train, is comparatively clean as it has little industry and lots of fresh air because it is by the sea. Yet in clean Hong Kong asthma rates are 15 percent, while in heavily polluted Guangzhou they are just 3 percent, exactly the opposite of what one would expect. No one can account for any of this... (Kindle Loc 3551)

In children, it is closely associated with both being obese and being underweight; obese children get it more often, but underweight children get it worse. The highest rate in the world is in the U.K., where 30 percent of children have shown asthma symptoms. The lowest rates are in China, Greece, Georgia, Romania, and Russia, with just 3 percent. All the English-speaking nations of the world have high rates, as do those of Latin America. There is no cure, though in 75 percent of young people asthma resolves itself by the time they reach early adulthood. No one knows how or why that happens either, or why it doesn’t happen for the unfortunate minority. Indeed, where asthma is concerned, no one knows much of anything.  (Kindle Loc 3567)

As we all know, it's Speaking English that kills you. There's a significant amount of medical history in the book, with lots of tidbits like this one:

in 1970 Congress canceled the only comprehensive federal nutrition survey ever attempted after the preliminary results proved embarrassing. “A significant proportion of the population surveyed is malnourished or at a high risk of developing nutritional problems,” the survey reported, just before it was axed. (Kindle Loc 3986)

 Bryson doesn't shy away from politically inconvenient facts, such as the US being the worst country in the world to get healthcare in the developed world:

Even now, however, there is huge variability in maternal mortality rates among countries of the developed world. In Italy, the number of women who die in childbirth is 3.9 per 100,000. Sweden is 4.6, Australia 5.1, Ireland 5.7, Canada 6.6. Britain comes only twenty-third on the list with 8.2 deaths per 100,000 live births, putting it below Hungary, Poland, and Albania. But also doing surprisingly poorly are Denmark (9.4 per 100,000) and France (10.0). Among developed nations, the United States is in a league of its own, with a maternal death rate of 16.7 per 100,000, putting it thirty-ninth among nations. (Kindle Loc 4830)

But even within the US, it's not evenly distributed. Much of the medical problems the US has can be addressed. For instance:

 California addressed preeclampsia and the other leading causes of maternal death in childbirth through a program called the Maternal Quality Care Collaborative, and in just six years reduced the rate of childbirth deaths from 17 per 100,000 to just 7.3 between 2006 and 2013. During the same period, alas, the national rate rose from 13.3 deaths to 22 deaths per 100,000. (Kindle Loc 4859)

Of course, this stuff doesn't make the news, and the libertarians are happy to tell you that "government can't solve any problems," even when other countries with government run healthcare manage to do far better than the USA's private system.

 The second thing that can be said with regard to life expectancy is that it is not a good idea to be an American. Compared with your peers in the rest of the industrialized world, even being well-off doesn’t help you here. A randomly selected American aged forty-five to fifty-four is more than twice as likely to die, from any cause, as someone from the same age-group in Sweden. Just consider that. If you are a middle-aged American, your risk of dying before your time is more than double that of a person picked at random off the streets of Uppsala or Stockholm or Linköping. It is much the same when other nationalities are brought in for comparison. For every 400 middle-aged Americans who die each year, just 220 die in Australia, 230 in Britain, 290 in Germany, and 300 in France. These health deficits begin at birth and go right on through life. Children in the United States are 70 percent more likely to die in childhood than children in the rest of the wealthy world. Among rich countries, America is at or near the bottom for virtually every measure of medical well-being—for chronic disease, depression, drug abuse, homicide, teenage pregnancies, HIV prevalence. Even sufferers of cystic fibrosis live ten years longer on average in Canada than in the United States. What is perhaps most surprising is that all these poorer outcomes apply not just to underprivileged citizens but to prosperous white college-educated Americans when compared with their socioeconomic equivalents abroad. (kindle Loc 5798)

You would think that being wealthy in the US would protect you from a lot of health problems, but it turns out that  many of the problems are systemic:

“Even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress.” The average Dutch or Swedish citizen consumes about 20 percent fewer calories than the average American, for instance. That doesn’t sound massively excessive, but it adds up to 250,000 calories over the course of a year. You would get a similar boost if you sat down about twice a week and ate an entire cheesecake. (Kindle Loc 5816)

And of course, that idiot driver will kill you just as easily in a country where no one has a choice but to drive everywhere:

 the United States records a really quite spectacular 11 traffic deaths per 100,000 people every year, compared with 3.1 in the United Kingdom, 3.4 in Sweden, and 4.3 in Japan. (Kindle Loc 5826)

 Finally, I enjoyed his treatment of longevity as well:

The longest-lived person that we know of was Jeanne Louise Calment of Arles, in Provence, who died at the decidedly ripe age of 122 years and 164 days in 1997. She was the first person to reach not only 122 but also 116, 117, 118, 119, 120, and 121. Calment had a leisurely life: her father was a rich shipbuilder and her husband a prosperous businessman. She never worked. She outlived her husband by more than half a century and her only child, a daughter, by sixty-three years. Calment smoked all her life—at the age of 117, when she finally gave up, she was still smoking two cigarettes a day—and ate two pounds of chocolate every week but was active up to the very end and enjoyed robust health. Her proud and charming boast in old age was, “I’ve never had but one wrinkle, and I’m sitting on it.” (Kindle Loc 6072)

In any case, the book's chock full of fun reading (I'm not even using half the stuff I highlighted for future reference), and even occasionally has some actionable stuff. Recommended.

Review: Dopesick

Dopesick is a book exploring the opoid epidemic in the USA, specifically in Virginia. Scarlet pointed me at the book, and it's very much worth reading for an overview of what some economists call "The diseases of despair." I learned a ton in this book.

For instance, I didn't know that selling addictive drugs has long been part of the history of the big pharmaceutical companies:

By 1899, Bayer was cranking out a ton of heroin a year and selling it in twenty-three countries. In the United States, cough drops and even baby-soothing syrups were laced with heroin, ballyhooed at a time when typical opioid consumers were by now not only war veterans but also middle-aged barbers and teachers, shopkeepers and housewives. Many were mostly functioning, doctor-approved users, able to hide their habits—as long as their supply remained steady, and as long as they didn’t overdo. (pg 24)

Even more importantly, I didn't realize that the subjective pain management scale and the relatively recent emphasis on pain management was propaganda foisted onto the medical profession by the pharmaceutical companies. It's astounding to me that the FDA allowed opoid-based pain medication out along without guidance on the possibilities of addiction to powerful drugs. Many of the drug addicts became addicted not because they were partying, but because they were prescribed a drug for too long (and it's not clear to me how studies are done about potential addiction to a pain-killer --- I remember a nurse injecting morphine into me after I'd gotten hit by a car, telling me: "don't worry, you won't get addicted to it." Mercifully, right after that injection I lost consciousness, and needless to say she was right --- I had no craving for morphine after that).

New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid. (pg 47)

Again, this is only something that happens in the USA. Other countries with government provided healthcare wouldn't have marketing driven prescriptions. Again and again, the politics of the situation rears its head. For instance, Virginia was one of the states that fought Obamacare by not expanding medicaid coverage.  That creates a cycle of drug use, since many of the addicts were too poor to afford rehab (not that they would have wanted rehab --- many of the victims had families that paid for and pushed them into rehab). After a US district attorney successfully sued Purdue Pharmaceuticals and got them to cough up a relatively small settlement, he was almost fired:

Eight days after it accepted the deal, Brownlee was stunned to see his name on a firing list, along with four other U.S. attorneys. Though he wasn’t ultimately fired, the incident provided fresh criticism of then–attorney general Alberto Gonzales, accused of trying to sway the work of U.S. attorneys’ offices. And it only underscored the long reach of Purdue: Udell’s defense lawyer Mary Jo White, a former Manhattan U.S. attorney, had been the one to press for more time in a call to a Department of Justice official. (Brownlee would break down how Purdue’s attempted influence peddling worked—or didn’t—in a later Senate hearing about the case.) (pg. 82)

I'm always amazed by how Americans seem to fear the government, which is subject to elections and public oversight, while heaping social approval on corporations, who are effectively legally required to be psychopaths in pursuit of maximum profits regardless of the social consequences, can't go to jail, and have so much money that even multi-million dollar fines have no incentive effect on their  behavior.

More importantly, the book provides case studies of the drug addicts. This not just puts a face on the victims, but also points out that many of these drug addicts do not fit your stereotype of one: these were successful men and women from good families who were doing well in school. Drug addiction really does change your brain, and turns you into a desperate junkie in search of the next fix no matter your economic class or social status. (There's even a person who was a doctor on probation due to addiction) If you're a parent you will probably come away from this book fearful for your kids.

Ironically, these diseases of despair only hit white people. The black population was spared this because:

Why had blacks failed to become ensnared in opioid addiction? That question was addressed in 2014 data issued by the Centers for Disease Control and Prevention: Doctors didn’t trust people of color not to abuse opioids, so they prescribed them painkillers at far lower rates than they did whites. “It’s a case where racial stereotyping actually seems to be having a protective effect,” marveled researcher Dr. Andrew Kolodny of Brandeis University. Put another way: By 2014, while young whites were dying of overdose at a rate three times higher than they did in 2002, the death rate for people of color was relatively unchanged. (pg. 253)

There's lots more in this book, such as the political fight over effective rehab (the scientifically proven to work stuff isn't used because the religious people and the AA types are ideologically opposed to it), and of course the individual case studies.

—he believes the five-year treatment model, common for addicted doctors and airline pilots, is ideal. It’s why they tend to have opioid-recovery rates as high as 70 to 90 percent. “There’s nothing scientific at all about twenty-eight days of [residential] treatment,” Loyd said of the kind heralded in movies and on reality TV. “It takes the frontal lobe, the insight and judgment part that’s been shut down by continued drug use, at least ninety days just to start to come back online and sometimes two years to be fully functioning.” (pg. 294)

There's a poignant section of the book where the author attends a "free healthcare" camp and compares it to 3rd world countries like Haiti:

In rural America, where overdose rates are still 50 percent higher than in urban areas, the Third World disaster imagery is apt, although the state of health of RAM patients was actually far worse. “In Central America, they’re eating beans and rice and walking everywhere,” a volunteer doctor told the New York Times reporter sent to cover the event. “They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.” (pg. 274)

There are comparisons with other countries that have decriminalized drugs and reduced the cost of addicts to society by providing working rehab programs. Again, ideology (mostly from the non-evidence based crowd) trumps effective operation of society in the USA in a way that's uniquely dysfunctional.

While the author works hard to draw your sympathy, by the end of the book I was starting to get irritated that the voters of Virginia continue to vote for politicians that propound ineffective solutions that kill their children and loved ones while criminalizing them and blaming them for being victims of big pharma. Unfortunately, this book does not have a happy ending, and of course, it's not clear that the country as a whole will have a happy ending if voters keep operating as though the opoid epidemic is a crime issue rather than a medical issue.

The book does have weaknesses: I would have wanted to see a more involved examination of the various rehab approaches and the studies involved. I would rather have seen more statistics about drug movement and distribution rather than a lone interview with a drug dealer (who, like the executives at Purdue Pharmaceuticals, demonstrated no remorse about the lives he ruined). But overall, that does not detract from the point that the book's very much worth your time reading. Recommended.

 

 

Review: Prognosis

Prognosis was for me that rarest of books: an Amazon First giveaway that drew me in and force me to read until I got to the finish. The author, Sarah Vallance was a smart, risk-seeking woman who was thrown off a horse and hit her head. This resulted in what's called a "mild brain injury."

As one of my friends learned ages ago, there's no such thing as a mild brain injury, and Vallance describes her process of recovery and healing from the trauma well: from the horror of not having executive function to months of recovering the ability to read or even put together sentences, and the stories of the medical professionals writing her off after she scored with an IQ of 80.

Part of it was her very angry personality, deliberately refusing the help of social workers and other professionals. On the other hand, this was someone who'd suffered a brain injury, and the professionals should know that brain injury victims are literally unable to make rational decisions. On the other hand, she was very lucky to get her brain injury in a country with universal healthcare. In the USA, she'd probably have had her house taken away, and ended up homeless and there would be no way that this book would have been written.

The recovery process was painful to even read, but what came through in the end was that despite her self-doubts, Vallance made a good recovery and performed at a very high level after she attained her PhD, won a fellowship, and became a HR professional and expat. While she's not a very likable person (and neither were much of her family as described), the writing flows, is easy to read, and you will have sympathy for her by the end of the story.

Recommended.