Sunday, August 11, 2013

Dissecting Two Damning Critiques of Medicine

I don't do a ton of op ed reading, but two pieces caught my eye in a span of a few days at the New York Times. Both are fairly savage critiques of medicine. Both should be taken very seriously, especially by those of us in the White Coat Tribe. But only one of them makes a compelling case.

One piece is called "When Doctors Discriminate" and is a meditation on the kinds of harm that non-psychiatrist MDs can inflict on patients with psychiatric conditions--in the author's case, a diagnosis of bipolar disorder. "You better get yourself together psychologically, or your stomach is never going to get better", the writer quotes a gastroenterologist as saying. This apparently was intended as a helpful piece of advice, and the article goes on to list the myriad ways in which physicians can negatively impact the health of these patients.

The second piece, called "Crazy Pills", notes the recent change in FDA policy toward the anti-malarial medication mefloquine, as it now includes a "black box warning" for the drug. The warning stems from mefloquine's neurologic and psychiatric side effects, which can persist well beyond the time period when it is taken (the drug is used to prevent malaria infection when people travel to areas with malaria). The author reports having had ongoing bouts of depression, panic attacks, and insomnia since his encounter with mefloquine as part of a stint in India for his Fulbright fellowship. The essay does not make for pretty reading, documenting murders and suicides, and lays them at the doorstep of the medication.

I heed the warnings explicit in both of these articles. Doctors should always be conscious about their biases, constantly on guard against anchoring their judgments based on one piece of data--in this case, a diagnosis of mental illness. Likewise, it's important for people to be aware of the potentially serious side effects of mefloquine, or any other medication for that matter. Nearly all doctors in Infectious Disease were keenly aware of mefloquine's psychiatric side effects even before the black box warning was issued. Nevertheless, making patients aware of the possible serious reactions to a medication, especially when a new warning is attached to it, is an important public service announcement.

But that being said, there is an enormous amount of innuendo and logical leaping in "Crazy Pills", while "When Doctors Discriminate" constructs its argument with a good deal more care. The author of "Crazy Pills" alleges that the drug was responsible for an Ohio man putting a shotgun to his head in 1999 after returning from a safari in Zimbabwe, as well as for the killing of a Somali prisoner by a Canadian soldier who took the drug. He also hints that Staff Sgt. Robert Bales, who went on a killing rampage in Afghanistan in 2012, was under mefloquine's influence. In the first example, we have no link to know any details beyond what is supplied to us by the author, and therefore no way to know anything else about this man. In the latter two examples, there appears to be no alternative hypotheses entertained for these most unfortunate horrors, but surely the fact that these men were under the duress of war might have played just as much a role, or indeed a more powerful one, than an antimalarial.

By contrast, "When Doctors Discriminate" relies not on a few carefully selected anecdotes that can't be considered in context, or even verified, but by noting broad research as reported by major public health organizations. It is a model of a well-constructed argument in the internet age, built not on hearsay, but on evidence, available for all readers to see should they choose to do so.

Lest I be misunderstood as being dismissive of mefloquine's side effects, I think that the inclusion of the black box warning was important for physicians and patients alike. But living in a malaria-endemic region with no prophylaxis is a very, very risky business: malaria kills. There are other drugs that protect against malaria--during my travels to Africa I took the drug Malarone without any problems at all, and it's a very well tolerated drug. But Malarone is expensive, and not all insurance companies will cover it. Should someone just avoid taking mefloquine if they can't have Malarone and take their chances?

That will very much depend on the numerical risks involved. The data presented in the op ed suggest that there's about a 6 percent chance of mefloquine causing a severe reaction for which it needs to be stopped. (The author ominously notes that "67 percent of people who took the drug experienced one or more adverse effects", which is, unintentionally or not, a scare tactic: "adverse effects" can include reactions as trivial as an upset stomach or a touch of insomnia.) Whether this number seems minor compared to the risk of full blown malaria is a proposition that patients and doctors must decide in a discussion, but I'm very concerned by the idea that everyone who needs malaria protection should just stop taking mefloquine if that's their drug. If his advice is heeded, we could soon be seeing NYT op eds about loved ones who went on safari and came home in a casket because they avoided protecting themselves against the great scourge of the tropics.

No comments:

Post a Comment