Inequity, DiseaseInequity, Disease

"He always kind of holds your feet to the fire," commented the master of ceremonies at a fundraiser attended by Dr Paul Farmer and described in a New Yorker article last year.¹ Indeed, Farmer's Infections and Inequalities: The Modern Plagues, recently released in a paperback edition, should make most involved in the delivery of health care uncomfortable. His case studies and scholarly analysis of the differential distribution and outcomes of disease among poor individuals and populations illustrate the dizzying drop-offs in the topography of national and global health policy, especially in reference to HIV and multidrug-resistant tuberculosis (MDRTB).

Farmer trained in internal medicine, infectious disease, and anthropology. He has spent the greater part of the past 20 years at work at the Clinique Bon Saveur in the central plateau of Haiti and at the helm of Partners in Health, which also maintains clinics in Peru and Massachusetts. He weaves these rich intellectual foundations and clinical experiences into 10 compelling chapters, which mandate that "double standards of care . . . be questioned." Throughout his book, Farmer examines the assumptions and resultant policies that rationalize these double standards, offers his own clinical examples that challenge the assumptions, and suggests future avenues of research and action that might help to eradicate these inequities.

"Immodest claims of causality," the "Luddite trap," and exaggeration of agency serve as leitmotivs for Farmer as he examines public health policy. His critical analysis of the interpretations of several anthropologic studies illustrate his point that cultural explanations for differential incidence of or outcome from disease often ignore or obscure more important economic or political factors. For example, he cites a study from Haiti, which emphasizes cultural ignorance on the part of a clinic's staff as the cause of tuberculosis treatment failure. However, Farmer refocuses on other data collected by the researcher: the painful cost of only 10 weeks of treatment, half of a typical family's yearly income. For the treatment failure, Farmer impugns not cultural ignorance but "lack of commitment to the destitute sick." At Farmer's clinic, this commitment includes financial aid for food and transportation in addition to free medication.

To promote a global commitment to the poor, Farmer hopes to spring policymakers from the "Luddite trap." He suggests that the policy-making community's dogged dedication to prevention and "community-based care" is unethical and contradicted by data which suggest that the delivery of standard-of-care therapies and the achievement of excellent disease outcomes is possible in resource-poor settings. Farmer's statement decrying double standards of care resonates powerfully when he describes his Haitian patients' dramatic improvement when treated for HIV or MDRTB. As he drolly observes, "it's almost as if they suffered from treatable infectious diseases."

Finally, his discussions focusing on the individual agency of the poor echo his thoughts on the two themes mentioned above. Farmer demands careful examination of the role of the political and economic matrix in which disenfranchised women, displaced Haitian or Peruvian peasants, and Russian prisoners are enmeshed. He does not discount the importance of culture or the role of prevention. However, he does argue that one overwhelming "culture" is poverty. The story of Lata, a 15-year-old Indian girl, highlights the cruel economic dilemmas faced by the poor. Farmer recounts how her low-caste Indian father unwittingly sold his daughter into prostitution, and ultimately to infection with HIV, in hopes of saving the rest of his family from the ravages of a bad harvest. In addition to recognizing poverty's role in undermining agency, Farmer cites studies which show that knowledge in the absence of economic or political empowerment does not change health beliefs, behaviors, or outcomes. His description of a woman named Corina's ultimately unsuccessful struggle with MDRTB in the context of Peru's economic devastation following "Fujishock" reinforces this point.

Throughout his book, Farmer's retelling of his own clinical experiences lends poignancy and sometimes irony to his fiery critiques. In his new introduction, he describes a meningococcal outbreak that required him to take rifampin with the resultant red-tinged body fluids. On first reading, his oratorical repetition of references to his own red tears seems melodramatic. However, Farmer's role as a physician-witness to patients' individual tragedies and to the horror of the "structural violence" meted out to these same patients by ineffective governments and also, at times, by monolithic aid organizations is indeed dramatic. His example challenges other physicians to use their clinical encounters as an opportunity to explore not only the molecular basis of disease in individuals and populations but also the social forces abetting those diseases.

Two years after this book's original publication, some indicators suggest that the inertia and complacency relative to the treatment of MDRTB and HIV in developing countries has lessened. Medications are becoming more available. The Brazilian government is providing highly-active antiretroviral therapy to its patients with HIV, and, after much haggling, an Indian company has begun producing generic antiretrovirals for sale in India and to aid organizations working in Africa. A Washington Post article from early in the summer trumpeted a United Nations declaration concerning the international body's policy toward AIDS, which says that "care and treatment must be an integral part of all national and international programs." Although Farmer is somewhat critical of current attention to "emerging infectious diseases," it is our awareness of our interdependence that may indeed be "emerging" and our beginning appreciation of the unacceptably high costs of the diseases of poverty, not only biologic and economic, but intensely human as well.²

Despite these hopeful indicators, Farmer continues to hold the medical community's "feet to the fire." He concluded a recent editorial reviewing a Turkish study of the treatment of MDRTB with the following statement: "Excellence without equity looms as the chief human-rights dilemma of health care in the 21st century."³

The majority of patients with epilepsy do not suffer from psychiatric problems, but as a group they are at increased risk for a variety of psychiatric disorders. Thus, psychiatric issues pose a frequent problem in the routine management of patients with seizures.

Although the association of epilepsy and psychiatric disease has been recognized since antiquity, there is a paucity of systematic studies investigating this relationship or examining psychiatric treatments in epilepsy. For example, there is only one published controlled study evaluating the efficacy of antidepressant drugs for the treatment of major depression in patients with epilepsy. This lack of information results in many psychiatric complications of epilepsy going untreated or, worse, mistreated.

Ettinger and Kanner along with 42 other experts provide a comprehensive review of our current knowledge of the psychiatric aspects of epilepsy. The 26 chapters cover an array of topics, including psychosis, depression, anxiety, attention deficit hyperactivity disorder, personality disorders, aggressive behavior, pseudoseizures, psychosocial issues, disorders in special populations (eg, pediatric and geriatric), sexual problems, and the effects of seizures, antiepileptic drugs, and epilepsy surgery on psychiatric disorders.

The book emphasizes many fascinating elements in the complex relationship between epilepsy and psychiatric disorders. For example, the depletion of the neurotransmitters norepinephrine and serotonin, which can lead to depression, can also facilitate the kindling process in an animal model of epilepsy. Several controversial topics are discussed, such as forced normalization and temporal lobe epilepsy personality syndrome. Thoughtful perspectives are offered on many negative traits that, unfortunately, have been attributed to patients with epilepsy. Topics are also put into historical context. In the fourth century, Hippocrates remarked that "epileptics become melancholic and melancholics epileptics." Compatible with this ancient observation, new epidemiologic data suggest that not only is epilepsy a risk factor for depression, but depression may also be a risk factor for epilepsy.

Many psychiatric problems in patients with epilepsy go untreated. The first reason is that they are frequently unrecognized. An example of such a problem is interictal dysphoric disorder, which is a subtle and common form of depression in patients with epilepsy. The authors highlight detection of the common psychiatric disorders in epilepsy patients and the differentiation of some aberrant behaviors from seizures. Another factor contributing to undertreatment is concern that psychotropic agents lower seizure threshold. The authors discuss the comparative risks across psychotropic agents of precipitating seizures or producing adverse drug interactions. Further, they offer treatment guidelines for the major psychiatric disorders in patients with epilepsy. Patients with epilepsy are vulnerable to poor psychosocial outcomes, even if they have normal intelligence and optimal control of seizures. For example, such patients have worse outcomes in educational achievements and employment and more social isolation. Practical discussions of quality of life in epilepsy are given that cover assessment and social interventions.

Antiepileptic drugs are the main therapeutic modality for the treatment of seizures. However, in recent years, less than 50% of the prescriptions written for antiepileptic drugs are for the indication of seizures. This shift reflects in part the frequent and increasing use of antiepileptic drugs for psychiatric disorders. Data supporting their use are reviewed.

Pseudoseizures are relatively common and can occur in patients with or without epilepsy. The heterogenicity of the underlying psychogenic processes is discussed. Proposed mechanisms include conversion disorder, somatization disorder, dissociative disorder, and, rarely, factitious disorder or malingering. Treatment approaches are provided.

Psychiatric Issues in Epilepsy is a comprehensive review of current knowledge of the psychiatric aspects of epilepsy. It emphasizes the gaps in knowledge that need to be addressed and offers many practical recommendations for diagnosis and management. It is an excellent source of information for health care professionals involved in the care of patients with epilepsy. Hopefully, it will also serve as a catalyst for much needed additional research in this area.

Psychiatry is not in any sort of crisis but it does have some problems and some sorting out to do. Out of Its Mind—Psychiatry in Crisis touches (pummels is more like it) most of the well-worn bases: Freud didn't get it all right; the current diagnostic scheme is not all it's cracked up to be; psychotropic drugs can be bad for you; the homeless mentally ill are not well cared for; it's time for the psychotherapy and biology camps to declare a truce.

Hobson, a sleep researcher at Harvard, and Leonard, a science writer, have come up with the answer to psychiatry's problems. It's "neurodynamics," a new psychiatry "informed" by what has been learned about the brain's role in psychiatric symptoms, or, more accurately, the authors' take on what the brain imaging and other research add up to. Anxiety? That's the amygdala acting up. Depression? Neurotransmitters, hormones, and frontal lobes gone awry.

The neurodynamic approach is no less intrepid with respect to treatment. Enlightened by the recognition that neither drugs nor psychotherapy are completely effective, neurodynamics dictates that, more often than not, both should be applied. Further, since neuroscience tells us that psychiatric symptoms involve structural brain changes, and therefore that psychiatric conditions are likely to be chronic and relapsing, treatment should be continued for a long time and patients carefully monitored. Despite the eerie similarity between neurodynamics and what psychiatrists have been doing for a long time, the authors strive mightily to convince us that neurodynamics is a revolutionary concept on the verge of replacing the old psychiatric theory and practice.

Out of Its Mind starts with four chapters on the history of psychiatry, emphasizing psychiatry's recent fall from grace at the hands of deinstitutionalization, managed care, side effects of psychotropic drugs, and psychoanalysis. The second section, "Psychiatry and the Brain," comprises three chapters: one on consciousness, one on sleep and dreams, and the third on Hobson's activation, information, modulation model of brain states. The chapters on consciousness and sleep are rather good. Although, like the rest of the book, the brain science tends to be dumbed down beyond recognition, the general reader will find a comprehensive and engaging discussion of the psychology of consciousness and dreams. The chapter outlining Hobson's brain model is mostly a gratuitous diatribe against psychotropic drugs and conventional diagnostic categories.

The third section gets at the basis for neurodynamics. It comprises chapters on brain pathophysiology in three psychiatric conditions: anxiety, depression, and schizophrenia. There are telling case descriptions in each of these chapters and good summaries of psychiatric phenomenology. But the authors see associations between psychiatric symptoms and brain lobes, neural pathways, and neurotransmitters that go far beyond the available data: "We now know where the processing of everything from visual inputs to higher-order thought occurs within the brain. We know how the brain generates a wide range of feelings—elation, satisfaction, anxiety, fear, sadness and others-as well as mental states that include waking, deep sleep, REM [rapid eye movement] sleep, dreaming, and various psychotic states associated with drug abuse or mental ills." The last section details the authors' prescription for a new psychiatry.

This book exaggerates to the point of inaccuracy both the problems facing psychiatry and the promise of brain science. It panders to prevalent misconceptions about psychotropic drugs, psychiatric hospitals, and psychoanalytic theory. And it offers a solution that is no solution at all. Nevertheless this book has its charms. It offers some telling riffs on the psychology of dreams and how psychotherapy works. And the authors' enthusiasm for brain science gives the book a bubbly, optimistic flavor.

Among this book's less charming quirks are repetitive swipes at foreign medical graduates and their imperfect English. On the very first page of text we are offered as an example of the ruinous state of psychiatry that "Patients and coworkers worry about numerous foreign psychiatric residents who can barely speak English" and later, out of left field, "less than half the foreign residents succeed in passing the board examinations," one reason being uncertain "command of English." Perhaps the authors have forgotten that the neuroscience findings that they highlight are to no small extent the work of foreign medical graduates. A further irony is that the writing in Out of Its Mind is less lively than one expects from a professional writer and is beset with odd analogies and metaphors that confuse more than clarify.

Although Hobson and Leonard do not tell us for whom this book is intended, I infer, from the presence of a medical writer, the oversimplification, and the definitions provided for terms familiar to health professionals, that they have a general audience in mind. But the general public interested in mind-brain matters, the substance of this book, is better served by the dozens of other recent books that are more comprehensive, engaging, and accurate, including John Horgan's The Undiscovered Mind, Steven Pinker's How the Mind Works, and Antonio Damasio's The Feeling of What Happens.

The reader most likely to benefit from this book is a future historian of science. Out of Its Mind describes the issues facing psychiatry at the turn of the millennium and one attempt, during this transitional period, to create order out of uncertainty.

Invariably any quest for a desired object, be it a yearned-for sports car, a pet boa, or a silvered disk flashing a spectrum of colors, requires an objective approach before purchase. The first viewing often leads to a desirable acquisition, which then becomes an inseparable necessity.

The 2001 update of the first, 1998, edition of the Gastroenterology Teaching Project CD-ROM features colorful new images, imaginative graphs, and informative legends. The abundant images (1624), accessible from a menu of 16 carefully chosen categories, give only an inkling of the CD's value. Three new units, "Colorectal Neoplasia—Genetics and Prevention," "Clinical Nutrition," and "Short Bowel Syndrome," reassure the recipient, learner, and teacher that one is as up-to-date as with most recent textbooks. While many of the 3000 citations are within the span of a decade, most are classic references that have withstood the ravages of time and critical peer review.

Installation is so easy, it seems to congratulate the novice user, who becomes immersed first in the CD's vast potential as a self-learning device, then as an educational tool for others. The freedom to browse, retrieve, create notebook supplements, and correlate the many images all enhance its use. Discoveries stimulate creation of more informative patient guides and unique lectures, as one becomes a more educated executive producer.

This new-media method of capturing and rendering these absorbing images becomes self-instructive, destined to keep the user awake and the audience attentive. The help-search feature extracts word or phrase matches in seeming nanoseconds. Image sizes are adjustable, making printed lecture handouts feasible and inexpensive.

The codirectors and planning committee for the CD have recognized that for maximum understanding of clinical states, symptom complexes should correlate with graphic molecular biologic interactions and histologic, radiographic, and endoscopic images. This mode prevails throughout the program. Colorful cartoons and graphs reflect the creativity of the medical artists, guided by a seemingly noncombative planning committee who amalgamated contributions into this ambitious yet successful arbeit.

The extent of biomedical research continues to be staggering. The vivid step-wise imagery of many recent cell biology concepts on the CD permits better understanding and promotes identification of genetic markers. Notable examples are the retinal images with "Congenital Hypertrophy of Retinal Pigmentation Associated with Familial Adenomatous Polyposis [FAP] Syndrome" (slides 11:33,34). Some photographic reproductions are worthy of festival awards, such as slide 11:21, vividly showing a sea of compacted colonic adenomata in the FAP syndrome. It often takes only a mouse click to capture rarely available images, especially those previously stored somewhere or other in obscure file drawers. Examples include the diagnostic rashes of scurvy and of zinc and tryptophan-niacin deficiencies. A picture of Casal's necklace, now identified in severe malnutritional and alcoholic states, can be extracted, viewed, and promptly shared.

Cellular immune mechanisms, acid-base disorders, and pharmacologic actions and interactions are illustrated with such clarity that we reassure ourselves of our own astute, intuitive knowledge. Risks in management come into focus as we analyze potential pitfalls in enteral and parenteral nutritional therapeutic attempts. The fund of useful knowledge about neurotransmitters in irritable colon syndrome is balanced by the recognition that, while we name them, we may not yet know them.

This self-study program will help practitioners overcome trends toward more rigid subspecialty barriers. Intraoperative views of liver transplantation, including vascular patterns in color Doppler flow studies, will aid in counseling donors, recipients, and their relatives.

House officers will better appreciate the importance of segmental liver anatomy. One is reminded of the ancient Assyrian clay tablets (viewed in the Babylonian Collection, Yale University, courtesy of Professor William W. Hallo, director/curator) revealing knowledge of importance of sheep liver segments. The army general's understanding of the anatomical liver contours as an omen was said to determine a battle's outcome, not unlike the preoperative rituals of a transplant team.

Familiarity with its versatility makes this CD-ROM even more desirable. Its most useful value is best expressed by Chaucer: "Gladly wolde he lerne and gladly teche."