QUIS CUSTODIET IPSOS CUSTODES?

NOTES WASHED UP IN A BOTTLE

Donald W. MacCorquodale, MD, MSPH

            A number of studies have suggested that environmental tobacco smoke (“secondhand smoke”) slightly but significantly increases the risk of those exposed to it for developing lung cancer and heart disease.  Some of us in the public health community were therefore surprised to see a new study recently published in the prestigious British Medical Journal, which suggested that exposure to environmental tobacco smoke does neither.  The lead author of the article in the BMJ is Dr. James Enstrom of the UCLA School of Public Health.

            Who is Dr. Enstrom?  According to the Wall Street Journal, May 16, 2003, he is not a physician, but he holds a Ph.D. in physics and a master’s of public health degree.  He also did postdoctoral training in epidemiology at UCLA.

            At one time Dr. Enstrom received a grant of $400,000 for his research from the Center for Indoor Air Research, a tobacco industry group, according to the WSJ.  In 1997 Dr. Enstrom wrote Richard Carchman, Philip Morris’s director of scientific affairs, that “a substantial research commitment on your part is necessary for me to effectively compete against the large mountain of epidemiologic data and opinion that already exists regarding the effects of [environmental tobacco smoke] and active smoking.” 

            Before it was accept by the BMJ, Dr. Enstrom’s article was rejected by the New England Journal of Medicine and the American Journal of Epidemiology.

            Who indeed will guard the guards themselves?

HYPERTENSION IN NORTH AMERICAN AND IN WESTERN EUROPE

            A group of American and European investigators recently published a report on the prevalence of hypertension in six European countries and North America (Wolf-Maier, K et al.  Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States.  JAMA 2002; 289:  2363-2369).  Hypertension was defined as a blood pressure of 140/90 or higher or current use of antihypertensive medication. 

Some of these studies were based on a random probability sample of the whole country’s population, and others were a series of regional samples.  None were restricted to a single province or subregion of the country.

The prevalence of hypertension and mean body mass index is shown below for each of the eight countries:

            Why is the prevalence of hypertension so much greater in Germany, twice as great, as that in the United States and Canada?  I would have been willing to make book that the difference was associated with body weight, but that is not the case.  Just glance at the BMI for Canada, the United States, and Germany.  The differences are negligible.  The authors point out that alcohol intake is higher in Europe overall. 

FROM A BOOK REVIEW OF “WHIPLASH AND OTHER USEFUL ILLNESSES

            The author of “Whiplash and Other Useful Illnesses,” Andrew Malleson is a Canadian psychiatrist, and he observes that “victimhood can bring much gratification.”  He describes the patients who have chronic physical symptoms for which no organic cause can be identified as suffering from “dissimulating disorders.” 

            The reviewer, Dr. Michael Fitzpatrick, a general practitioner in London, wrote that American psychiatry recognizes three categories of such disorders:  malingering, factitious disorders, and somatoform disorders.  Malingering occurs when symptoms are intentionally produced in order to get some tangible benefit.  Symptoms are intentionally produced in the case of factitious disorders as well, but the motivation is said to be unconscious.  In somatoform disorders, both motivation and symptoms arise from unconscious processes.

            Dr. Malleson exposes how doctors, alternative practitioners, lawyers, and patients have colluded in promoting disorders that cost societies billions.  Patients with serious neck injuries are said to have a good prognosis whereas minor collisions producing no demonstrable tissue damage often result in lifelong disability in perhaps 10% of such cases.

            Dr. Malleson includes whiplash as one of a family of “fashionable conditions,” including fibromyalgia, chronic fatigue syndrome, occupational back pain, chronic pain syndrome, and post-traumatic stress disorder.  He wrote of whiplash:  “In perceiving a small auto collision as a cause of persistent and disabling psychiatric disorder we diminish the calibre of our souls.  We dissipate our human heritage of courage.”