Thursday, October 29, 2009

Lend Me Your Ears

There are very few things in medicine that yield instantaneous results that please nearly everyone. The ones that do are usually quite simple.

Take the case of Mr. Barnes, who came in today unable to hear out of his left ear. He didn’t know why, but a single glance told me the whole story. Unknown to him, a swarm of honeybees had invaded his otic canal and constructed a very very very compact hive. It was dense, it was thick, and it was the color of the Big Mac Special Sauce when it’s had a chance to congeal a bit. (And for the record, I have eaten that.)

Most people don’t like the process of getting wax out of ears. It’s wet, repetitive work, an entry-level job serving as a rite of passage to doing more useful things such as taking rectal temperatures. However, I think its’ great fun. The trick is to dissolve away the wax just enough to create a small gap between the wall of the ear canal and plug. One you’ve got the hole, you irrigate the daylights out of the ear with warm water under high pressure (like generated by a squirt gun or a syringe with a plastic tip). If done right, the water flows through the gap and builds up pressure on the other side of the wax, and the cerumen (that’s the doctor cocktail party word for it, and why we can bill so much more than you) pops out whole for you to display to the astonished onlookers as the patient shouts out “I can HEAR! Thank the LORD!”

(The method also works with foreign bodies like pencil erasers. I know this because one of my other patients today was a young man who had just been named the “Most Inspirational” member of his high school class for his pastoral work. What he was inspired to do today was to place a pencil eraser on the sharp end of a pick-up stix and poke it in his ear to see what would happen. Using the above method, this popped out whole as well. I’ve been promised a “shout-out” in his next sermon. I’ll take all the heavenly points I can get…got a feeling I’m gonna need them someday.

This effect is even more dramatic when both ears are affected. Let me serve as an example. About two years ago I started to have trouble hearing. I had a feeling like both of my ears were blocked, and having had some sinus problems in the past I figured it was just a chronic buildup of fluid in the middle ear. But weeks went by and a continual diet of decongestants never seemed to help. To be honest, it wasn’t all bad. I’d go to meeting where I knew I was going to be asked some question that I couldn’t answer, and the “I’m sorry, can’t hear well, got an ear problem” excuse gave me some extra leeway to respond eloquently to a question other than the one asked. But I was trying to pull this off one morning with a pediatrician in attendance, and in calling my bluff he suggested that I drop by the office later that day.

So at noon I’m sitting in a chair in his office, looking up at happy elephant stickers perambulating across the ceiling, getting my ears hosed out with a high-pressure squirt gun by two nurses who are trying, but not succeeding, to stifle a snicker at the predicament of the State Health Director. I have to tell you that the sensation of the ears getting cleared out was really quite amazing…one moment you simply hear a low rumble of the water shooting against the wax, then a second later you hear the roar of a tsunami wailing on your eardrum, along with some nausea and dizziness induced by the water’s chill. (This is known as the caloric response, for those of you keeping score). And for the first moments I could hear everything…the whine of the neon lights, the hum of the air handling system, the traffic in the parking lot…all the noises we filter out during our daily life because they’re just too common. It was mind-numbing, one of those moments when you are simply overwhelmed in a way that defies description, like when you come over a hilltop to see an unexpectedly glorious valley below. It’s a very transient feeling, a few seconds at best, and then your mind readapts to it’s usual mode of work. I don’t know that I’d go out of my way to do it again…at least not with the ear wax…but definitely an experiential moment of note.

Speaking of ears (hahahahaha), one of the other instant cures is getting a live bug out of an ear. The best method to resolve this problem (translated as the funniest mode) is the Pedal Technique. You place the patient in a dark room, and shine a light into the ear canal. Just like cockroaches on your kitchen counter, the bug will run from the light. It exits the ear canal and the patient jumps up screaming. The cockroach falls to the floor and the physician steps on it. That’ll be $40.00, please.

"Three-liner" Religious Commentary

One of the nurses last night said she needed a joke. This was my offerring (recycled from The Spouse):

A priest walks into a bar.

A rabbi walks into a bar.

The nun ducks.

Wednesday, October 28, 2009

Compliance, Adherence, and Rush

Despite the protestations of the right, I really do believe Rush Limbaugh is an entertainer. I believe this because entertainers make hay with political correctness is order to provoke, amuse, and grow rich. So while Rush, the Reverend Al Sharpton, and Glenn Back are crazier than loons (and that's a very grave insult to the loons, one of America's finest community waterfowl), at least they never struggle with the language of the PC crowd.

One of the hallowed terms in clinical medicine is "non-compliance." A patient is non-compliant when they fail to follow a prescribed course of care. The non-compliance may be overt, as in a patient who simply tells you there's no way he's going to rehab for his alcohol problem; or it may be covert, like when the patient tells you they're taking their blood pressure pills when the prescription actually never got filled. The term suggests an active and conscious effort to resist the suggested plan of medical care. It's a term that over the years we've applied broadly to any patient who doesn't do exactly as we say. (I would put in a real-world caveat here that it shouldn't apply to those who have legitimate religious reasons for refusing certain aspects of care, but technically the term would apply to them as well.)

However, in my own personal nod to the PC culture (and putting yet another nail in the coffin of my nascent career in stand-up comedy), I'm consciously trying to use a different term when I see patients in the ED. While many people do not follow through with their plan of care, in many cases it's not their choice. Sometimes they truly don't have the money to afford their medications. Sometimes they may not qualify for any assistance program that allows them access to a physician. Sometimes they lack transport to the doctor's office. Sometimes their medical condition prohibits their compliance with aspects of care. Sometimes they may be confused and take too much or too little of their medications. And sometimes they may simply be acting like human beings and just forget. Researchers have proposed the term "non-adherent" to these patients who would actually like to comply with care but for reasons other than their own are unable to do so. And while the term smacks of political correctness it actually makes clinical sense.

I think some of my colleagues in the ED would say that I give patients a harder time about compliance than some of my peers. Despite the attitude I consciously try to project, I take seriously the role of "fighting the good fight" to use our health care resources wisely. (It's a leftover of a public health career I'm still working to shake off.) So while I have no problem with the system caring for you at taxpayer's expense...if fact, I believe it's the morally right thing to do...I also believe that the individually has a responsibility to take the benefit offered by the system and use it appropriately in order to achieve the end goal of health. So I think that as we look at health care reform, and recognize that the primary way to achieve the simultaneous goals of quality, cost constraints, and access to care is to place some limits on benefits, it's important to try to ferret out the differences between patients who are non-complaint and those who are inadvertently non-adherent. The former group may lose access to care; the latter should be facilitated to maximize their chances of following the medical plan. The trick for policymakers, of course, is how to accomplish this on a national level. The trick for me is to keep the difference in mind in the middle of the night.

Tuesday, October 27, 2009

Why I Didn't Blog Last Night

11:30 PM Leave ED to head home after evening shift. Fight urge to stop at Taco Bell due to sudden vision of non-roughage food items descending through aging GI tract coupled with fresh memories of colon cleansing infomercial seen last night. Take a moment to remember Gidget the Chihuahua. Wonder if Les Nessman still believes the dog is really called a chi-hoo-a-hoo-a. Sing WKRP theme song in head. Promise to look up lyrics to second verse online. Recall that turkeys don’t fly. Oh, the humanity of it all!

Midnight: In door, shoes off, leftover spaghetti in microwave. Acknowledge presence of cat. Continue to be gracious to cat as it follows me into kitchen. Introduce cat to science of aerodynamics as it jumps on kitchen counter.

12:17 AM: Spaghetti prepared. Bow placed next to laptop, which is now aglow with a steely blue stare and challenging me to write. Log onto blogspot.com. Think of interesting anecdotes, important issues, or response to news items to share with loyal readers who, as best I can tell, number me and my sister. Wonder if it would just be easier to call her.

12:35 AM: Got nothing. Log onto Fantasy Football site. Place waiver claims for Cardinals defense. Lament over the fact that in order to win, I have to pick against my own team. Rationalize selection of offensive stars working against Kansas City by saying that it’ll be a 56-48 game, with the Chiefs on top. Know that despite inside information and throwback jerseys featuring Buccaneer Bruce, still will not select the Tampa Bay defense.

12:53 AM: Recall amusing comment made to me by our ED pediatrician about patients and cellphones. Wonder if I could adapt it to my piece on new vital signs published earlier in the blog, with the amount of time you spend on the cellphone being an inverse measure of true emergency need.

1:06 AM: Nope, that didn’t work.

1:08 AM: No new emails, either.

1:10 AM: Or Facebook news.

1:12 AM: I have no friends.

1:15 AM: Look up from laptop to find cold spaghetti bowl being licked by cat.

1:30 AM: Fire up computer game in effort to relax and stir the creative juices for blogging. Recognize early that this is an excuse, as I ‘m really annoyed because I can’t break through the last mission of the Terran Campaign in StarCraft: Brood Wars. See, what’s happened is that the United Earth Directorate has come to clear this sector of the Zerg, a race of fanged and carapaced arachnids who know nothing but death and conquest. The UED has found the Psi Disrupter and the Zerg broods are in disarray. But the Overmind must be pacified in order to eliminate the threat to humanity. So I need to eliminate the three Cerebrates still loyal to the Overmind, each of which has a specific mode of defense, and then use medics to inject the Overmind with a powerful neuropoison. Hope that’s clear.

1:59 AM: Where did that Ultralisk come from? And forgot to save the game. Damn.

2:41 AM: Battlecrusiers kill Ultralisks. But now Battlecrusiers can’t target ground defenses…must be one of the unique Cerebrate defense modes… so my guys can’t get through to mine more crystals so I can build up my fleet. I should’ve read the hint book. But I have integrity.

3:10 AM: Red Zerg down. Brown and Orange to go. Fifteen fully upgraded Battlecrusiers armed with Yamato guns ought to do it.

4:30 AM: Success! The Zerg are destroyed, the sector preserved for humanity. We regret the loss of our brave comrades, but rejoice in their victory.

4:31 AM: Exit game. Look at time clock. It’s 4:31 in the freakin’ morning! How did that happen?

4:38 AM: Trying to get to sleep. Counting sheep fails because instead of numbers, sheep get names appropriate for their color of wool and overall personality. Mind wanders to humorous stories involving lonely individuals and companionate sheep. Laugh out loud. Cat looks puzzled.

4:42 AM: Angry. How many nights have I wasted with this game? And with the original StarCraft? Or Warcraft? Warcraft II? Warcraft III? Civilizaiton III? Civilization IV? The Warloards Expansion? Age of Empires? Age of Empires II? The Conquers Expansion? Age of Mythology? Age of Empires III? And that’s not even addressing all the television I’ve watched. My life is gone, the opportunity to make a difference in this world vanished like the temporary intimacy of a girl and a six-pack under the wrong circumstances. I wanted to be an astronaut, a United States Senator, a well-known author. Instead, all I have to show for my time on earth are some hollow victories on the “easy setting” and the unsettling knowledge that fourteen-year-old boys with no life experience are waaaaay better at these games than I am, and that when I am old these same children will be Congressional Staffers running the country.

4:48 AM: Reassure self that Starfleet Command II was never a waste of time.

4:51 AM: Under the covers, counting again. Wonder if ex-wife has anything in common with Zerg overmind. Thought recurs that that if I had avoided wasting my life, I really could’ve been a contender. But then would not know WKRP theme song. Trade seems fair. Nod to Pepys. “And so to bed.”

Monday, October 26, 2009

Bad Science: Vaccines and Autism

The town of Protection lies just before the Red Hills of Southwest Kansas, an area of rugged scarlet gypsum crags that looks as if it came straight from the Acme-painted landscape of a Road Runner cartoon. It’s a small town of about 500 people, and with apologies to John Mellencamp it’s like most small towns in rural America…one bank, two restaurants, a tribute gallery to the local boy made good (in this case Stan Herd, the crop artist…stop laughing and check out www.stanherdart.com); a town that’s aging, hurting, patiently awaiting it’s long-known fate. Nobody knows how the town got it’s name. One version says it was the result of a joke, when cowboys faked an Indian raid to frighten the settlers and the townspeople collected under a bluff for protection. There’s another story, and a better one, too:

"About a year later a post office was started on the Kiowa and called Protection. Among the prominent members of the old Protection Town Company were E. P. Hickok, W. P. Gibson, J. W. Johnson and one or two others, all republicans, good and true. When it came to selecting a name for the new post office, there was some difference of opinion, and it was finally agreed to leave the naming to the postmaster general, who was a republican also. In the political platforms of those days there was much said in regard to "protection," as compared with "free trade," when speaking of the development of American industries and the employment of labor, and it was but the natural thing for the postmaster general to think of the word "Protection" for the new post office on the Kiowa in Comanche-co., Kansas. That, as I understand it, was how the city of Protection got its name." -- Hiram O. Holderby, The Western Star, April 8, 1921.

Even then, Kansans were nothing if not conservative.

The town of Protection is important because its name led the National Polio Foundation to make it the first community in the United States to have everyone under 50 years of age immunized against polio. Today, we can’t conceive of what threat polio was to children, especially during the summer. My father recalls times when no one was allowed to use public swimming pools or engage in other summer fun because of the spectre of polio. And while many of us have seen pictures of Franklin Roosevelt (probably the world’s most famous victim…and conqueror…of polio), the only way today to get a sense of what polio was like is to lay for a time in an old iron lung and imagine that you may, or may not, be able to leave it. Now imagine yourself, or your son or daughter, lying there as an uncomprehending four-year old. The advent of the Salk injectable polio vaccine, and the Sabin oral vaccine that followed, resorted the joy of childhood for millions in this nation and around the world.

Immunizations are one of the true success stories of public health. Most authorities would rank vaccination and the provision of clean drinking water as the top two achievements in health over the last century, besting antibiotics, hospital care, or surgery. (A health wonk like me would want to point out that, according to the CDC, fully 25 of the 30 additional years of life expectancy over the last 125 years have come from the world of public health, and not from the health care system.) Vaccines work so well that when there is an even a small outbreak of measles or mumps, it becomes newsworthy. Vaccination is proof that science works. So it’s disturbing to see that bad science is being used to link vaccines…and specifically a preservative contained within vaccines called thimerosal… with neurodevelopmental disorders such as autism. It’s especially worrisome when aggressive vaccination is one of the key tools we have to prevent the further spread of pandemic H1N1 “swine flu.”

The concern over mercury compounds such as thimerosal is linked to the idea that the presence of these chemicals in vaccine products can retard neurologic development, and more specifically results in autistic disorders (clinicians refer to autism not as a specific condition, but as a term applying to range of problems known as “autistic spectrum disorders,” or ASD). It is true that there is a correlation between total body exposure to mercury and impaired neurologic development. As a result, in 2001 the Institute of Medicine (IOM) recommended that thimerosal be removed from all vaccines administered to infants, children, or pregnant women in the U.S.

On the surface, that single recommendation would suggest the case is closed. There’s a link, the Institute of Medicine said to remove the thimerosal, and why would they do that if it wasn’t the cause of autism and other developmental delays?

The spinmeisters keep trying to tell us the world works in sound bites, but most of us know better than that. Sound bites represent a fraction of the larger discourse, just as exposure to mercury in one venue does not reflect the total exposure to this element. A careful reading of the IOM report shows that the recommendation was a precautionary step to limit the cumulative exposure infants might have to ethyl mercury. The concern of the IOM was not based on the dose within the vaccine, but on the cumulative dose of mercury received from environmental exposures, such as eating fish laced with industrial mercury wastes and mercury leeching into the fetus from dental amalgams. This hypothesis is supported by studies that document a lack of link between thimerosal in vaccines and the development of neurologic disorders, but suggest that cumulative environmental mercury exposure raises the risk. The IOM felt that the mercury in vaccines was a controllable exposure, whereas that in the environment at large was not. Therefore, as non-mercury alternatives could be identified, they should be used. Their recommendation was seen as a step towards mitigating a larger problem, and certainly not as a “cause-and-effect” solution unto itself.

Nonetheless, there continues to be a belief that any mercury in a vaccine is necessarily the cause of neurologic abnormalities, especially when used in combination with the MMR (measles, mumps, and rubella) vaccine. Knowing that measles virus can cause encephalitis in severe cases of clinical illness, the theory contends that measles virus is absorbed into the body through the vaccine and that the thimerosol in the vaccine product both alters the appropriate immune response and poses a direct toxic effect, resulting in an inflammation of cerebral tissues resulting in autism. Much of this belief comes from the work of Dr. Andrew Wakefield, a British doctor who led the initial works claiming a link between autism and the MMR (measles, mumps, and rubella) vaccine. While the studies were ripe with flaws, press coverage insured that the effects of his work on vaccine uptake in the United Kingdom were immediate and significant. A Canadian source notes that, “At one point MMR vaccination rates sunk to 75 per cent in Britain, well below the 95 per cent authorities say is needed to keep these diseases from circulating. While the rate has since climbed to about 85 per cent, Britain continues to suffer outbreaks of these three diseases and to seed the diseases abroad (CTV.ca, July 16, 2007).” We’ve seen similar things happen in the United States as a result of unthinking publicity. For example, Kansas saw that in the summer of 1999, there was a dramatic drop in the number of Kansas newborns receiving immunization against Hepatitis B after a recommendation to suspend vaccination with this agent due to thimerosal content in the vaccine. A thimerosal-free product was released four moths later, but even now we still have yet to see a return of vaccination rates to 1999 levels.

(Interestingly, the Wakefield saga continues to this day. In 2004, ten of his collaborators retracted the work, and it was later revealed that Wakefield was doing research for pay on behalf of parents who were seeking legal damages from vaccine companies. He had also taken out a patent for a new form of the vaccine, providing possible incentive to bias his results. He is now facing revocation of his medical license from the British General Medical Council.)

The medical community, recognizing the value of vaccination, was quick to respond. A brief search through the National Library of Medicine collection revealed over 130 papers reviewing the links between thimerosal, vaccines, and neurologic development within the past decade, and both the United States Centers for Disease Control and the Institute of Medicine have reviewed the issue in depth.

The bottom line is that the studies have failed to establish a firm link between exposure to thimerosal in childhood vaccines and the development of neurologic disorders. One of the best works was performed in Denmark to review the incidence of autism in over 500,000 children before and after the advent of laws mandating that all vaccines be free of thimerosal. In that nation, the incidence of autism continued to rise despite the lack of thimerosal in the vaccinations (JAMA 2004; 291:180-1). On our side of the pond, the California Department of Public Health just this year published work which demonstrated identical results (Arch Gen Psych 2008; 65:19-24). Clearly, there is something that is behind the rise in these developmental disorders. It may be environmental, genetic, or (I suspect) related to both the appropriately increased awareness and diagnosis of the spectrum of ASD as well as the harmful societal urge to “medicalize” behavioral issues in order to divert accountability. But there certainly appears to be no cause-and-effect link between vaccine use and the development of autism.

As might be expected in this country, the vaccine-mercury-autism issue has a legal dimension as well. Over 5,000 families have filed adverse event claims with the National Vaccine Injury Compensation Program (NVICP), claiming a causal link between the MMR vaccine, thimerosal within the vaccine, and neurodevelopmental delay. Three test cases were selected for adjucation, and in all three cases claims for compensation based on an alleged thimerosol-autism link were denied early this year by Special Masters appointed by the United States Court of Federal Claims. (In all three cases, the denial was upheld on appeal.) The basis for these denials was well summarized as follows:

“After considering the record as a whole, I hold that petitioners have failed to establish by preponderant evidence that (the child’s) condition was caused or significantly aggravated by a vaccine or any component thereof. The evidence presented was both voluminous and extraordinarily complex. After careful consideration of all of the evidence, it was abundantly clear that petitioners’ theories of causation were speculative and unpersuasive. Respondent’s experts were far more qualified, better supported by the weight of scientific research and authority, and simply more persuasive on nearly every point in contention. (The) parents brought this action in good faith and upon a reasonable basis. However, they have failed to demonstrate vaccine causation of (the child’s) condition by a preponderance of the evidence.”

(United States Court of Federal Claims, Office of Special Masters, No. 01-162V, February 12, 2009)


All this being said, most of those involved in the debate still don’t recognize that since 1999, the only commonly used childhood vaccines containing thimerosal are the influenza vaccine (and specifically only the vaccine found in multi-dose vials) and the combination vaccine against both hepatitis A and B (there are thimerosal-free forms of vaccines against only hepatitis A or B, but none in combination). In many ways, the thimerosal question is one of the past and not of the present.

From a public policy standpoint, it’s not just the concern of bad laws being derived form bad science. Laws requiring all vaccines to be mercury-free may impact the ability of state and local governments to prepare for public health outbreaks such as the current spread of H1N1 influenza. While thimerosal-free influenza vaccine is available, in recent years only about 10%of the total supply is manufactured in that form. The most cost-effective and efficient way to immunize children against this virus is through the use of multi-dose vials that contain thimerosal. Children do die of influenza and its complications, and the limitations of these policies mean that children may be at risk of not being able to receive the vaccine they need.

Some proposals may truly enter the realm of “unintended consequences.” Several years ago, there was a bill proposed to eliminate the use of any drug product containing mercury in Kansas. This meant that adults, as well as children, may not be able to receive influenza vaccination from multi-dose vials. They may also not be able to receive travel vaccinations such as those against encephalitis. Snake and spider antivenins also contain mercury products as preservatives, as do many prescription and “over-the-counter” products for the eyes, ears, and nose. We’re fortunate that in Kansas, the legislature has not passed any such bills out of committee.

So if the science is bad and the thimerosal is gone, why are we having this dispute? In my view, this is one of those areas in public policy where personal passion meets the public stage. I’m very blessed to have a happy and healthy eleven-year-old boy. If my son had autism, I’d be doing exactly what the proponents of these laws are doing. I’d be looking for an answer, something that I could see as a cause for the condition, and I’d be doing what I could to prevent it from happening to others. Knowing that, hearing the heartbreak in these parent’s voices and seeing them struggle with their children, it’s hard to look at the issue objectively. I just wish I could agree.

Saturday, October 17, 2009

Climate Change: It's Hot in Topeka!

In the summer of 2006, it was hot in Topeka. Very hot. Record-breakingly hot. Swimming-pool-and-bath-water-what’s-the-difference hot. Even lizards are unhappy hot. So hot, in fact, that when the character of Blue in the Cartoon Network show “Foster’s Home for Imaginary Friends” was watching an animated weatherman note that there were showers in Spokane and that it was hot in Topeka, the latter phrase quickly morphed into a frantic chant of “It’s hot! My toe is hot! I’m a hot toe picker. Pick my toe!” Needless to say, he was rapidly adopted as a community icon, and virtually everyone could be found sitting on their doorstop in the evening shade picking at their pedal piggies. (See for yourself at http://www.youtube.com/watch?v=AzdWMcLvn2g.)

Of course, Al Gore would tell us that in the future, we’ll all be hot (and presumably it’ll be HOTTER in Topeka, in which case we’ll be picking the toes of otters). But while most people in our polarized world see climate change as an either/or problem, a battle between “greens” and “greenbacks,” it’s always been interesting to me that the real battleground is this country is not in the heavily populated or industrialized states but in rural America. Certainly there are articles and stories about ethanol production, and every now and then you’ll hear about some work on using bovine methane as an energy source (and if you’ve ever hung around a feed lot, you have no doubt as to that potential). By and large, however, rural America is often thought of as immune to energy politics, except when trying to determine how many cows you can displace for a wind farm.

But in Kansas, energy politics dominated the legislative process for the past two years and virtually paralyzed the rest of state government. At issue was the decision of the Secretary of Kansas Department of Health and Environment (KDHE) to reject a permit for building a coal-fired power plant in Southwest Kansas. The reasons for and against the plant are too numerous to mention in this brief piece, but essentially it became a conflict between legislators from poorer rural areas who wanted development versus those from relatively more affluent urban areas who were more eco-friendly. But what I think is most unfortunate about the situation is that it bodes poorly for national efforts after health care reform, as energy policy and “cap and trade” are next on the President’s Wish List. For just as the West Coast tends to be a harbinger of social change, for better or for worse Kansas has always been ahead of the curve on political conflict. (While Republicans nationally are now recognizing the depth of the schism within their party, Kansas has essentially been a three party state for a decade. Of course, we put our own twist on it…our parties are Libertarian Conservatives, Traditional Republicans, and Conservative Democrats who would be considered Liberal Republicans anywhere within 60 miles of either coast.)

As some of my readers know, I was the Director of Health within KDHE during the time of this decision, though I was not directly involved in it. Shortly after leaving the state agency, however, I was asked to summarize for some legislators what we do and do not know, from the perspective of science and health, about global warming and specifically what it would mean to a state like Kansas. With the winter coming up, energy costs rising again, and the President’s focus on energy policy, it seems like the time is ripe to revisit the issue, with some specific attention (and a shout out) to that place I still call home.

The Warm Earth and Greenhouse Gases

To properly begin this review, it’s vital to note that the earth normally goes through cycles of global warming and cooling. These cycles are a result of a number of a number of factors, the most significant of which is the relative quantity of “greenhouse gases” in the atmosphere. Less important drivers include solar variation, subtle changes in the earth’s orbit, plate tectonics, volcanism, and the manner in which the oceans distribute heat. (Try getting all that into one sentence at a cocktail party.)

The role of “greenhouse gases” is critical to note. The atmosphere of the earth can be thought of as a “closed” system, within which no substance save energy (heat) can get in or out. Greenhouse gases are those molecules within the atmosphere that trap the sun’s heat energy within the atmosphere, preventing it from being radiated into space and, in turn, radiating the energy back to the surface. These gases include water vapor, carbon dioxide (CO2), methane (CH4), and other compounds. They are crucial to maintaining normal global temperatures; without them, the mean temperature of the earth’s surface would hover just below 0 F. Not all greenhouse gases are created equal; a molecule of methane has 23 times the Global Warming Potential, or GWP, than a molecule of CO2. (This gets us back to the cows, suggesting that if we all go to Chik-Fil-A more often, we can combat global warming.)

Increased amounts of greenhouse gases within the atmosphere lead to increased surface temperatures. For example, increased surface temperatures induce evaporation of ice sheets and bodies of water, increasing the content of water vapor in the atmosphere. This increases global heat retention, and the cycle is magnified and begins again. The planet Venus, often thought of as the “twin” of the earth, is an example of a runaway greenhouse gas effect. It’s atmosphere is composed mostly of carbon dioxide, and it’s barren and arid surface bakes at over 872 F, hot enough to melt lead. From the standpoint of human activity, increased temperatures increase demand for cooling of homes and business, driving up CO2 production at power stations and further increasing the temperature, which again drives increased energy demands and further CO2 production.

What is Climate Change?

It’s important at the outset to differentiate weather from climate. Weather refers to events that occur in the “present,” over days or perhaps weeks. Climate describes the overall character of events and conditions as measured over time (decades, centuries, or more). This difference is critical, for you’ll often hear that the presence of a cold snap argues against a theory of global warming. Similarly, a heat spell cannot be taken n and of itself as evidence of climate change. (While the contemporary debate rightly focuses on global warming, climate change is actually a more correct term to use because it describes epochs when the earth cools as well.)

As previously noted, the earth normally undergoes cyclical climate changes of both warming and cooling throughout history. In the context of the history of the earth, we are still technically in an ice age (defined as a time in which sheets of ice continue to cover areas of the planet). We happen to be in a warmer period of the current ice age known as an interglacial. This is important to note because glaciers have been recognized as a sensitive early indicator of climate change. But just as weather cannot be taken as an indication of climate, the fact that we still have ice on the planet does not argue against the concept of global warming. This key difference is emphasized by noting the current retraction of the glacier sheet across the globe.

While climate change is a long-term natural phenomena, there is unmistakable evidence that the normal cycle of global warming is being accelerated, and that the cause of this acceleration is human activity (“anthropogenic” factors). The majority of the impact is caused by the burning of fossil fuels such as oil and coal, followed by the production of methane though large-scale agricultural production. Both of these activities produce “greenhouse gases,“ which are significant drivers of global warming as we‘ve discussed. Interestingly, cement manufacturing also accounts for a small percentage of CO2 release. There is also a human influence on global warming based on land use patterns, deforestation, and development, but this effect is marginalized by the contributions of greenhouse gas production.

Since the 1850’s, CO2 levels have risen from 280 parts per million (ppm) to 380 today, and if they continue on the current trend they would near 600 ppm by the end of the century. CO2 levels are known to be higher now than at any time in the past 750,000 years, and it‘s speculated that they are higher now than at any point in the past 20 million years.

Predicted Effects of Climate Change on Health

The increase in CO2, and the accelerated “greenhouse effect,” lie behind the predictions of a mean global temperature change of up to 6 C during our children’s lifetime. Rises in global temperature are considered to result in rises in sea level and changes in agricultural production, biodiversity (species extinctions), the number and severity of extreme weather events, and significant effects on human health.

It’s somewhat more difficult to specify the effects of climate change on an individual state like Kansas. The climate of Kansas features a large air mass division across the middle of the state, which is one of the reasons for the stark differences in the ecology between the forested eastern half of the state and the high plains that characterize the western plateau. As a result of this air mass, different parts of Kansas could expect to see differing effects in an era of global warming. Eastern Kansas will become wetter, while western counties will become drier and more arid. Experts in climatology would be better equipped to provide more detailed estimates of the effects of climate change on both the agricultural industry and upon the parks and wetlands of Kansas. But you can guess that if’s it hard to make a specific prediction for an area as large as a state, it’s all the more difficult to determine the effects global warming on a local area, or of a greenhouse gas producer on its’ immediate proximity.

The predicted health effects of climate change fall into five major categories. The first is that of temperature-related death and disability. This category includes direct effects such as heat strokes and heat illness, as well as indirect effects such as stress on other organ systems induced by heat. The second relates to changes in rates of vector-borne (mosquitos, et al) diseases due to hotter, wetter environments. Problems linked to air pollution represent a third broad class, and increases in food and water-borne disease encompass a fourth. The fifth category includes the negative health effects of extreme weather events such as tornadoes and flooding.

In Kansas, it’s probably safe to say that all of these categories would be likely to apply. However, it should be noted that these effects are posited to occur in a regional sense at best. Models do not yet exist that can accurately predict specific local effects. This being said, thinking specifically about Kansas a final possible health effect comes to mind. Climactic changes may also result in decreased agricultural production and crop-shifting. While it’s unlikely that Kansans will suffer from nutritional disorders as may occur in the undeveloped world, these events may influence the economic well-being of the state.

Mitigating the Effects of Climate Change

While climate change is inevitable over geologic time, human activity is clearly accelerating the timeline of events, making the consequences of global warming something our children can expect to confront rather than an event in the remote future. As someone interested in public health (where I’ve always said you can be a paid professional liberal), I hope to see the human effects of climate change minimized. So let’s briefly review some strategies that can be used to prevent worsening of the problem.

There are three main strategies to mitigating these effects. The first is to simply eliminate the means of production of greenhouse gases. Industries and means of transportation that produce greenhouse gases are no longer sanctioned and alternatives, such as solar or wind power, must be identified and developed. Speaking strictly from the standpoint of efficacy, without regard for the economics of the issue, it is the most immediate way to curb greenhouse gas emissions.

A second strategy is to get rid of the greenhouse gases produced. For example, carbon dioxide can be taken up by a “sink,” a reservoir used to remove CO2 from the atmosphere. Examples of this strategy include reforestation, in which the large-scale planting of trees encourages CO2 uptake in the process of photosynthesis. Encouraging plankton growth in bodies of water and adapting agricultural processes are other examples of “natural“ ways to enhance CO2 removal from the environment. “Artificial“ methods include carbon capture during the combustion process and injecting CO2 into underground geologic formations such as oil fields, coal seams, and saline aquifers.

Each of these methods is controversial to a degree. For example, there is some debate as to the efficacy of reforestation given different climatic and geographic conditions; and in many cases, experience and technology have yet to fully support the theory. Nonetheless, they do offer real potential and, in my own view, should be aggressively explored as part of a comprehensive, cutting-edge energy plan

The third strategy is to maximize the energy output per unit of greenhouse gas created, therefore decreasing the “carbon footprint” of the total amount of energy produced. This can be done in two ways. The first is by influencing the process of production itself, using technologies to burn fuels more efficiently with less “off-gassing.“ The second is the use alternate energy sources to increase the total amount of energy produced per unit of greenhouse gas. On a small-scale, this is what hybrid automobiles do; they use the power from the combustion engine to charge a battery, which provides more power for the auto given the same amount of fuel used than a traditional gasoline engine. Supplementing fossil fuel power plants with wind or solar energy projects is a larger model for the same basic concept. Combustion of agricultural methane to produce both energy and CO2, a gas with a lower GWP than methane, is a variation of this idea.

I have deliberately left out the idea of “carbon offsets” in this discussion. The term is most often thought of as an economic tool where permits for industry resulting in greenhouse gas production are “traded” for dollars to be used elsewhere to remove or reduce other emissions or develop alternative energy sources. But scientifically, it means simply that if carbon is released into the atmosphere through one mechanism, something else removes it form the air so there is an even balance of production and disposal. In this sense, the use of “carbon offsets” is most similar to the sequestration strategies noted above.

All of these are large-scale mitigation strategies. To my understanding, accurate models do not yet exist that are able to predict how much or how little any single project contributes to global climate change, nor how much or how little any particular strategy will mitigate these effects. One is not necessarily preferable to the other, and all are reasonable and logical ways to approach the problem. This being said, if we acknowledge that global warming is a reality and that human activity is accelerating the process to our detriment, it is my personal belief that we have an obligation to begin to lay a groundwork for change using any or all of our options.

That being said, a friend has just told me that on this Friday night in mid October, it’s rainy and cold in Topeka. Cold rain on my toe. My toe has a cold. Pick that toe!

(And just for the record, the only other mention of Topeka in popular culture? The remarkable Loretta Lynn lyrics that remind us:

“But here in Topeka, the rain is a fallin'
The faucet is a drippin', and the kids are a bawlin'
One is a toddlin,' and one is a crawlin'
And one's on the way.”)

Friday, October 16, 2009

Sibling Wisdom

The Brother says:

"There's a new drinking game actually endorsed by Alcoholics Anonymous. Whenever Rush Limbaugh says something positive, THAT'S when you can take a drink."