MacDoctor

A survivor of a hunting “accident” asks the question “Why are people still being shot?“. The MacDoctor can help with this one. He was an ED doctor for 9 years in Southland, literally the “Happy Hunting Ground” of New Zealand. Of the dozens of shooting incidents he has seen, he has yet to see one where the perpetrator was sober at the time of the shooting. Not one. Zero. Nada. Several of the shooters could hardly stand, let alone aim and shoot a gun.

Telling these people to “check their targets” before shooting is fairly pointless. They are quite likely to reply “which one?”

The MacDoctor would like to suggest that drinking and firing is just as dangerous as drinking and driving and should be policed in a similar manner. At the risk of being accused of authoritarianism, the MacDoctor would like to suggest mandatory jail-time for those found discharging firearms while having alcohol in their blood streams. By all means go duck shooting and get hammered – just don’t load your gun until you can blow in your personal breath alcohol meter and get 0.00. That should be the first target you check.

A man managed to get across the US/Canada border using a scanned copy of his passport on his iPad. That was nice of the customs official who could have insisted on the paper version. After all, it would be fairly simple to alter a scanned copy of a passport to look like anyone you please. In addition, you cannot access any of the data contained in the little chip found in most modern passports.

It stuck me when reading of this otherwise happy story, that it is probably time for the immigration department to move into the digital age. One could easily construct a digital passport (there are plenty of models around used for other purposes). Attached to the passport could be all the biometric data of a person, including fingerprints and retinal scans, if required. There are plenty of biometric readers in operation including face readers (already used at airports), retinal scanners and thumbprint readers. You could have your passport stored on your smartphone, tablet or small RFID tag. A brief pause at the biometric reader and you would be through. No more long waits for a very bored, tired customs officials. Said official would only be needed for the few times when the passport, available visas and biometrics don’t match up.

Anything that can speed up the interminable wait to get out of the terminal after a long-haul flight would be welcome.

Talking about the death toll from the February killer quake in Christchurch, Professor Mike Ardagh reckons that there will be a number of others who will have died from the quake who are not yet part of this toll. He is thinking mainly of those who succumbed to complications from their injuries or died as a result of the stress immediately after the quake. He is right, of course.

There is a much bigger (and harder to quantify) hidden cause of both costs and further indirect deaths that Mike has not yet identified. That hidden cause is the vast mental health issues caused by the earthquake. This is not a reflection on Prof. Ardagh who, being an emergency physician, is somewhat focussed on trauma. You see the mental-health ravages of the quake much more clearly down at GP level.

Pharmac reports a 16% increase in scripts for mental-health related drugs, including sedatives and hypnotics (sleeping tablets), over the whole of the country. This is not a trivial amount. We spend around a billion dollars a year in mental health services only – and these are just the direct health costs. Add to this the cost of unemployment, sickness benefits, imprisonment, physical ill health and damaged family structures and you have a potentially very large cost indeed, both in terms of the economy and in terms of society as a whole.

That 16% represents new scripts only. There is no way we can measure accurately how the quake(s) have exacerbated the status of those who already have established mental health problems. Even hospital admissions or suicide rates are only a very blunt indicator (and I don’t have ready access to those stats for the past year). And none of the markers mentioned so far gives us any clue to the level of stress-related illnesses in the more stoic portion of the Canterbury population.

All I can tell you is that I have treated a number of people in Auckland who have moved (mostly permanently) from Christchurch. They are, in general, a mess. Insomnia is rife, depression is common and stress is universal. I have seen a number of people with full-blown Post-Traumatic Stress Disorder. While I acknowledge that the first people to move from Christchurch are likely to be the most affected and that they will be likely to gravitate to the GP for help, the overall look of these poor folk is not good. If the ones still there are even a tenth as bad, they are not going to take the latest string of quakes well. I expect a much larger exodus from Christchurch over the next few months.

We can rebuild the city of Christchurch but, for some, the scars left by the moving ground are not visible and will take much, much longer to heal. I suspect we will continue paying for these quakes long after the city is rebuilt and the debt incurred for the rebuild repaid.

Yesterday, John Roughan’s column in the Herald was about the people of Christchurch and their need to know “the worst they might face”. He draws his story from the reluctance of the GNS to make comments about the possibility of further strong earthquakes even though they knew there was good scientific evidence that there would be further large shocks. While I have plenty of sympathy for the people of Christchurch and much admiration for the way they have stood up to things so far, I do not think that Roughan is correct in his desire to see such scientific information released. I do not think it would be helpful to the long-suffering people of Canterbury.

The problem is that Roughan, like most lay people, does not understand the wide range of levels of evidence available to scientists. In our day-to-day lives, we mostly encounter two types of evidence – established (or empirical) fact and testimonials. We either know something is true or we think it is true because someone (whose opinion/knowledge we respect) told us so. Science uses these types of evidence alongside a third – statistical evidence. There are multiple levels of statistical evidence.

Obviously, experimentally verifiable fact is the highest level of evidence available to science. Unfortunately, many lay-people think that when they hear a scientific expert speak, s/he is speaking from this level of evidence. This is rarely so. Most are talking from some level of statistical evidence. This is because we are usually dealing with very complex systems that are difficult to experiment on.

If we are lucky, we can be making our statements based on level A evidence. This is the level of the randomised, double-blinded clinical trial in medicine. Readers of MacDoctor will know that this level of evidence is by no means the same thing as established fact, but it is good evidence, nevertheless. Sadly, this type of controlled experiment can only be easily performed on closed complex systems such as people and animals. Geological systems are much harder to perform experiments upon.

The commonest level of evidence available in most disciplines is Level B evidence. This would be the equivalent of observational and cohort studies in medicine. The system is too large to easily manipulate and it can only be observed and studied. Readers of MacDoctor will also know that this sort of evidence is very prone to confounding effects where it becomes very difficult to prove that correlation is actually causation. In medicine, conclusions made from this sort of data are then tested with Level A studies, often leading to the opposite conclusion. This option is not available to geologists, climatologists, vulcanologists and other disciplines dealing with large, open-ended stochastic systems. These disciplines rely on accumulation of large amounts of Level B evidence from multiple sources to refine their theories.

The “lowest” level of evidence is again one that a lay-person would be more familiar with, the level of experience and expert opinion. While this type of evidence is indeed extremely useful, it is not the type of evidence that we should be formulating major policies upon. This is often really the only available information for unique disaster situations – not necessarily a bad thing in the initial stages of a disaster, but a real problem when it comes to long-term planning.

The people at GNS would not have concerned themselves much with the public’s right to know. After all, they are scientists and the scientist’s raison d’être is to impart knowledge. No, the question they would have wrestled with is “does the level of certainty of this information warrant the possible  consequences of releasing it?“. Like John Roughan, most people will think this information is like any other “fact” that they know and accept it as “truth”. Unfortunately, a 90% certainty of another magnitude 6 quake in the next 6 months does not tell us a lot if the quake’s epicentre is 100Km deep and 50 Km out to sea.

It is exactly this sort of uncertainty that makes it so difficult for experts to speak out; especially experts with good credibility whose word will therefore be easily accepted by the public as gospel. What if the revealing of this information had many thousands more leaving the city of Christchurch, leading to a complete collapse of Christchurch’s economic structure? What if it then turns out that the quakes either did not occur or were trivial? This is a piece of information where the consequences are very different to a false tsunami warning, which is merely an inconvenience.

Alternatively, the geologists could try and couch the information in dozens of caveats. This will sound to the general public like the experts don’t really know anything or that they are dismissing the quakes as unlikely (people hear what they want to hear unless the message is emphatic). What if there was then a quake in which there was loss of life? Who would then be “to blame”?

Roughan would like the people of Christchurch to cease being in the limbo of uncertainty. The GNS would like that too. Unfortunately, despite good, educated opinion and evidence, they cannot provide the sort of certainty that Roughan is hoping for. Nature may be susceptible to analysis on a wide scale but is wildly unpredictable in any one locality.

That is the only real fact.

MacDoctor wishes all his readers a happy new year. 2011 has been marked as a year of disasters both for New Zealand and for other countries, notably Japan. We hope and pray that 2012 will be a better year.

To all those who think that this year is our last, simply because the Mayans could not be bothered to extend their calendar beyond 21st December 2012, the MacDoctor would respectfully like to suggest that you get a life and live it. Every year could technically be our last. Every day could be the final one for us. This is the human condition. If we stop living because we think we are going to die then we are dead already.

So get out there and make 2012 a good year.

The police have finally made an arrest in the horrifying case of the depraved assault on the five-year-old child holidaying at a caravan park in Turangi. We know nothing about the accused except that he is local and aged 16. The moralising has now begun:

“Pre-show, Detective Inspector Mark Loper had a word. He had the usual praise for hard work and a quick catch, but then went off script. “New Zealand society needs to have a good look at itself,” he said.”

This kind of sermonising is unhelpful, because it obscures the real issues. They are the issues of personal choice and responsibility, not of corporate guilt. New Zealand Society has no global blame for this terrible event. This is not a problem of our failing moral values, except in the broadest sense. New Zealanders have stood up and condemned this heinous act in no uncertain terms. Clearly, it is not a matter of this act being a slight moral failure. People are using the word evil to describe this young man. That is not a word of moral ambivalence. That is a word of distinct and quite absolute meaning. New Zealanders are, quite simply, revolted.

There is a chain of blame that starts firmly with this distressing specimen of youth, should he be guilty. Its maximum weight lies squarely across his back. It lies heavily on his parents and weighs on his extended family. Coils of that chain are likely to run through the Mongrel Mob who are firmly ensconced in Turangi. There will be loose links lying on the community and perhaps some lighter coils on certain government services. But there the chain will end. It does not extend to government nor to society as a whole and to suggest it does is merely a distraction.

A statistically-likely profile of this youth is that he is Maori, from a fatherless family, has a problem with alcohol and has connections to the Mongrel Mob. He is extremely likely to have been abused as a child. Even if all of this is so, I could pick dozens of 16-year-olds with similar histories and circumstances out of South Auckland alone. None of them will have attacked and raped a defenseless 5-year-old because they have chosen not to. That choice was available to this young man. It is not possible that he did not know that what he planned was wrong. The act is so far removed from societal norms and values that there can be no confusion. The responsibility for this act is therefore his, and his alone. There is no excuse, no “there but for the grace of God…”, no “it was my stepfather/uncle/mother/aunt’s fault” – he chose to perform a deed, and there will (and MUST) be consequences.

Though he cannot blame his parents for his deed, the chain of blame lies very heavy upon their shoulders. While even the best of parents may find themselves with a wayward child, it is extremely likely that their parenting, or lack of it, has contributed greatly to this youth’s extreme lack of a sense of responsibility, moral judgement or even common sense.

Sadly, if the comment below is anything to go by the immediate family and community are unwilling to accept the chain of blame upon them.

“Another local tells us the “perpetrator” of the crime is filthy and disgusting. But in the worst thing to happen today, qualifies it. “Who,” she says, “goes to another country and leaves kids on their own?””

The answer to this question is “people who did not realize that they were camping amongst a pack of ferals”.  The hidden agenda under this ugly remark is obvious – to distract attention from the parents, family and Whanau who allowed this youth to turn into a soulless predator.

In the aftermath of this event people will twitter on about inequality and the poor of society, as if being poor automatically makes you into some sort of wild animal. The chattering classes will cry out for more money to be lavished on the denizens of Turangi, as if money would somehow replace the fathers of broken families and attract young people away from the false brotherhood of the Mongrel Mob. Reviews of CYFS and police reports will fall from heaven like rain.

Few will want to ask about the distorted, poisonous society created by the Mongrel Mob. Few will ask how no-one in the immediate family could spot the aberrant behavior of this young man, before it was too late. Few will ask how many other youths in Turangi are as disturbed. No-one will ask the community what they will do to prevent this from happening again.

Instead, we will blame society and nothing will change.

Note: Unlike the locals hanging around the court, I have no idea if the police have their man. He is innocent until proven guilty. The remarks above are general ones that would pertain to any perpetrator of the crime, not just the current youth in custody. Any specific accusations of guilt or identification of this youth will be immediately deleted from the comments.

The Herald appears to be obsessed with the fact that the Attorney-General is seeking almost $14,000 in costs from Bradley Ambrose, the journalist who made an unauthorised recording of John Key and John Banks during the private part (i.e. the part where all the journos were firmly asked to leave) of their otherwise public meeting. The Herald has run articles on this today, yesterday and Tuesday. The recent articles heavily feature Bryce Edwards whining about how nasty the government is to be seeking court costs from Ambrose.

Ambrose, to his credit, is not the one who is complaining, possibly because someone (ie. the Herald or TV3) will be paying it on his behalf. But even if this is not the case, the taxpayer (i.e. me) should not be paying for an essentially frivolous, self-serving lawsuit. I can think of at least 14,000 reasons why not.

However Mr Edwards may like to dress this up as an issue of freedom of the press, this is about where the acceptable ethical boundaries lie in journalism. It is exceedingly clear from the entire event that this was not about the media holding the government to account, but about the right of the media to publish any old tittle-tattle to sell newspapers and pull viewers. Had there been anything of consequence in the tapes, there can be no doubt that the Herald and TV3 would have published the entire contents and sorted out the legalities later. That legal fight would indeed have been about media freedoms. The silence of the media under the threat of legal action merely demonstrated the essentially trivial nature of the tapes.

Bradley Ambrose tried to dress the court case up as a way of “re-establishing his reputation”. This is balderdash. Ambrose had no public reputation to uphold and his business reputation with the media was almost certainly enhanced by the episode. He is still making money for the Herald, as evidenced by these new articles on his court costs.

No, there was only one reason why Ambrose was willing to take a fairly forlorn long-shot to the High Court. If the judge had declared the conversation to be in the public domain, the Herald and TV3 could have published the contents bit by bit (for maximum embarrassment). You see, while the contents were not significant enough to warrant publishing under the threat of legal action, there would certainly be enough in a casual conversation to embarrass both Key and Banks; particularly if released piecemeal, with each remark out of context. Ambrose would have been paid well for his “contribution” and the Herald would have sold many thousands more papers.

So while Bryce Edwards berates the government for “political vindictiveness”, we beg to differ. The MacDoctor sees no reason at all for the taxpayer to be fleeced (yet again) merely because Mr Ambrose wishes to chance his luck. He is quite in agreement with the Attorney-General seeking costs, although he wonders why the A-G is not asking for the full $23,442.95?

It is interesting to see how Mr Edwards accuses the government of an ”extraordinarily aggressive and hostile” approach to the media. From where the MacDoctor stands on the right side of the political spectrum, it seems very clear from this episode that the shoe is, in fact, on the other foot. The Media has adopted an aggressive and hostile approach to the government, particularly in this instance. This is all the more extraordinary because Labour and the Greens have recently espoused policies that are distinctly media-unfriendly.

I have absolutely no wish to see New Zealand’s journalists become government sycophants. By all means they should ask the hard questions. The real hard questions, not the patsy left-wing spin questions. Hard questions like what is being done to enable business to generate new jobs? What is being done to fix the gaps in CYFS that enabled a 9 year old girl to be tortured under their noses? Why is New Zealand still insisting on a full-blown ETS when it is clear that it will make no difference to global warming and none of our major trading partners have one? 

Let us also see hard questions asked of the opposition (what would they do instead of…? would be a good start). Let us see, especially, some hard questions put to the Greens about their policies, particularly their economic ones.  Let us see none of the trite nonsense that makes up “political discourse” in the media at present – no regurgitation of press releases; no sensationalist, prurient tripe; no patsy interviews; no partisan “experts”.

In other words, let us see the media do their job.

Vi♦ta♦myth [vahy-tuh-mith; Brit. also vit-uh-mith]

A factoid about vitamins that is wildly inaccurate or untrue

Vitamyths come from both ends of the vitamin spectrum. Those who promote the consumption of vast amounts of vitamins are usually happy to make outlandish claims about their efficacy. This is, in some ways, quite understandable, as it is in the nature of merchandising to exaggerate. Less understandable is the tendency of clinically orientated professionals to magnify the significance of every negative result while completely ignoring any positive findings. An excellent example of this can be found in todays Herald (nicked from the Daily Mail) entitled, tellingly, Multi-vitamin pills ‘a waste of money’ – study.

The study in question is the latest paper[1] to come from the Su.Vi.Max study, a well-known French double-blind clinical trail of over 12,000 men and women who took either a placebo or a multi-vitamin (C, E, Beta-carotene, Zinc and Selenium). The headline, of course, is not the actual conclusion of the study but the reiteration of a common vitamyth – the “waste of money” myth. The study concludes:

“The perception that supplementation improves general well-being is not supported by this trial.”

The idea that vitamins make you feel better is also a vitamyth. We already knew that. Any competent vitaminologist (scientist who studies, rather than peddles, vitamins) could have told you this. Exercise makes you stronger and fitter and energises you. Vitamins will not.

We can conclude from the headline that this will not be a balanced review of a vitamin study. Enter the Dietician.

Dietitians are notorious for demonizing vitamin supplementation. They are also very good at producing vitamyths.

“Many users fall into the category of the ‘worried well’ – healthy adults who believe the pills will insure them against deadly illnesses – according to Catherine Collins, chief dietician at St George’s Hospital in London.”

New Zealand is, apparently, the third fattest nation in the world according to OECD statistics. Yet fighting the obesity “epidemic” is not rocket science. Apart from the very few people who have some serious metabolic disorder, all that causes obesity is taking in more calories than you burn up. Yes, it is rather more complicated than that, but not from the view of the practical outcome. If you exercise and eat fewer calories, you will always lose weight in the long run.

Notice I don’t say, if you eat less, you will lose weight. It is tragically easy to eat smaller quantities, but switch our diet to very calorie-rich products, often promoted as “health” products – but stuffed with fats and carbohydrates. Thus, I do understand where this article by Tony Falkenstein is coming from when he advocates a tax on sugar. Unfortunately nearly everything is the article is incorrect and Mr. Falkenstein’s understanding of the subject woefully deficient. A sugar tax is a very poor way of fighting obesity and a counterproductive way of fighting diabetes.

Let’s start with diabetes, a subject of which I know a considerable amount being not only a doctor but a type 2 diabetic. Diabetes is not caused by obesity. Morbidly obese people (people weighing over 50% more than their expected body weight for their height) are often diabetic, but this is because their fat renders insulin (the hormone that pushes fat and sugar into cells) less efficient. But you need a lot of excess fat to become diabetic solely due to your weight.

Type 2 diabetes is a genetic condition where insulin does not work as well as it should (unlike type 1 diabetes where the pancreas makes little or no insulin). It is found in about 50% of Pakeha and 90% of Maori, Pacific Islanders and Asians. In ancient times the gene would have been an evolutionary advantage as, during times of famine, it would have kept your blood sugar levels up. Your brain can only use sugar for energy (most of the body can burn fat). Consequently, low blood sugar makes you less able to hunt, gather or seek a mate.

Fast forward to the present day and most OECD countries have no shortage of food at all. In addition, carbohydrates are the easiest energy source to produce and therefore the most abundant in the types of food we eat.  Worse, most carbohydrates are in a form that is readily metabolised straight to glucose (so-called high glycaemic index food). Should you have the gene for insulin resistance your sugar levels will gradually rise as your poor pancreas tries to cope with the sugar load. Eventually the pancreas loses the fight and you develop diabetes (note: not everyone with this gene will develop diabetes)

Immediately one can see the absolute pointlessness of a sugar tax. Potatoes, white bread, rice and pasta become sugar in the body as fast as pure cane sugar and nearly as fast as glucose powder. Taxing sugar is like sticking your finger in the dyke when the tsunami alarm has just gone off. And taxing carbohydrates in general is just adding a tax to nearly all food.

It is the combination of plentiful food and high levels of easily accessible cheap carbohydrates that has produced both the diabetes and the obesity epidemics. This is unlikely to be easily changed because plentiful, cheap food is a GOOD thing, despite the few disadvantages. There is no famine in New Zealand and even the poorest of people should not go hungry (some, of  course, do, but that is not usually due to food being unobtainable).

Mr Falkenstein suggests we are all addicted to sugar in the same way that people are addicted to tobacco. This is a very poor analogy. We are wired to like the taste of fats and carbohydrates in our basic genes because these are the high-calories foods we need to consume in order to survive. We are not in any way wired to like burning tobacco. While I have some sympathy for the view of Mr. Falkenstein that the health industry uses false advertising techniques similar to the tobacco companies, I should point out that Mr. Falkenstein himself in the CEO of a bottled water company, surely the biggest health con of the lot!

Be that as it may, the food industry in general is merely responding to what people like to eat. We want tasty fats and carbohydrates. Therefore, that is what they provide and advertise. Unlike, tobacco, which requires a certain amount of peer pressure and brand-generated desire to produce a habit, the food industry merely has to produce something appetising. The product will then continue to sell itself.

So sugar is not an addiction, in any meaningful sense of the word. This does not entirely invalidate the argument that a tax will get us to consume less sugar (though the value of this in the war against obesity is questionable), but let us not have images of the noble government trying to save it’s addicted population. What we should be looking at with a critical eye is exactly what would be taxed in this regime proposed by Mr Falkenstein, because we are not simply talking about candy bars and coke.

• Honey 80% sugar
• Packet mixed nuts and raisins 27% (without raisins 5%)
• Tomato sauce 16% sugar (Baked beans 8.2%)
• Fruit juice 10.4%
• Peanut butter 5%
• Milk 4.2%
• Bread 2%
• Packet of Pringles 1%

Now, when you can explain to me how a packet of Pringles in a child’s lunchbox is somehow better than a packet of nuts and raisins, I will agree that a tax on sugar is a good thing. Until then, let me leave you with this gem from the article:

“Last month, Denmark, which has one of the lowest obesity rates (one-third of the New Zealand rate) introduced the world’s first fat tax, levied on foods, including butter and bacon, that contain more than 2.3 per cent saturated fat. [emphasis mine]”

And there you have it in a nutshell. Denmark has one of the lowest obesity rates in the first world and yet simply has to introduce a new tax. The correct question here is not Mr. Falkenstein’s “why not here?” but “When will they stop interfering?”

The answer is never in our lifetime.

“First they came for the sugar
Then they came for the fat
Then they came for carbonated bubbles
and made the coke quite flat

“Then they came for the beef, the chicken and the lamb
Suddenly there was nothing with a taste worth a damn
Finally they came for everything left that was nice
We were left with spinach, asparagus and rice

“All because we were timid, silent mice.”

(Apologies to Martin Niemöller)

MacDoctor wishes all his readers a blessed Christmas.

Now go away and do something festive, instead of reading this blog.