2013-06-24

The Current situation with the Rotavirus Vaccine- The Advanced Pediatrics Perspective

The Current situation with the Rotavirus Vaccine:
Not a very dangerous illness
Norovirus is taking the place of Rotavirus
Vaccine carries some risk


Rotavirus was the #1 cause of stomach flu in the United States prior to the introduction of a vaccine to prevent this infection in 2007.  Prior to the development of the vaccine for rotavirus, this virus would sweep across our region every year sometime in February and disappear sometime in the summer.

Rotavirus infection is no fun, it causes vomiting, diarrhea, and stomach upset.  It is the stomach flu that almost everyone has experienced, unpleasant, uncomfortable.  The vomiting and diarrhea can lead to enough loss of fluid to require IV hydration.  For most children, the rotavirus stomach flu is unpleasant, but fluids can be given at home and no need for an IV develops.  For some, IV fluid is needed, and for a very few, enough IV fluid is needed that a brief stay in the hospital occurs.

More rarely, rotavirus infection can cause the intestine to telescope.  Think of the intestine as a long tube and imagine one segment sliding over the next segment, like a telescope can do.   When that happens the gut gets very swollen and can even become blocked or act blocked.  That situation goes by the difficult to spell and pronounce name of intussusception.   

In our own experience with rotavirus, we have been able to monitor the impact of this infection in families who come to Advanced Pediatrics over the last 10 years.  During this period the vast majority of children in the practice have experienced rotavirus stomach flu, and many dozen have had to go to the ER for IV fluids to be given over a several hour period.  Less than a dozen have needed IV fluid for long enough to require a day or so in the hospital, and even fewer have developed intussusception.  During this time period, essentially single child in the practice who has had a stomach flu infection has had a full, complete, and uncomplicated recovery- to the best of our knowledge.

So, given this experience, we have studied whether offering rotavirus vaccination would be, overall, a benefit to the families at Advanced Pediatrics.

There are three reasons why it might not offer much benefit:
1.  The actual infection the vaccine is trying to prevent is too minor to detect much benefit.
2.  The vaccine may carry side effects that make the situation worse.
3.  Eliminating rotavirus may become irrelevant if another stomach flu virus takes its place.

The first rotavirus vaccine came out in the 1990's, and our first response was that the actual experience of stomach flu was to mild that even if the vaccine had very rare but serious side effects, a child was better off not getting it, so we held off recommending its use.  Not long after it was found that that first version of the rotavirus vaccine indeed caused a jump in the chance of the child's bowel obstructing via the condition of intussusception, described above.   That vaccine was taken off the market.

In 2007, a second version of the rotavirus vaccine was introduced.  At Advanced Pediatrics we came to our earlier conclusion.  Namely, since no child in the practice with stomach flu had ever suffered a serious consequence, it made sense to be sure that this new version of a vaccine be observed, to make sure it too did not turn out to be harmful enough to be taken off the market.

Fortunately, this time, the vaccine did not cause enough of an increase in the rates of intussusception to be taken off the market, and no other serious side effects have emerged over the last 6 years.

This month, June of 2013, a major paper on the chance of developing intussusception after use of this and a third and newest rotavirus vaccine was published.   Together with other studies, we now have a clearer picture of whether getting the rotavirus vaccine raises risk or lowers it, and if the lower risk is sufficient to justify its use.

What the studies have found is that for infant ages 8-11 weeks, which is the age the first dose of rotavirus vaccine is to be given, the chance of intussusception does increase over the chance of getting it if you are not vaccinated.  The chances are remote in either case, the rates are per 100,000 infants.  But if you are not vaccinated the chance of being admitted to a hospital for intussusception is about 7 per 100,000 infants, and if you are vaccinated the risk goes up to 11.5.

So the risk of intussusception is increased if you get the rotavirus vaccine, not by much, but by some.

A second trend has also emerged, and that is the appearance of the norovirus.  Noroviruses are famous as the cause of cruise-ship stomach flu epidemics, but they are also the #1 cause of food related illness with an incubation period of about 12 hours.  

About 85% of American infants have become vaccinated for rotavirus, but norovirus has stepped into the gap and now causes more stomach flu than any other virus.  In fact, there is so much norovirus around that even if you are vaccinated for rotavirus, you are just about as likely to get stomach flu.  The drop in rotavirus stomach flu has been matched by the rise in norovirus stomach flu.

BOTTOM LINE
Putting it all together the case for using the rotavirus vaccine seems quite weak:

Our experience with stomach flu is reassuring
No lasting harm from a case of stomach flu has occurred

Norovirus has replaced rotavirus
Giving the rotavirus vaccine will have little impact on the chance of your child getting stomach flu.

Intussusception risk
A large body of data from the last 6 years establishes that getting the rotavirus vaccine increases the chance that your child will develop intussusception- a process that can cause bowel obstruction.

Not much protection from getting stomach flu and an increased risk of a serious complication combine to lead us to continue recommend against the routine use of rotavirus immunization at Advanced Pediatrics.   The American Academy of Pediatrics and Centers for Disease Control both do recommend universal use of rotavirus vaccine in early infancy, and so we do make the vaccine available, and remain happy to discuss the topic.



*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

A Moment to Mark an Important Success;; The HPV Vaccine

A Moment to Mark an Important Success:
The HPV Vaccine

A recent report has proven that the use of the HPV vaccine in the United States has cut the chance of a 14-19 year old young woman being infected with key HPV strains in more than half.

Since 2006, the chance of a 14-19 year old young woman being infected with key HPV straind dropped 56%!

That is a very dramatic success, and occurs even with the rate of immunization for HPV not reaching 100%.

The trend suggests that if everyone got the HPV immunization, the chance of being infected with strains of HPV most likely to cause cervical cancer would dramatically disappear.

Why is this so  exciting?

Because the 4 strains in the HPV vaccine account for the vast majority of cases of cervical cancer.  We now have facts on the ground establishing that the HPV immunization program could nearly eliminate the chance of a woman experiencing cervical cancer, and sharply reducing the chance she could experience the terrible experience of a questionable Pap smear.

When the HPV vaccine was first introduced we raised questions about how well would it work.  How long would it last after the 3 shot series was concluded?  Was there enough cervical tissue abnormality in the US to see a benefit from less HPV infections?

Well, now we have some real world answers.  The 3 shot series works, and works well, and lasts.  It works so well we can now be confident that getting the HPV series will change the lives of a large number of women, nearly eliminating cervical cancer and the risk of such.

Bottom Line
This report moves Advanced Pediatrics towards enthusiastically recommending that all girls and boys receive the 3-shot HPV immunization series in late middle school or early high school.

Dr. Arthur Lavin



*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2013-05-07

SPRING ALLERGIES!

SPRING ALLERGIES!

Right now our community is experiencing a fierce burst of allergies, so it makes sense to go over what this is, and what can be done.

Why such a rough year?   I believe it is because an unusually cold spring kept the grass and trees (see below) from blooming for many weeks, leading to a supercharged, nearly instant, explosive amount of blooming.  A very unusual phenomenon that has, locally, created such a pulse of pollen that it is overwhelming therapies.

What are allergies?
The word allergy is derived from the Greek words for other and energy, and so it literally means energy from otherness.

What it really means is that something that is not you, from outside your body, gets your immune system to react in certain particular ways that we call allergies.

At its heart, an allergy occurs when your body develops an antibody to a particular molecule, and everytime your body contacts that molecule, the immune system attacks, causing inflammation.

There are three key differences between the inflammation caused by allergic reaction and other inflammations (like infections, auto-immune disorders), and the are:

1.  The inflammation in allergies itches
2.  The inflammation in allergies does not tend to cause severe pain.
3.  The inflammation in allergies causes very little damage.

On this last point consider the inflammation seen in untreated bacterial pneumonia or arthritis- one actually can destroy the lungs and the other, the joints.  Allergic reactions tend not to destroy tissue or organs, once the allergic reaction passes, your body returns to very much how it was before the allergic inflammation.

The inflammation of allergies is so distinctive, in these three ways, because there is a special class of antibodies that cause it, the E-class.  Infections are dealt with by M and G type of antibodies, only the E type of antibody, or Immunoglobulin E, or IgE, cause true allergies.

And so, one cannot be allergic to something unless you make IgE to that particular thing.

Spring Allergies
The allergies that are afflicting Ohio now are all due to the E-class of antibody, or IgE, to pollen.

If you are having itchy eyes, sneezy nose, cough, from allergies and it just hit the last week or so, you are allergic to pollen, via having the antibody (E-class) to pollen.

Pollen is the grain that holds the sperm of plants and some plants need to make zillions of such grains to get their seeds fertilized, or pollinated.

All the misery of this time is due to two types of pollen- tree and grass.  Not so much flowers.  Why? Because garden flowers simply do not pump the volumes of pollen into the air that grass and trees do.

So these spring allergies are due to pollen in the air, and so, the areas of the body that react and get inflamed (and miserable) are the parts the pollen hits- eyes, nose, throat, and lungs.

In each instance, the story of cause and effect is the same, pollen hits the body, the body, if it has the right IgE antibody to that pollen, reacts with itchy inflammation- including swelling, redness, itch, and fluid

Let's see how it shakes out then at each site:

Eyes
The pollen hits the eyes, and if your allergic to it, the eyes get red, intensely itchy, swollen, and fluid (mucus) accumulates.  If you lie down overnight, the swelling and mucus can combine to cause the eyes to swell shut and be matted with dried, caked mucus.  When all is said and done, though, the eyes return to normal, there is no change in vision, no harm done, only intense suffering during the period of inflammation.

Nose
The pollen hits the nose, and if your allergic to it, the nose get red, intensely itchy, swollen, and fluid (mucus) accumulates.  If you lie down overnight, the swelling and mucus can combine to cause the nose to swell  and be matted with dried, caked mucus.  When all is said and done, though, the nose returns to normal, there is no change in smell, no harm done, only intense suffering during the period of inflammation.

Throat
The pollen hits the throat,  and if your allergic to it, the throat gets red, intensely itchy and sore, swollen, and fluid (mucus) accumulates.   When all is said and done, though, the throat returns to normal, only intense suffering during the period of inflammation.

LungsThe pollen is breathed in to the lungs, and if your allergic to it, the lungs get red, intensely itchy, swollen, and fluid (mucus) accumulates- causing the main experience of lung allergies:  cough and wheezing.
When all is said and done, though, the lungs return to normal, there is no change in breathing, no harm done, only intense suffering during the period of inflammation.

No Anaphylaxis
Although reported, the very dangerous reactions seen to some drugs and foods where breathing actually is compromised and blood pressure drops, known as anaphylaxis, is very, very rare in spring allergies to pollen.  Another reason to know the terrible allergies being seen now are miserable, but not dangerous.

What to Do?

There are basically three therapies that help control allergies:
  • Antihistamines and other blockers- These drugs block key sequences in the chemical pathways that cause the itchy inflammation to occur.  Good blocking means no reaction, no suffering, problems controlled.
  • Steroids- These drugs kill the cells of the immune system that cause all inflammation, including allergic inflammation.  When these drugs work allergy symptoms tend to improve since the cells making the reaction happen are wiped out.
  • Allergy Shots- This technique creates a different class of antibody to the thing you are allergic to, so when that thing comes in contact with you, there will be no reaction.
Antihistamines and other blockers
One of the key tools in finding relief from all the swelling, itch, and fluid of allergies are antihistamines.
There are basically four oral forms and several eye forms available, and they are available to everyone since they are all over-the-counter and so safe even young infants can use them safely.
All four are truly very safe medications, the only significant side effect seen is sleepiness, and three of the four are formulated to make that uncommon.
It turns out everyone is different when it comes to which work.  For some, this one works and that one does not, so it is best to try one, if it doesn't help, try the other.
Here are the four:

  • Loratidine or Claritin- each dose (ranges 5-10 mg) lasts 24 hour, less drowsy
  • Cetirizine or Zyrtec- each dose  (ranges 5-10 mg) lasts 24 hour, less drowsy
  • Fexofenadine or Allegra- each dose  (ranges 60-180 mg) lasts 24 hour, less drowsy
  • Diphenhydramine or Benadryl- each dose (ranges 6.25-25 mg) lasts 4 hours, more drowsy
People tend to try the three non-drowsy, once a day preparations first, but keep in mind that diphenhydramine is the most powerful of the four, so if the allergies are very irritating, some drowsiness may be worth the relief diphenhydramine can sometimes deliver.

EYE ANTIHISTAMINES are a powerful and wonderful therapy.
They come in over-the-counter brands and prescription brands.  Potency in OTC and prescription brands is comparable, but changing the brand when one does not works makes good sense.

One more blocking drug to mention is Singulair, which has very few side effects, does not cause drowsiness, and is taken once a day.  It blocks another chemical in the allergy chemistry, and can work very well, too.

Steroids
There are many types of steroids, the ones used for allergies are technically the glucocorticoid steroids, not the ones used in sports.  As noted these steroids kill the cells that orchestrate the whole allergy cycle, so they work better than anything.

One problem- steroids have an encyclopedia of very serious side effects.
The solution- use the topically.  Essentially all of the hazards of steroid use can be avoided with the topical strategy for two reasons- the amount needed is a small fraction of that needed in oral treatments, and the drug is being applied to the inflamed area directly, allowing for a much smaller dose to still have a big impact.

The most familiar example of topical steroid use is steroid cream for eczema.  Rub a little hydrocortisone cream on a patch of eczema and the inflammation clears, with very little hazard.

There are two topical strategies of steroid use in spring allergies: the nose and the lung.

The nasal steroid systems are essentially nose sprays that deposit a small amount of steroid on the lining of the nose.   There are many, many brands of these sprays, and they all work about equally well.  There is not much point in switching brands except for price.

The lung steroid systems are inhaled steroids and they are delivered by a hand-held inhaler or a mist making machine called a nebulizer.  Again, the brands work about equally well, only price should cause a change in brand.

Both the nasal and inhaled steroids work well and are very safe.

There are oral steroids too, Prednisone and Prednisolone, but this strategy requires a much, much larger dose of steroid use and it being delivered to the entire body.  This is a far riskier move, and we typically reserve its use for more serious conditions such as life-threatening allergic reactions and severe breathing distress from severe asthma attacks.   We do not recommend the use of oral steroids in the routine of treatments for spring allergies.

Allergy Shots
Allergy shots create antibodies to the pollen that block future allergic reactions.  When they work, you are left no longer allergic to the pollen your treatment targeted.
The problem with allergy shots is that it requires a weekly injection, sometimes for years.  The benefit can take quite a long time to realize.
We recommend trying all the available antihistamines and topical steroid treatments first.
These treatments work well for most people, spring allergies tend to be well-controlled by them, and treatments with them are painless, do not require a doctor's visit every week, and give relief nearly immediately.


BOTTOM LINE
This year we are seeing a true explosion of spring allergies.  Here are some key points to remember:
  1. This is an unusually severe year of allergy.   Don't make long-term treatment plans based on the severity of this year's reactions.
  2. Spring allergies are the result of an allergy to pollen, mainly the pollen from grass and trees, not flowers.   There is no need to go searching for what your child is allergic to if their symptoms are itchy eyes and runny nose without fever in the spring during peak blossom times- the cause is pollen allergy.
  3. Treatments include oral antihistamine for all allergic symptoms, and:
    1. Eye antihistamines for inflamed eyes
    2. Nasal steroids for inflamed nose
    3. Inhaled steroids for inflamed lungs
  4. Spring allergies are harmless- they cause great agonies, but no harm.  And they are very temporary, passing as the blooming intervals pass.  And they are very treatable.  
So no need for panic.  The cause is easy to describe, the treatments are readily at hand, and the outcome is outstanding.

Here is to an enjoyable Spring for us all.

Dr. Lavin



*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2013-04-24

The Prescription Drug Epidemic- Important Points to Teach Your Kids

Ritalin

The Prescription Drug Epidemic- 
Important Points to Teach Your Kids

It even sounds strange to say it, "prescription," "drug," and "epidemic"  all in one phrase.

But here we are, a study of nearly 4,000 teens just published demonstrates that the abuse of prescription drugs in the US in teens, had popped up 33%.

About 1 in 4 US teens have abused a prescription drug at least once in the last year!


What is prescription drug abuse?  It's taking a drug that requires a prescription, without a prescription.

This is actually an extremely dangerous category of drug abuse, since it opens the door to use of drugs that, in the right combination,will kill you.

The reason the abuse of prescription drugs is so deadly is that they are designed to pack a punch, and if the punch is not delivered carefully or mixed with other punches, you can come to grief.

Very recently, we were deeply shocked to find that about 6 kids who had graduated from Orange High School not long ago died of use of prescription drugs.  Some died from taking too many, some died from mixing the wrong mix, none intended to die to the best of our knowledge.

When you read findings from the study you will note following key points:
  1. This problem is now officially rampant.  When you get to the level of 1 in 4 teens abusing prescription drugs, that means nearly every family with teens has a child with or a friend with this problem.  
  2. The #1 category of abused drugs in the US in teens are the stimulant medications such as Ritalin or Adderall.   About 1 in 8 teens in the US abuse stimulants.  Combining these drugs with others can be quite dangerous.
  3. It's not new, but it's newly big.  The rates are up 33% in the last 5 years!
  4. Kids use them to enhance performance, and to experiment. Consider skittle parties- where teens dump all the family's drugs into a bowl and pop away.
It wasn't that long ago that the use of steroids in sports was the great scandal- Barry Bonds may never enter the Baseball Hall of Fame for his alleged use of them.  The outrage was that great athletes would risk hurting their bodies to enhance their performance.

Today we see a parallel fad hitting, the phenomenon of performance enhancing in school.  The problem is similar to steroids, in both instances the drugs really do work.  Steroids boost batting averages, stimulants boost grade point averages.

The major difference is that nearly all prescription drugs also have quite good uses, but they should be limited to use under the direction of a licensed, thoughtful medical professional.

WHAT TO DO:
  1. Know that the abuse of prescription drugs demands the attention of every parent of a child over age 8-10.  With the rate hitting 1:4, no one can assume that their child is not at risk.
  2. Know that this is a very dangerous problem.  Children and teens really do come to harm from this practice.
  3. So, talk to you children, let them know a prescription drug is a chemical with power.  It's build to change the body, for real.   
  4. Let your children know that using prescription drugs without a prescription is common, and dangerous.  Let them know combining drugs can be deadly.
  5. **Keep every prescription drug in your home under control**  That means knowing where every such bottle is, and checking the pill count at regularly timed intervals, to make sure that the number of pills leaving the bottle does not exceed the prescribed amount or rate.
Obviously, the use of prescription drugs as prescribed can be very important.  

But, just as clearly, we have reached a point where every parent of an older child or adolescent should be talking to their child(ren) and monitoring every bottle of pills in the home.

Dr. Arthur Lavin




*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2013-04-01

Stomach Flu- Noro Takes over from Rota

Stomach Flu- Noro Takes over from Rota

This information is already known to most families in our community, but you might find out why it is so interesting.

This winter, even right now, we are experiencing an intense amount of stomach flu- that is, feeling sick, with fever, vomiting, and diarrhea.  Not everyone has all these symptoms,  but most do.  The illness lasts a few days, and the diarrhea can go on for as much as a week or two.  You can feel pretty lousy with this illness, and even get too dry.

Not long ago, there were hopes that the stomach flus of December through April would be gone.  Those stomach flus were once caused mainly by one virus, the rotavirus, and a vaccine was developed to end its impact.  As with other vaccines, the use of Rotavirus vaccine across the United States sharply reduced the incidence of infections of Rotavirus, and if all had gone according to plan, we would be seeing a sharp decrease in the rate of stomach flus this winter and early spring.

But nature has responded, with the rise of the Norovirus group, which includes what once was the cause of most of the non-Rotaviral stomach flu- the Norwalk agent.   As one might have guessed, when Rotavirus was knocked out of the running, Noroviruses stepped in.

Just last week, the New England Journal of Medicine reported that the Noroviruses now are causing more stomach flu than Rotavirus, and they causing enough trouble that rates of stomach flu in the United States are about the same as they were before the Rotavirus vaccine was given.

This is unfortunate, but it explains why there is still so much stomach flu around, even as Rotavirus has decreased.  It also is an argument against the use of the Rotavirus vaccine- it prevents a normally harmless illness, and over the course of the last few years, the illness it was designed to prevent is becoming more common as the Norovirus emerges and takes its chance to cause stomach flu.

Dr. Lavin



*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2013-03-18

The Flu, Influenza, Testing, and Treating

The Flu, Influenza, Testing, and Treating

As the 2012-13 influenza epidemic continues its sharp decline, rapidly approaching its disappearance, it seemed timely to review some of the key facts about the influenza germ, about what is flu, the utility of testing for the influenza virus, and the pros and cons of using Tamiflu.

The Influenza Virus v. The Flu
Let's start with some definitions.   As we all know, the vast majority of all infections in childhood are caused by a category of germs called viruses.  In fact, aside from the example of strep throat, ear infection, and urinary tract infections, nearly all the common infections of childhood are viral.

It turns out there are lots of different types of viruses, and that when it comes to infections of the nose, throat, and lungs, they can all cause the same looking disease:  runny nose, sore throat, fever, terrible coughing, achiness, loss of appetite, disrupted sleep, feeling miserable.    This illness goes by a few different names, but most typically is called a cold or a flu.  Often the illness is called a cold if the family thinks it's not such a bad illness, but if people feel it's causing more than the usual misery, it's called a flu.  So the definition of a cold or a flu is not a medical choice, it's really based on the sense the family and child have about how miserable it is making them.

Now, of the many, many types of viruses causing colds and flus, there is one whose name has the word flu in it, and that would be the influenza virus.  Not all flus are from the influenza virus and not all infections with the influenza virus are flus.   If we look at all the colds and flus (of the respiratory tree, not stomach flus), then the influenza virus is responsible for about 1/3 of them every winter.

So the influenza virus is one species of virus that causes colds and flus, but about 2/3 of colds and flus are caused by other viruses than the influenza virus.

The Seasonal Nature of the Influenza Virus
The influenza virus has a striking quality of showing up every fall, burgeoning into an epidemic, then completely vanishing in the spring and summer.   This year the influenza virus had its peak at the end of December and since New Year's Day has been in very rapid and sharp decline.  That means today, if your child has a cold or flu, it is becoming very unlikely that it will be caused by the influenza virus.
http://www.cdc.gov/flu/weekly/


Are there antibiotics for viruses?  What does Tamiflu do?
As many of you know, most antibiotics only kill bacteria.  That's because bacteria are radically different than viruses, and us.  Bacteria are little one-celled organisms with their own special chemistry.  Drugs like penicillin wreak havoc on their special chemistry, but since viruses and us do not use that chemistry, these antibiotics are harmless to us.

That leaves us fairly powerless to treat nearly all viruses, since we have very few drugs that really interfere with their chemistry.

There are a couple of exceptions, a group of drugs that kill viruses, although when it comes to killing viruses, each drug tends to kill only one type of virus.  This is a bit different than antibiotics killing bacteria, where one antibiotic can kill a very wide variety of bacteria of many diverse species.  So there are drugs like Acyclovir that kill herpes but not influenza virus.  And then there is Tamiflu which can halt the infection process of influenza species viruses, but not herpes or other viruses.

Now Tamiflu, or oseltamivir, actually does not kill the influenza virus, at all.  It interferes with one step in its reproduction.  Viruses work by invading our cells, commanding them to make copies, and then spewing out the new viruses to repeat the cycle.   Tamiflu simply keeps the newly created viruses from separating from our cells, they get stuck, and the infection does not continue.

How well does Tamiflu work?
In thinking about how well Tamiflu works, it is good to keep in mind that it can only control infections with one species of virus, the influenza virus.  So if you have a cold from some other virus, Tamiflu will not do anything to help at all.   As of mid-March, 2013, the number of colds caused by the influenza virus has dropped to the point that 95% of all colds and flus are not caused by the influenza virus.

But what if you know your virus is the influenza species of virus?  Tamiflu turns out to be a very weak drug in actual practice.  One of its failings is that if you take after 48 hours of being sick with the influenza virus, you likely will notice no benefit at all.   And, if you take it right at the start of symptoms, on the average, your viral infection will last only 36 hours less.

Now why is the help it offers measured in average numbers less of being ill?  That's because it's impact is so mild that if you take Tamiflu with an influenza viral infection, you will still be sick, and so it's hard to know if it "worked."  To get some measure of if it works, the studies take a bunch of people all infected with influenza virus and give half of them Tamiflu, and half nothing.   All of them get well in a week or two, or less.  And so the effect of Tamiflu is measured in the difference in the average number of hours the treated group is sick compared to the untreated group.  And that difference was 36 hours.

To our minds, that's not a very dramatic impact.  If you get an influenza viral illness, you might be sick for 9 1/2 days without Tamiflu and, on average, 8 days with Tamiflu.

But what about everyone's friend who was treated with Tamiflu and was well the next day?  That happens, but when it does, it is impossible to know if that person was about to get well without the Tamiflu.  That's the value of the studies, we can actually measure how groups fare with and without treatment.   No study has ever demonstrated any pattern towards rapid and complete recovery within a day of taking Tamiflu.  

So the evidence strongly suggests that if you have had the flu from the influenza virus for a week, get so exasperated about being ill that you go to the doctor, get placed on Tamiflu, and are fine the next day; then, you are far more likely to have been on the last day of your illness and destined to feel well the next day, than for your recovery to be so dramatic from use of Tamiflu.

A review of the impact on the health of those infected with influenza in England concluded that the use of Tamiflu may have reduced symptoms by about a day (in line with the 36 hours quoted above), but had no impact on the risk of anything serious happening- including complications and hospital admissions.

What harm can Tamiflu cause?
It turns out that Tamiflu is not harmless.  Lots of people who take it get nausea and even vomit.
More rarely it can damage your liver and cause dangerous heart rhythms.
And, it is becoming clear that taking Tamiflu can have a serious impact on your moods and thinking.
In countries where Tamiflu has become a common drug to use with influenza infections, there has been a rise in dangerous neurological and/or psychiatric reactions.

Should otherwise healthy children who catch a cold or flu, and found to have it by an influenza virus, be treated with Tamiflu?
The answer to this question, as all such questions should be answered, hangs on how well Tamiflu might help and how badly it might hurt.

The consensus across nearly all studies is that Tamiflu doesn't really do much.  It clearly fails to stop the illness to any dramatic degree.  It is useless after 48 hours of being ill.  And even in the best of circumstances, can only be expected to shave a day or so off the illness.  It prevents no complications.  This is a very weak intervention.  So the benefit is quite limited.

On the negative side, there are very serious harms risked in taking it.  Harm to the liver is a very dangerous event, as are dangerous heart arrhythmias.  The prospect of inducing dangerous psychological events, particularly in children, is deeply disturbing.   And for what benefit are these risks being taken- 1 day less of a cold or flu.  

In balance, the choice seems clear that a city's children will be better off without using Tamiflu for routine, uncomplicated infections with the influenza virus, and clearly better off in not using it for other viral infections for which it does even less.

One last point, there is no doubt whatsoever that if we begin to use Tamiflu routinely for childhood influenza viral infections, the virus will develop resistance.  So this practice, which offers so little benefit and very real risk, will in the space of a few years render the drug completely useless.  This is an issue for the rare instance of a very serious infection with an influenza virus where even a very limited bit of help from a drug like Tamiflu could save a life.  Using up the potential of this drug saving a life for rare infections with the influenza virus by letting its use go widespread for fairly mild illness seems like a very dangerous plan.

Testing for influenza virus
When someone has a cold or flu of the respiratory system (nose, throat, lungs) it could be caused by a dozen or so various species of virus.  When should your child get a test to see if it is influenza?  Our recommendation is that such testing is useless in mild, uncomplicated situations.  The only reason to find out if a cold or flu in an otherwise healthy child is due to the influenza virus or not would be to see if Tamiflu might help.  But if we agree that the use of Tamiflu is more likely to cause harm than help, then even if the test showed the infection was from influenza, the right decision most likely would be not to treat, in which case the test led to no change in plan, and would be unhelpful.

Now, there are situations when testing makes sense.  They nearly always involve some degree of complexity-either the child has a serious underlying condition, or the presenting symptoms are dangerously severe.  In either case, the very minimal help offered by Tamiflu might make an important difference, so testing to see if the virus is influenza makes sense.

BOTTOM LINES
  1. Most respiratory colds and flus are not caused by the influenza virus
  2. The influenza virus is here usually from November to April.  It is right now vanishing from the US, until its return at the end of this year.
  3. Tamiflu only has an impact on viral infections caused by the species influenza (not on all colds and flus).
  4. Tamiflu has no or very little impact on your colds or flus if you have been sick for 48 hours or more.
  5. If you take Tamiflu before you have been ill for 48 hours, it has very little impact, at best shaving about 36 hours of illness of your course.
  6. Tamiflu is not harmless.  It can hurt your liver, cause dangerous heart rhythms to appear, and especially for children it can cause serious psychological problems.
  7. Countries and communities that get excited about using Tamiflu for mild colds and flus risk hurrying the emergence of resistant influenza viruses, eliminating the use of Tamiflu for very serious situations.
  8. Tamiflu has a good role to play, with its very limited impact on an influenza infection, when that infection is very severe or in a very unhealthy child.
  9. Putting it all together, we do not recommend the use of Tamiflu in otherwise healthy children with uncomplicated influenza infection, and therefore do not see a purpose in testing for influenza virus in such situations as well

Colds and flus are a source of great trouble and discomfort.  We support the effort to find a cure and to keep them from happening.  Tamiflu is neither.  We are still waiting for the medicine or immunization that will truly reduce the burden from colds and flus.


Dr. Arthur Lavin










*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2013-02-27

Hooray for Science

A Moment to Celebrate Science

In February, we celebrate the birthday of two people whose simple observations established much of what we consider modern science:  Darwin (Feb. 12) and Galileo (Feb. 15).

Each of these people made observations that change the way we think, and to a rather extraordinary extent, defined the best of how doctors should practice medicine.

You might think that the whole approach to thinking about medical practice is soundly based on the firmest principles of science, but we find that as time goes on, the connection between medicine and science actually may be getting weaker and stronger at the same time.

Given that there are forces that would reverse the power of science to help heal humanity, it seems fitting to mention a word about what science is about, why it is suspect, and why it should be valued as the ultimate foundation for good medical practice.

What is Science?
At its best, science is a well-defined approach to two big challenges in life- figuring out why things happen, and figuring out how to make things happen.  Perhaps the most curious reason both of these challenges are challenges, is that our minds did not evolve to answer either question very clearly.

It turns out our mind was built to make the best guess possible in the moment.  The people who were best, at a glance, at knowing a tiger was over there were more likely to have descendants than those who did not.  Life itself values the best guess over almost any other technique.

But over time, our minds progressed to allow us the option of thinking past the best guess, and towards a deeper understanding of true causes and true effects.  

Science, then, is an approach to thinking about the world that asks us to go beyond what is apparent and try to figure out what is real, particularly when it comes to explaining why something happens, or how to make something happen.

Galileo and Darwin's work both serve as outstanding examples of what is science.   In every instance, the great work done by Galileo was simply seeing something and asking a question about it.  There are many examples, but my two favorites are the observation about weight and gravity, and the one about not noticing our motion.

The thing Galileo noticed that we still have trouble believing today, is that a very heavy ball will drop to Earth from a height at exactly the same rate as a light ball.  Heavy things don't fall faster than light things.  He proved this by dropping a very heavy cannonball and a light ball from a very tall tower and then seeing that they landed at the same time.  

The other observation he made was that even though we are whizzing through space at truly high speeds, we don't feel as if the earth is moving at all.    But we are.  We spin around the Earth at about 1000 miles per hour, and spin around the Sun at about 67,000 miles per hour.  If we got in a car and went in a big circle at 67,000 mph or a tighter circle at 1,000 mph, we would feel it, and dramatically.

So how could we possibly move at such tremendous speeds (a bullet goes about 6000 mph), and not feel as though we are moving at all?  It turns out no matter how fast you move, if it is a constant rate and your background doesn't change much, you do not notice moving at all.  Believe it or not, it was this observation, just simply noticing that the we don't feel the Earth spin or rotate, that launched a several century move towards the theory of relativity.

And, of course Darwin observed that animals and plants change in response to changes in their environment, that species evolve.  His entire theory of evolution came from simple observations of the world.

So science is an approach to understanding why things happen based on observing what is actually happening around us.

Why is Science Suspect?

One might assume that simply observing what actually happens would not be controversial, but we live in a time of great tension in response to the ways of science.

On the one hand, we treasure it.  Almost everyone uses, treasures, or depends on some form of electronic wonder- not only the fancy things like smartphones, the cloud, the Internet, but also even television itself.  Not many people would gladly go back to a day before we knew what electricity was.   And when it comes time for a major medical intervention, like having appendicitis and needing your appendix removed, nearly everyone is grateful for the progress made in fields like medicine, surgery, microbiology, and yes, pharmaceuticals.

But on the other hand, there is a deep unease with science, a suspicion, and a reaction against it.
It is not clear what truly fuels this suspicion.  The unease may be in part due to the sense that the heady days of science actually solving our problems have given way to a sense that so many of our problems are more complicated and not likely to have quick fixes.  It may be in part due to a sense that in many cases scientific work gets caught up in money-making- research giving way to business.

We see this suspicion across the medical sciences when drug companies devote so much resource to promoting taking an ever-growing array of drugs or when medical centers push so hard for people to have a rapidly growing choice of tests and procedures.

Whatever the reasons, we are living through an era that is witnessing the rise of well organized opposition to even the most direct and simple observations.  From religion to politics to grass roots non-profits, people are organized to deny the observations made about evolution, the melting of our ice caps, and the benefits of some basic medical interventions.

But Science Turns out the be the Best Foundation for Good Medical Practice.

I am very sympathetic to many of the suspicions raised by science, but find most of the troubles are related to how the observations science makes are used, not the observations themselves.  Consider the example noted above regarding the actual experience people have with science when it comes to medicines, even just antibiotics.  The observation that certain chemicals kill bacteria is one of the great discoveries of history, but the actual use of antibiotics is a bit crazy right now.  They are soaking our livestock, and being way overused for conditions, like colds, for which they offer no help at all.  Everyone has an uneasy feeling that we are being oversold on the use of medications, and that much harm is done to us as a result.

Our main point is that we should be very careful not to confuse the problem with science.  
The problem in this example is the sale of antibiotics, not the discovery of them.

BOTTOM LINE

  1. Science has come under unfair suspicion recently, for a number of reasons.
  2. But most of the trouble related to science comes from how its products are used and sold.
  3. Science itself is a wonderful approach to the world that simply consists of observing what happens and learning what really goes on, how things work, and how to make things better.
  4. The challenge we all face today is how to oppose the abuse of the products of science without rejecting science itself, AND without embracing clearly irrational approaches to problem-solving (also known as quackery)
  5. Science stands alone in its ability to improve our understanding of how things work in the world and how to make things work better.    This is not only a good foundation for the practice of medicine, it is essential if medicine is to really help anyone.
  6. At Advanced Pediatrics we work hard to respect and learn from the great observations science delivers and to combine that with the second pillar of medical care- caring and connecting.

Dr. Arthur Lavin

PS- Here is one of the all time best essays on science, an essay on Galileo, I have read recently:
http://www.newyorker.com/arts/critics/atlarge/2013/02/11/130211crat_atlarge_gopnik?printable=true



*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

http://www.newyorker.com/arts/critics/atlarge/2013/02/11/130211crat_atlarge_gopnik?printable=true&currentPage=all

A CRITIC AT LARGE

MOON MAN

What Galileo saw.

by FEBRUARY 11, 2013

Galileo facing the Inquisition: he provided every argument for toleration he could, and still the Church couldn
Galileo facing the Inquisition: he provided every argument for toleration he could, and still the Church couldn’t tolerate him.

Although Galileo and Shakespeare were both born in 1564, just coming up on a shared four-hundred-and-fiftieth birthday, Shakespeare never wrote a play about his contemporary. (Wise man that he was, Shakespeare never wrote a play about anyone who was alive to protest.) The founder of modern science had to wait three hundred years, but when he got his play it was a good one: Bertolt Brecht’s “Galileo,” which is the most Shakespearean of modern history plays, the most vivid and densely ambivalent. It was produced with Charles Laughton in 1947, during Brecht’s Hollywood exile, and Brecht’s image of the scientist as a worldly sensualist and ironist is hard to beat, or forget. Brecht’s Galileo steals the idea for the telescope from the Dutch, flatters the Medici into giving him a sinecure, creates two new sciences from sheer smarts and gumption—and then, threatened by the Church with torture for holding the wrong views on man’s place in the universe, he collapses, recants, and lives on in a twilight of shame.
It might be said that Brecht, who truckled to the House Un-American Activities Committee—“My activities . . . have always been purely literary activities of a strictly independent nature”—and then spent the next bit of his own life, post-Hollywood, accessorized to the Stalinist government of East Germany, was the last man in the world to be pointing a finger at someone for selling out honesty for comfort. But then the last man who ought to point that finger is always the one who does. Galileo’s shame, or apostasy, certainly shapes the origin myth of modern science, giving it not a martyr-hero but a turncoat, albeit one of genius. “Unhappy is the land that breeds no heroes,” his former apprentice says at the play’s climax to the master who has betrayed the Copernican faith. “No,” Galileo replies, “unhappy is the land that needs a hero.” It is a bitter valediction for the birth of the new learning. The myth that, once condemned, he muttered under his breath, about the earth, “But still, it moves,” provides small comfort for the persecuted, and is not one that Brecht adopted.
A number of books have come out in anticipation of the anniversary, including a fine big biography, “Galileo” (Oxford), by the Berkeley historian of science John L. Heilbron, and new studies reflecting new research within the archives of the Roman Inquisition. Modern scholars have a gravitational pull toward ancient bureaucrats—keep records even of your cruelties and history will love you—and the new research has produced a slightly, if significantly, revised picture of Galileo’s enemies. The newer (and, unsurprisingly, Church-endorsed) view is that Galileo made needless trouble for himself by being impolitic, and that, in the circumstances of the time, it would have been hard for the Church to act otherwise. The Church wanted, as today’s intelligent designers now say, to be allowed to “teach the controversy”—to teach the Copernican and Aristotelian views as rival hypotheses, both plausible, both unproved. All Galileo had to do was give the Church a break and say that you could see it that way if you wanted to. He wouldn’t give it a break. The complaint is, in a way, the familiar torturer’s complaint: Why did you force us to do this to you? But the answer is the story of his life.
Although the twinship of Shakespeare and Galileo is one that we see retrospectively, another, even more auspicious twinning was noted and celebrated during Galileo’s lifetime: Galileo was born in Pisa on the day that Michelangelo died. In truth, it was probably about a week later, but the records were tweaked to make it seem so. The connection was real, and deep. Galileo spent his life as an engineer and astronomer, but his primary education was almost exclusively in what we would call the liberal arts: music, drawing, poetry, and rhetoric—the kind of thing that had made Michelangelo’s Florence the capital of culture in the previous hundred years.
Galileo was afflicted with a cold and crazy mother—after he made his first telescope, she tried to bribe a servant to betray its secret so that she could sell it on the market!—and some of the chauvinism that flecks his life and his writing may have derived from weird-mom worries. He was, however, very close to his father, Vincenzo Galilei, a lute player and, more important, a musical theorist. Vincenzo wrote a book, startlingly similar in tone and style to the ones his son wrote later, ripping apart ancient Ptolemaic systems of lute tuning, as his son ripped apart Ptolemaic astronomy. Evidently, there were numerological prejudices in the ancient tuning that didn’t pass the test of the ear. The young Galileo took for granted the intellectual freedom conceded to Renaissance musicians. The Inquisition was all ears, but not at concerts.
Part of Galileo’s genius was to transfer the spirit of the Italian Renaissance in the plastic arts to the mathematical and observational ones. He took the competitive, empirical drive with which Florentine painters had been looking at the world and used it to look at the night sky. The intellectual practices of doubting authority and trying out experiments happened on lutes and with tempera on gesso before they turned toward the stars. You had only to study the previous two centuries of Florentine drawing, from the rocky pillars of Masaccio to the twisting perfection of Michelangelo, to see how knowledge grew through a contest in observation. As the physicist and historian of science Mark Peterson points out, the young Galileo used his newly acquired skills as a geometer to lecture on the architecture of Hell as Dante had imagined it, grasping the hidden truth of “scaling up”: an Inferno that big couldn’t be built on classical engineering principles. But the painters and poets could look at the world, safely, through the lens of religious subjects; Galileo, looking through his lens, saw the religious non-subject. They looked at people and saw angels; he looked at the heavens, and didn’t.
In the fifteen-eighties, Galileo studied at the University of Pisa, where he absorbed the Aristotelian orthodoxy of his time—one as synthetic as most orthodoxy is. There were Arab-spiced versions of Aristotle, which led first to alchemy and then to chemistry; more pious alternatives merged the Greek philosopher with St. Thomas Aquinas. They all agreed that what made things move in nature was an impetus locked into the moving things themselves. The universe was divided into neat eternal zones: the earth was rough, rugged, and corrupt with mortality, and therefore had settled in, heavy and unhappy, at the center of the universe. Things up above were pure and shining and smooth, and were held aloft, like the ladies in the Renaissance romances, by the conceited self-knowledge of their perfection. Movement was absolute. Things had essences, constantly revealed. You could know in advance how something would move or act by knowing what it was. A brick and a cannonball, dropped from a tower, would fall at different rates based on their weight. And the best argument, often the only argument, for all these beliefs was that Aristotle had said so, and who were you to say otherwise?
Galileo soon began to have doubts about this orthodoxy, which he aired in conversation with friends and then in correspondence with other natural philosophers in Europe, particularly the great German astronomer Johannes Kepler. Mail was already the miracle of the age. In correspondence, the new science passed back and forth through Europe, almost as fluidly as it does in the e-mail era. It’s astonishing to follow the three-way correspondence among Tycho Brahe, Kepler, and Galileo, and see how little time was lost in disseminating gossip and discovery. Human curiosity is an amazing accelerant.
Kepler encouraged Galileo to announce publicly his agreement with the sun-centered cosmology of the Polish astronomer monk Copernik, better known to history by the far less euphonious, Latinized name of Copernicus. His system, which greatly eased astronomical calculation, had been published in 1543, to little ideological agitation. It was only half a century later, as the consequences of pushing the earth out into plebeian orbit dawned on the priests, that it became too hot to handle, or even touch.
In 1592, Galileo made his way to Padua, right outside Venice, to teach at the university. He promised to help the Venetian Navy, at the Arsenale, regain its primacy, by using physics to improve the placement of oars on the convict-rowed galleys. Once there, he earned money designing and selling new gadgets. He made a kind of military compass and fought bitterly in support of his claim to have invented it. Oddly, he also made money by casting horoscopes for his students and wealthy patrons. (Did he believe in astrology? Maybe so. He cast them for himself and his daughters, without being paid.)
If you were trying to choose the best places in history to have lived—making allowances for syphilis, childbirth mortality, and all the other pre-antibiotic plagues—Venice in Galileo’s day would have to be high on the list. The most beautiful of cities, with the paint still wet on the late Bellinis and Titians, Venice also had wonderful music, geisha-like courtesans, and a life of endless, mostly free conversation. Galileo called these years the happiest of his life.
He became an ever more convinced Copernican, but he had his crotchets. He never accepted Kepler’s proof that the orbits of the planets in the Copernican system had to be ellipses, because he loved the perfection of circles; and he was sure that the movement of the tides was the best proof that the earth was turning, since the ocean water on the earth’s surface was so obviously sloshing around as it turned. The truth—that the moon was pulling the water at a distance—seemed to him obvious nonsense, and he never tired of mocking it.
Although Copernicus didn’t see any big ideas flowing from the sun-centered system, the Church was slowly beginning to suspect that heliocentrism, heretically, elbowed man right out of the center of things. Galileo alone saw something more: the most interesting thing about the earth’s spinning at high speeds around the sun was that, in the normal course of things, none of us noticed. One of the deepest insights in the history of thought was his slowly developed idea of what we now call the “inertial system”: the idea that the physics stays the same within a system whether it’s in rapid movement or at rest—indeed, that “rest” and “movement” are relative terms. Physical laws, he insisted, are the same in all inertial systems. We experience the earth as stable and still, but it might well be racing around the cosmos, just as we could lock ourselves up in the hold of a ship and, if it was moving evenly, never know that it was moving at all. (The insight is nicely available to New Yorkers when the local and the express trains catch up on parallel subway tracks, and, travelling alongside each other at the same speed, suddenly seem to stand still.) Fast and slow, large and small, up and down are all relative conditions, and change depending on where you stand and how fast you’re moving. The idea demolished absolutes and democratized the movement of the spheres. Galileo grasped some of the significance of what he had discovered, writing later that “to our natural and human reason, I say that these terms ‘large,’ ‘small,’ ‘immense,’ ‘minute,’ etc. are not absolute but relative; the same thing in comparison with various others may be called at one time ‘immense’ and at another ‘imperceptible.’ ” But he saw only sporadically just how far you could push the principle: he saw the sun at the center of things, and didn’t reflect, at any length, that the sun might itself be turning around some other star.
In 1609, Galileo heard rumors about a Dutch gadget that gave you a closeup look at faraway ships and distant buildings. After a friend sent him the dimensions and the basic layout—two lenses in a forty-eight-inch tube—he got to work, and within weeks had made his own telescope. One night in December, he turned it on the moon, and saw what no man had seen before. Or, rather, since there were Dutch gadgets in many hands by then, and many eyes, he understood what he was seeing as no man of his time had before—that shadows from some of the splotches were craters and others mountains. The moon was not a hard, pure sphere; it was geological.
A few weeks later, he pointed his gadget at Jupiter. Some of his notes, scratched on the back of an envelope, still exist, here in New York, at the Morgan Library. He was startled to see four little stars near the planet. In an episode in the history of thought that can still make the heart beat faster, he noticed that, night after night, they were waltzing back and forth near the big planet: first left, then right, never quite clearing its path, as though the planet were sticky and they wanted to stay near it. In a flash of intuition, he had it: the new stars near Jupiter were actually moons, orbiting the planet as our moon orbits us. So their light might be reflected light, as is our moon’s. All moonlight might be sunshine, bounced off a hall of celestial mirrors. More important still, there in the sky was a miniature Copernican system, visible to the aided eye.
It’s hard to overstate how important the telescope was to Galileo’s image. It was his emblem and icon, the first next big thing, the ancestor of Edison’s light bulb and Steve Jobs’s iPhone. A Tuscan opportunist to the bone, Galileo rushed off letters to the Medici duke in Florence, hinting that, in exchange for a job, he would name the new stars after the Medici. He wanted to go back to Florence, partly, it seems, because he wanted to persuade the smart, well-educated Jesuits who clustered there to accept his world picture. Sell the powerful Jesuits on the New Science, he thought, and you wouldn’t have to worry about the Inquisition or the Pope. Galileo felt himself already under enough religious pressure to continue to encode all talk of his discoveries in his correspondence with Kepler. He even sent him a letter about the phases of Venus in cipher, ending, “Oy!” Really, he did. Heilbron suggests, smilingly, that this hints at Jewish ancestry. (No evidence exists that Kepler replied “Vey!”)
Throughout Italy, the Inquisition was what Heilbron calls “low-level background terrorism.” (One of Galileo’s servants had already reported him for not going to Mass regularly.) It was an Italian Inquisition, meaning subject to the laws and influences of clan, and cheerfully corrupt, but disinclined to killing. Disinclined but not incapable; as recently as 1600, the Roman Inquisition had burned alive, in public, the great Giordano Bruno, who taught the doctrine of the plurality of worlds, uncomfortably like Galileo’s doctrine of many moons. It was unusual for the Inquisition to burn philosophers alive; on the other hand, how many philosophers do you have to burn alive to keep other philosophers from thinking twice before they say anything inflammatory?
The Catholic Church in Italy then was very much like the Communist Party in China now: an institution in which few of the rulers took their own ideology seriously but still held a monopoly on moral and legal authority, and also the one place where ambitious, intelligent people could rise, even without family connections (though they helped). Like the Party in China now, the Church then was pluralistic in practice about everything except an affront to its core powers.
For the next two decades, Galileo tried to do what we would now call basic research while simultaneously negotiating with the Church to let him do it. Eventually, he and the Church came to an implicit understanding: if he would treat Copernicanism merely as a hypothesis, rather than as a truth about the world, it would be acceptable—if he would claim his work only as “istoria,” not as “dimostrazione,” the Inquisitors would leave him alone. The Italian words convey the same ideas as the English equivalents: a new story about the cosmos to contemplate for pleasure is fine, a demonstration of the way things work is not. You could calculate, consider, and even hypothesize with Copernicus. You just couldn’t believe in him.
Again, the distinction, bewildering on the surface, makes sense transposed to contemporary China: you can engage in the free market, and make every calculation that the University of Chicago demands. But you can’t publish a book saying that Milton Friedman was right about everything and Mao was wrong. Galileo even seems to have had six interviews with the sympathetic new Pope, Urban VIII—a member of the sophisticated Barberini family—in which he was more or less promised freedom of expression in exchange for keeping quiet about his Copernicanism. It was a poisoned promise: though Galileo, vain as ever, thought he could finesse the point, Copernicanism was at the heart of what he wanted to express.
It all came to a head in 1632, with the publication of his masterpiece, manifesto, poem, and comedy, “Dialogue Concerning the Two Chief World Systems.” Set in Venice as a conversation among three curious friends, the book was in part an evocation of happy times there—a highly stylized version of the kinds of evenings and conversations Galileo had once had. It was in honor of those evenings that he named two of the characters after his friends: Salviati, who here speaks entirely for Galileo, and Sagredo, who represents an honest non-scientist of common sense. He invented a third puppet, Simplicio, who speaks, stumblingly, for Aristotle and the establishment—the other World System. Salviati describes him as “one of that herd who, in order to learn how matters such as this take place, do not betake themselves to ships or crossbows or cannons, but retire into their studies and glance through an index and a table of contents to see whether Aristotle has said anything about them.” Aristotle is to Simplicio one of those complete thinkers, of the Heidegger or Ayn Rand kind, whose every thought must be true even if you can’t show why it is in this particular instance: it explains everything except anything.
“Dialogue Concerning the Two Chief World Systems” is the most entertaining classic of science ever published. Written in the vernacular—the best modern translation is by Stillman Drake—it uses every device of Renaissance humanism: irony, drama, comedy, sarcasm, pointed conflict, and a special kind of fantastic poetry. There are passages that are still funny, four hundred years later. At one point, the dispute takes up the high-minded Aristotelian view that “corrupt” elements must have trajectories different from pure ones, and Sagredo points out that an Aristotelian author “must believe that if a dead cat falls out of a window, a live one cannot possibly fall, too, since it is not a proper thing for a corpse to share in qualities suitable for the living.” The dialogue is also philosophically sophisticated. Though Galileo/Salviati wants to convince Simplicio and Sagredo of the importance of looking for yourself, he also wants to convince them of the importance of not looking for yourself. The Copernican system is counterintuitive, he admits—the earth certainly doesn’t seem to move. It takes intellectual courage to grasp the argument that it does.
Galileo’s tone is thrilling: he is struggling to find things out, and his eye covers everything from the movement of birds in the air to the actual motion of cannonballs fired at the horizon, from the way stars glow to the way all movable bones of animals are rounded. There’s even a lovely moment when, trying to explain to Simplicio how deceptive appearances can be, Sagredo refers to “the appearance to those who travel along a street by night of being followed by the moon, with steps equal to theirs, when they see it go gliding along the eaves of the roofs.” You can’t trust your eyes, but you can’t trust old books, either. What can you trust? Nothing, really, is Galileo/Salviati’s answer, only some fluid mixture of sense impression and strong argument. “Therefore, Simplicius, come either with arguments and demonstrations,” Salviati declares, in Thomas Salusbury’s fine Jacobean translation, in words that remain the slogan of science, “and bring us no more Texts and authorities, for our disputes are about the Sensible World, and not one of Paper.”
Contemporary historians of science have a tendency to deprecate the originality of the so-called scientific revolution, and to stress, instead, its continuities with medieval astrology and alchemy. And they have a point. It wasn’t that one day people were doing astrology in Europe and then there was this revolution and everyone started doing astronomy. Newton practiced alchemy; Galileo drew up all those horoscopes. But if you can’t tell the difference in tone and temperament between Galileo’s sound and that of what went before, then you can’t tell the difference between chalk and cheese. The difference is apparent if you compare what astrologers actually did and what the new astronomers were doing. “The Arch-Conjuror of England” (Yale), Glynn Parry’s entertaining new biography of Galileo’s contemporary the English magician and astrologer John Dee, shows that Dee was, in his own odd way, an honest man and a true intellectual. He races from Prague to Paris, holding conferences with other astrologers and publishing papers, consulting with allies and insulting rivals. He wasn’t a fraud. His life has all the look and sound of a fully respectable intellectual activity, rather like, one feels uneasily, the life of a string theorist today.
The look and the sound of science . . . but it does have a funny smell. Dee doesn’t once ask himself, “Is any of this real or is it all just bullshit?” If it works, sort of, and you draw up a chart that looks cool, it counts. Galileo never stopped asking himself that question, even when it wasn’t bullshit but sounded as though it might well be. That’s why he went wrong on the tides; the-moon-does-it-at-a-distance explanation sounds too much like the assertion of magic. The temperament is not all-seeing and curious; it is, instead, irritable and impatient with the usual stories. The new stories might be ugly, but they’re not crap. “It is true that the Copernican system creates disturbances in the Aristotelian universe,” Salviati admits in the “Dialogue,” “but we are dealing with our own real and actual universe.”
What is so strange, and sad, given what would soon happen, is that “Two Chief World Systems” contains some of the best “accommodationist” rhetoric that has ever been written. To the objections that the Copernican universe, with its vast spaces outside the solar system, is now too big to be beautiful, Galileo has his puppets ask, Too big for whom? How presumptuous to say it is too big for God’s mind! God’s idea of beauty is surely different and more encompassing than ours. The truth that God has his eye on the sparrow means that the space between the sparrow and outer space is impossible for us to see as God sees it.
These are the arguments that, less eloquently put, are used now by smart accommodationists in favor of evolution. Evolution is not an alternative to intelligent design; it is intelligent design, seen from the point of view of a truly intelligent designer. Galileo was happy enough to go on doing research under the generally benevolent umbrella of the Church if only it would let him.
It wouldn’t let him. He provided every argument for toleration he could, and still he wasn’t tolerated. Part of the trouble was traceable to his hubris: he had remembered at the last minute to put the Pope’s favorite argument for a “hypothetical” reading of Copernicus into his book, but he had made it into a closing speech for Simplicio, and when you are going to put the Pope’s words in a puppet’s mouth it is a good idea first to make sure that the puppet is not named Dumbso. But it went deeper than the insult. Whatever might be said to accord faith and Copernicus, religion depends for its myth on a certain sense of scale. Small domestic dogmatists are always merely funny (like Alceste, in “The Misanthrope,” or the dad in just about any American sitcom). Man must be at the center of a universe on a stable planet, or else the core Catholic claim that the omnipotent ruler of the cosmos could satisfy his sense of justice only by sending his son here to be tortured to death begins to seem a little frayed. Scale matters. If Clark Kent had never left Smallville, then the significance of Superman would be much reduced.
Two new books by the historian Thomas F. Mayer take up exactly what happened to Galileo: “The Trial of Galileo” (Toronto) is specifically about the scientist’s persecution by the Inquisition, while his much longer “The Roman Inquisition: A Papal Bureaucracy and Its Laws in the Age of Galileo” (Pennsylvania) delves into its social and intellectual context. Mayer deprecates the conventional account as, in the words of another scholar, “shrouded in myth and misunderstanding.” But, when you’ve read through his collected evidence, the myth seems pretty much right: Galileo wrote a book about the world saying that the earth goes around the sun, and the Church threatened to have him tortured or killed if he didn’t stop saying it, so he stopped saying it. Mayer believes that had Galileo been less pugnacious things would have worked out better for science; yet his argument is basically one of those “If you put it in context, threatening people with hideous torture in order to get them to shut up about their ideas was just one of the ways they did things then” efforts, much loved by contemporary historians.
To be sure, Galileo’s trial was a bureaucratic muddle, with crossing lines of responsibility, and it left fruitfully unsettled the question of whether Copernican ideas had been declared heretical or if Galileo had simply been condemned as an individual for continuing to promote them after he had promised not to. But what is certain is that, in 1633, Galileo was threatened with torture, forced on his knees to abjure his beliefs and his book, and then kept under house arrest and close watch for the rest of his life. (Albeit of a fairly loose kind: John Milton came to see him, and the image of the imprisoned scientist appears in Milton’s defense of free speech, the “Areopagitica.”) Galileo’s words, read a certain way, were not innocent of irony: “I do not hold the Copernican opinion, and have not held it after being ordered by injunction to abandon it.” Notice that he does not say that he never held it, or that he would not still hold it, had he not been forced to abandon it.
Could he, as Brecht might have wanted, have done otherwise, acted more heroically? Milton’s Galileo was a free man imprisoned by intolerance. What would Shakespeare’s Galileo have been, one wonders, had he ever written him? Well, in a sense, he had written him, as Falstaff, the man of appetite and wit who sees through the game of honor and fidelity. Galileo’s myth is not unlike the fat knight’s, the story of a medieval ethic of courage and honor supplanted by the modern one of cunning, wit, and self-knowledge. Martyrdom is the test of faith, but the test of truth is truth. Once the book was published, who cared what transparent lies you had to tell to save your life? The best reason we have to believe in miracles is the miracle that people are prepared to die for them. But the best reason that we have to believe in the moons of Jupiter is that no one has to be prepared to die for them in order for them to be real.
So the scientist can shrug at the torturer and say, Any way you want me to tell it, I will. You’ve got the waterboard. The stars are still there. It may be no accident that so many of the great scientists really have followed Galileo, in ducking and avoiding the consequences of what they discovered. In the roster of genius, evasion of worldly responsibility seems practically a fixed theme. Newton escaped the world through nuttiness, Darwin through elaborate evasive courtesies and by farming out the politics to Huxley. Heisenberg’s uncertainty was political—he did nuclear-fission research for Hitler—as well as quantum-mechanical. Science demands heroic minds, but not heroic morals. It’s one of the things that make it move. 
ART: DE AGOSTINI EDITORE/BRIDGEMAN

Read more: http://www.newyorker.com/arts/critics/atlarge/2013/02/11/130211crat_atlarge_gopnik?printable=true#ixzz2KJby2NQa 
Enhanced by Zemanta