Saturday, January 26, 2019

Separating children and parents at the border causes lifelong damage

There is an important scientific fact that we need to be aware of as the political drama at the border unfolds: when children are separated from their parents, they can be damaged for the rest of their lives.

Research shows that when children face strong, frequent, or prolonged adversity without adequate support from adults, it causes a stress response that can have terrible consequences. This “toxic stress” affects both the mind and the body.

It disrupts normal brain development, leading to not just emotional problems, but problems with thinking and learning. Children who are exposed to toxic stress have a higher risk of depression and substance abuse. They are more likely to drop out of school, engage in risky behaviors, and commit suicide.

The health risks are serious as well. When the physical stress response of the body — the “flight or fight” response — is turned on for prolonged periods of time, it causes damage to body organs. Children who are exposed to toxic stress have a higher risk of heart disease, obesity, diabetes, cancer, stroke, and lung disease, among other problems — and are more likely to die early.

The earlier in life the stress starts, the worse it is for children. Not only are young children more fragile, their brains are still developing. In order for young brains to develop normally, they need ongoing nurturing interactions with adults, something called “serve and return.” When these interactions don’t happen, it can literally and permanently change the architecture of the brain. The damage can be devastating, and it can’t be undone.

Remember, these are children who have already endured toxic stress — not just the stress of the journey to our border, but the poverty or violence or both that caused their parents to make the journey. They need us to help when they arrive, not make things worse.

Taking children away from their parents at the border and putting them into detention centers or foster care isn’t just sad. It can cause harm that lasts forever, even if they are ultimately reunited with their parents. It can change their future — and shorten their lives. That goes beyond sad: it is cruel.

It is clearly wrong to use children as pawns in any battle, especially a political one. But what is happening at the border goes beyond using children as pawns. The science is clear. We are literally ruining their lives. And the only reason we seem to be doing it is to make a point. It’s finally getting warm here in New England, and most of us have plans to enjoy the beautiful weather. And that’s why the Centers for Disease Control and Prevention (CDC) recently released a report raising awareness about how to prevent the tickborne infections that typically occur during this time of the year. Lyme disease is probably the most well-known, and the one for which diagnosis and treatment are most controversial.
What is Lyme disease?

Several countries around the world, especially in the Northern Hemisphere, and all 50 states in the US have already reported cases of Lyme. The disease is caused by bacteria called Borrelia, and it is spread by ticks. One of the biggest controversies surrounding Lyme is determining whether or not someone has the so-called persistent or chronic Lyme disease. The CDC and most specialists prefer to use a different term, post-treatment Lyme disease (PTLD).
What is post-treatment Lyme disease (PTLD)?

Most people diagnosed with Lyme do very well after taking a prescribed course of antibiotics. They can go on with their lives, and they never have any long-term complications. However, doctors noticed a subset of patients who develop symptoms that can last for months and even years after treatment. PTLD symptoms are vague and other illnesses present in a similar way: fatigue, brain fog, numbness, tingling, palpitations, dizziness, aches, and pain. There are a few case studies in the medical literature describing people who continued to have evidence of infection despite adequate treatment, but in most cases there is no laboratory proof the bacteria is still present.

Conventional medicine has a hard time treating something we cannot see or isolate. However, we cannot ignore that people’s lives changed after the diagnosis of Lyme disease. Their suffering is real. And the frustration is widespread. On one side, we have distressed patients tired with the lack of answers; on the other side, we have doctors who cannot find a biological proof of what is happening. Finally, we have an economic system where insurance companies regulate payment concerning how we diagnose and treat diseases. Physicians typically must see a patient every 15 to 20 minutes and find solutions that fit their goals, with little time to listen and address vague complaints. Lyme disease is the poster child for the disconnect we have in our current healthcare system. This scenario led a group of patients and clinicians to get together to seek solutions for this problem.
The main controversies surrounding Lyme disease

The blood test the CDC recommends to diagnose Lyme checks for an immune response to the bacteria, not for the Borrelia itself. That’s why the test can be negative if the disease is present for less than a month. It takes at least a couple of weeks to mount an immune response that would turn the test positive. It is easier to diagnose Lyme if you have the classic bull’s-eye rash that shows up a few days after the tick bite. In these cases, testing is not even necessary. But the rash only shows up in 80% of cases.

If making a diagnosis can be complex, the controversy about the treatment is so intense that some have even coined the dispute “Lyme wars.” The clash emerged from doctors’ offices, and spread to public hearings in statehouses around the country. One of the main points of contention is the duration of antibiotic treatment — not only for acute Lyme but also for PTLD. The evidence to recommend a specific length of antibiotics treatment is scarce. Most physicians follow the two- to-four-week treatment the CDC recommends. Some studies funded by the National Institutes of Health did not show any benefit when patients used several months of antibiotics. However, there is anecdotal evidence from a few patients who improved after months of antibiotic treatment. The naysayers believe this is probably due to a placebo effect.
A reasonable approach to post-treatment Lyme disease

If you are being treated for PTLD, there is no magic bullet to treat this problem, but here are some important steps to consider:

    Choose a doctor you trust and who can work closely with you.
    If your doctor agrees to start antibiotics for several months, make sure you talk about the risks and cost, as this can be dangerous and expensive.
    Make sure not to rely solely on antibiotics. The evidence for a benefit from antibiotics is weak, and we rely mostly on physicians’ clinical experience and interest in the disease to design a personalized therapeutic plan. For some, a more holistic approach may be the way to go.
    If you try supplements, ask about their source and purity, as they are not FDA-regulated.
    Consider looking for services in medical school hospitals or clinics where they may have programs with ongoing research on how to diagnose and treat Lyme.

I know there are many people who have experiences to share. This dialogue is vital to spark an open conversation in the medical community. We have to understand and provide more comprehensive and better care to patients. I see the “Lyme wars” as an advance in health care. Patients affected by a disease got organized, and together with like-minded doctors rallied to shed light on what works best for them. It reminds me of the progress in treating HIV/AIDS. In the 1980s and ‘90s a similar community spurred a drive to fund more research. Because of that research, although we still do not have a cure for HIV/AIDS, it is no longer a death sentence. I am hoping in the years to come more research drives better answers for Lyme the same way it did for HIV. Shortly after our son, William, died of an accidental heroin overdose at age 24, I stumbled upon this unflinching reflection of addiction as a family disease: “Addiction isn’t a spectator sport. Eventually the entire family gets to play.” It is a disease that can yield many symptoms, many different forms of expression, not just the physical symptoms and silent longings suffered by the person whose system is under the thrall of the substances they’ve come to crave. It is not a disease family members get to choose. We may try to deny its existence, but even that “choice” is a symptom of the disease.

For family members another symptom of the disease can linger, sometimes tucked away until it suddenly manifests itself again, sometimes staring us down daily. I call it the “what ifs”: a repetitive and exhausting review of all the intersections where some action, imagined or real on a survivor’s part, might — I stress might — have led to a different outcome.

Since William’s death, my wife Margot and I have been introduced to many brave people who have lost family members to addiction. People whose lives, like ours, are scarred with the collateral consequences of addiction. People who, like us, ask themselves over and over, “What if?” In our case, what if William had not been released from inpatient rehab “against clinical advice” after a mere 10 days, because his insurers would not approve any further treatment? What if any one of four different hospital emergency rooms had recognized that William’s repeated overdoses made him a danger to himself and entertained the notion, indeed assumed the responsibility, of assessing him for a dual diagnosis? What if, when he arrived at a hospital of his own volition, with his bag packed (including two books, George Carlin’s When Will Jesus Bring the Pork Chops? and John Medina’s Brain Rules), his request for inpatient detoxification was considered medically necessary, rather than a denial of treatment four days before he fatally overdosed? What if, despondent, he hadn’t overdosed in a Starbucks bathroom within hours of being denied, then been treated and released from a hospital, all in less than a day’s time and without our knowledge? What if we’d happened to look into our living room where he was “watching TV” just a few minutes sooner, before I discovered him slumped over, a needle on the floor, in or about to be in cardiac arrest?

Artists and scientists use “What if?” to search for the truth in their work. For them too, the question that prompts the quest can be agonizing, as they struggle to employ their imagination in order prove a hypothesis or illuminate a story in the name of truth. Yet once their work is proven, or created, they are free to move on. Those of us afflicted with the “what ifs” of addiction find ourselves trapped in a repetitive cycle. The protective membrane in our imagination between health and disease, between discovery and repetition, is semi-permeable at best. Addiction drags imagination to the disease side of the membrane and locks us in.

I find myself inspired by the writer and lecturer Andrew Solomon when he says in his book Far from the Tree, “…we all have our darkness and the trick is making something exalted of it.” When the “what ifs” emerge from our dark places, as they invariably do, perhaps the most important thing we can do is to share them with others; to recall and then share the stories that prompted them, so that we can properly scrutinize the disease of addiction. Addiction thrives on the stigma composed in part of secrecy, shame, judgment, and darkness. Telling our stories brings healing light. What if we begin telling our stories more openly and more often? What if we use our stories to effect change? What if we strive toward the healing and the exalted? Many things improve with age; unfortunately, your skin is not one of them. Wrinkles, brown spots, and general dullness often start to creep in as the years tick by. To reverse these problems many women are turning to a skin serum. Serums are light, easily absorbed oil- or water-based liquids that you spread on your skin. They typically come in small bottles with a dropper, and you only need a few drops to treat your whole face.

A skin serum is not a moisturizer, like a lotion or cream, says Dr. Abigail Waldman, instructor of dermatology at Harvard Medical School. Rather, they are highly concentrated formulations that are designed to sink into the skin quickly, delivering an intensive dose of ingredients that can address common skin complaints. “I definitely recommend serums for anyone who is concerned about aging. It’s a really good way to get extra anti-aging effects, more than your typical moisturizer and sunscreen,” says Dr. Waldman.
How do you choose and use a skin serum?

Serums are typically applied to skin after cleansing but before moisturizing, says Dr. Maryam M. Asgari, associate professor in the department of dermatology at Harvard Medical School. Some serums have one main ingredient, while others, including those that target the signs of aging, are combination formulas. “I use and recommend serums that have a combination of vitamin C, vitamin E, and ferulic acid,” says Dr. Waldman. “There is good literature that shows that vitamin C in particular can prevent brown spots, reverse damage from ultraviolet rays, and stimulate the growth of new collagen.”

Other good skin serum options to target wrinkles are those with antioxidants including tea polyphenols and resveratrol. Retinol, which reduces inflammation, is another good option, as is niacinamide.

If you are looking to fight blotchiness and discoloration, look for formulas that can brighten and lighten dark patches, including kojic acid and glycolic acid. If your skin is dry, tight, and flaky, find a skin serum that contains vitamin E, niacinamide, and glycolic acid. Also look for ceramides, which are fatty molecules that help hold the skin together and keep moisture from escaping. Other good options are serums that contain hyaluronic acid, or those with collagen peptides, epidermal growth factors, or stem cells.
Are all skin serums created equal?

Not all serums work the same. How well they work depends on the active ingredients, the formulation, the vehicle, and the stability of the compound, says Dr. Asgari. The prices of serums vary from less than $20 to hundreds of dollars. “To be honest, I don’t think price makes a difference,” says Dr. Waldman. More important than price are the ingredients in the serum — so the best practice is to read labels to find the best formulation for your needs.
Caveats when using a skin serum

“Powerful ingredients can irritate sensitive skin,” says Dr. Asgari. “Always test a small area before you apply a skin serum widely.” And use caution when combining acid-containing serums with other products that also contain acids. For example, your skin may get irritated if you use a serum with vitamin C (which is acidic) and as well as a retinol cream, or if you use a retinol serum along with a prescription retinol cream.

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