Facts and ideas from anywhere

MARIJUANA, MENTAL ILLNESS, AND VIOLENCE

The January 2019 issue of Imprimis, Hillsdale College’s monthly publication, contained an edited speech by Alex Berenson. Mr. Berenson is a journalist who has been a business reporter, investigative reporter, Iraq War correspondent, and author of 11 novels and two nonfiction books, including Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence. This piece summarizes views expressed in the latter book.¹

Fueled by his wife’s suggestion to check out the theory that marijuana causes schizophrenia, Mr. Berenson delved into the marijuana problem by reading everything he could find on the topic and talking to every psychiatrist and brain scientist who would talk to him. He soon realized that in all of his years as a journalist, he had never seen a story where the gap between insider and outsider knowledge was so great or the stakes so high. With the stocks of cannabis companies soaring and politicians promoting legalization as a low-risk way to raise revenue and reduce crime, he had never heard the truth about marijuana, mental illness, and violence. He concluded that almost everything he had known about the health effects of cannabis, almost everything that advocates and the media had told him for generations, was wrong.

We have all been told that marijuana has many different medical uses. Marijuana and its active ingredient, delta-9-tetrahydrocannabinol or THC, the chemical in cannabis responsible for its psychoactive effects, have been shown to work only in a few narrow conditions. They are most commonly prescribed for pain relief, but they are rarely tested against other pain relief drugs, like ibuprofen. In July 2018, a large 4-year study of patients with chronic pain in Australia showed that cannabis use was associated with greater pain over time. We’ve been told that cannabis can stem opioid use. Like alcohol, marijuana is too weak as a painkiller to work for most people who truly need opiates, such as patients with a terminal cancer diagnosis. Even some cannabis advocates acknowledge that they have always viewed medical marijuana laws primarily as a way to protect recreational users.

As for the marijuana-reduces-opiate-use theory, it is based largely on a single article comparing overdose deaths by state before 2010 to the spread of medical marijuana laws—and the article’s finding is probably a result of simple geographic coincidence. The opiate epidemic began in Appalachia, and the first states to legalize medical marijuana were in the West. Since 2010, as both the epidemic and medical marijuana laws have spread nationally, the finding has vanished. The Western part of the USA has the most cannabis use, and it also has by far the worst problem with opioids.

Research on individual users—a better way to trace cause and effect than looking at aggregate state-level data—consistently shows that marijuana use leads to other drug use. Cannabis users migrate to opiates almost three times as frequently as noncannabis users.

Most of all, marijuana advocates have claimed that marijuana is not just safe for people with psychiatric problems, like depression, but is a potential treatment for these patients. On its website, the cannabis delivery service Eaze suggests that marijuana is good therapy for anxiety and depression (see Leafly, the largest cannabis website). Numerous peer-reviewed articles in top medical journals show that marijuana can cause or worsen severe mental illness, especially psychosis, the medical term for a break from reality. Teenagers who smoke marijuana regularly are about three times as likely to develop schizophrenia, the most devastating psychotic disorder, as those who do not.

After an exhaustive review, the National Academy of Medicine found in 2017 that “cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use, the greater the risk.” In addition, “regular cannabis use is likely to increase the risk for developing social anxiety disorder.”

Over the past decade, as legalization has spread, patterns of marijuana use—and the drug itself—have changed in dangerous ways. Legalization has not led to a huge increase in the casual use of the drug. About 15% of Americans used cannabis at least once in 2017, up from 10% in 2006. (By contrast, about 65% of Americans drank alcohol in 2017.) But the number of Americans who use cannabis heavily is soaring. In 2006, about 3 million Americans reported using cannabis at least 300 times a year, the standard for daily use. By 2017, that number had nearly tripled, to 8 million, approaching the 12 million Americans who drank alcohol every day. Put another way, one in 15 consume alcohol daily; about one in five marijuana users used cannabis that often.

Cannabis users today also are consuming a drug that is far more potent than ever before, as measured by the amount of THC it contains. Today, marijuana routinely contains 20% to 25% THC, thanks to sophisticated farming and cloning techniques—as well as to a demand by users for cannabis that produces a stronger high more quickly. In states where cannabis is legal, many users prefer extracts that are nearly pure THC!

These new patterns of use have caused problems with the drug to soar. In 2014, people who had diagnosable “cannabis use disorder,” the medical term for marijuana abuse or addiction, made up about 1.5% of Americans. But they accounted for 11% of all the psychosis cases in emergency rooms—90,000 cases, 250 a day, triple the number in 2006. In states like Colorado, emergency room physicians have become experts on dealing with cannabis-induced psychosis.

Cannabis advocates often argue that the drug cannot be neurotoxic, as studies suggest, because otherwise Western countries would have seen population-wide increases in psychosis alongside rising use. Accurately tracking psychosis cases is impossible in the USA. The government carefully tracks diseases like cancer with central registries, but no such registry exists for schizophrenia or other severe mental illnesses. Finland and Denmark track mental illness more comprehensively, and they show a significant increase in psychosis since 2000, following an increase in cannabis use. In September 2018, a large federal survey found a rise in serious mental illness in the USA as well, especially among young adults, the heaviest users of cannabis. According to this latter study, 7.5% of adults aged 18 to 25 met the criteria for serious mental illness in 2017, double the rate in 2008.

Advocates for people with mental illness do not like discussing the link between schizophrenia and crime. They fear that it will stigmatize people with the disease. In truth, psychosis is a shockingly high risk factor for violence. The best analysis came in an article in 2009 by Dr. Seena Fazel, an Oxford University psychiatrist and epidemiologist. She found that people with schizophrenia are five times as likely to commit violent crimes as healthy people and almost 20 times as likely to commit homicide. Although schizophrenia is rare, people with the disorder commit 6% to 9% of all murders. The marijuana–psychosis–violence connection is even stronger than these figures suggest. People with schizophrenia are only moderately more likely to become violent than healthy people when they are taking antipsychotic medicines and avoiding recreational drugs. When they use drugs, however, their risk of violence skyrockets.

Along with alcohol, the drug that psychotic patients use more than any other is cannabis. A study in 2010 found that 27% of people with schizophrenia had been diagnosed with cannabis use disorder. A Swiss study of 265 psychotic patients found that over a 3-year period, young men with psychosis who used cannabis had a 50% chance of becoming violent. That risk was four times higher than for those with psychosis who didn’t use cannabis. Cannabis fuels violence in psychotic people through its tendency to cause paranoia—something even cannabis advocates acknowledge that the drug can cause. The risk is so obvious that users joke about it and dispensaries advertise certain strains as less likely to induce paranoia. And for people with psychotic disorders, paranoia can fuel extreme violence. A 2007 article in the Medical Journal of Australia on 88 defendants who had committed homicide during psychotic episodes found that most believed they were in danger from the victim, and almost two-thirds reported misusing cannabis—more than alcohol and amphetamines combined.

The link between marijuana and violence does not appear to be limited to people with preexisting psychosis. Investigators have studied alcohol and violence for generations, proving that alcohol is a risk factor for domestic abuse, assault, and even murder. Far less work has been done on marijuana, in part because advocates have stigmatized anyone who raises the issue. But studies showing that marijuana use is a significant risk factor for violence have quietly piled up. Many were not even designed to catch the link, but they did, covering everything from bullying by high school students to fighting among vacationers. The first four states to legalize marijuana for recreational use were Colorado and Washington in 2014 and Alaska and Oregon in 2015. Combined, those four states had about 450 murders and 30,300 aggravated assaults in 2013. In 2017, they had almost 620 murders and 38,000 aggravated assaults—an increase of 37% for murders and 25% for aggravated assaults, far greater than the national increase.

Knowing how much of the increase is related to cannabis is impossible with researching every crime. But police reports, news stories, and arrest warrants suggest a close link in many cases. Cannabis is also associated with a disturbing number of child deaths from abuse and neglect—many more than with alcohol and more than with cocaine, methamphetamines, and opioids combined—according to reports from Texas, one of the few states to provide detailed information on drug use by perpetrators.

These crimes rarely receive more than local attention. Psychosis-induced violence takes particularly ugly forms and is frequently directed at helpless family members. The elite national media prefer to ignore the crimes as tabloid fodder. Even police departments, which see this violence up close, have been slow to recognize the trend, in part because the epidemic of opioid overdose deaths has overwhelmed them.

For centuries, people worldwide have understood that cannabis causes mental illness and violence. Hard data on the relation between marijuana and madness dates back 150 years to British asylum registers in India. Yet 20 years ago, the USA moved to encourage wider use of cannabis and opiates. In both cases, we decided that we could outsmart these drugs, that we could have their benefits without their costs. And in both cases, we were wrong! Opiates are riskier, and the overdose deaths have monopolized our focus. But soon enough the mental illness and violence that follow cannabis use will also be too widespread to ignore.

Whether to use cannabis, or any drug, is a personal decision. Whether it should be legal is a political issue. But its precise legal status is far less important than making sure that anyone who uses it is aware of its risks. Most cigarette smokers don’t die of lung cancer, but it’s widely known that it is the major cause of lung cancer. Not all who drink and drive have fatal accidents, but we have highlighted cases of those who do. We need equally unambiguous and well-funded advertising campaigns on the risks of cannabis. We are now in the worst of all worlds: marijuana is legal in some states, illegal in others, dangerously potent, and sold without warnings everywhere.

OPIOID NATION

Dr. Marcia Angell, former associate editor of The New England Journal of Medicine, summarized observations in four recent books having to do with the opioid epidemic.² The following comes from her review in The New York Review of Books.

The National Institute on Drug Abuse estimated that 72,000 Americans died from drug overdoses in 2017, 64,000 in 2016, and 52,000 in 2015. Most involved opioids. The term opioid is now used to include opiates, which are derivatives of the opium poppy, and opioids, which originally referred only to synthesized drugs that act in the same way opiates do. Opium, the sap from the poppy, has been used throughout the world for thousands of years to treat pain and dyspnea, to suppress cough and diarrhea, and, maybe most common, simply for its tranquilizing effect. The active ingredient of opium, morphine, was identified in 1806. Soon a variety of morphine tinctures became readily available without any social opprobrium, used in some accounts to combat the travails of Victorian women. Heroin, a stronger opiate made from morphine, entered the market later in the 19th century. It was not until the 20th century that synthetic or partially synthetic opioids including fentanyl, methadone, oxycodone (Percodan), hydrocodone (Vicodin), and hydromorphone (Dilaudid) were developed.

In 1996, a new form of oxycodone called OxyContin came on the market. Many blame the opioid epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated to be released more slowly and therefore last longer. The company claimed that the drug’s slow release would make it less addictive than ordinary oxycodone, because the initial euphoria—the high—would be muted. Based on this theory and little else, the Food and Drug Administration (FDA) permitted OxyContin to contain twice the usual dose of oxycodone. Like all opioids, however, OxyContin is addictive. Users soon found that they could crush the pills or dissolve the coating and then snort the drug like cocaine or inject it like heroin. Each pill would then become essentially a double dose of oxycodone.

OxyContin almost immediately became a blockbuster; that is, a prescription drug with annual sales of more than $1 billion. It was widely used, not just for those for whom the prescription was written but by their relatives and friends. The pills were also sold or stolen or otherwise diverted to street use. In addition, “pill-mills” sprang up where unethical physicians wrote innumerable prescriptions of OxyContin and refilled them automatically without ever seeing the patient.

Purdue Pharma and the Sackler family who founded it are hard to defend. By aggressively marketing OxyContin, even after they knew that it was being widely abused, the family became enormously wealthy. But the FDA was also guilty. It permitted OxyContin to be sold as a relatively nonaddictive opioid without good evidence to support that claim. OxyContin addiction grew into an epidemic. The epicenter was central Appalachia, and its victims were mainly white people in small, economically depressed, coal mining communities in southern West Virginia, parts of Kentucky, and Tennessee. In 2007, Purdue Pharma pled guilty to criminal charges of fraudulently marketing OxyContin and settled for $600 million in fines and penalties. The company’s fine was trivial compared to its profits from OxyContin.

OxyContin did not give rise to opioid addiction, although it jump-started the current epidemic. Heroin has been a common street drug ever since it was banned in 1924. Morphine has also been widely abused. Thus, taking OxyContin off the market would not end the epidemic. Most opioid deaths are caused not by OxyContin but by combinations of fentanyl, heroin, and cocaine, often brought in from China via Mexican cartels and frequently taken along with benzodiazepines (such as Valium or Xanax) and alcohol. These drugs are cheaper and stronger, particularly fentanyl, which was synthesized in 1960 and soon became widely used as an anesthetic and powerful painkiller. It is legally manufactured and highly effective when used appropriately, often for short medical procedures such as colonoscopies. The illicit production and street use is relatively new, but it is now the main cause of most opioid-related deaths.

The steady increase in opioid deaths after OxyContin came on the market has been supplanted by a much faster increase starting around 2013, when heroin and fentanyl use increased dramatically. We now have two epidemics: the overuse of prescription drugs and the much deadlier and now largely unrelated epidemic of street drugs.

Efforts to deal with the epidemic have been inadequate. Possession of illegal drugs (and legal drugs used illicitly) is still a federal crime, and prisons are full of people with that as their only crime. Many states, counties, and cities have now begun to regard opioid addiction as a public health issue, not a police issue. They are opening centers in which people who seek help are shifted to less powerful opioids like methadone and buprenorphine (Subutex), a method known as “medication-assisted” treatment. Naloxone (Narcan), the antidote for an opioid overdose, is now sold over the counter in almost all states. If used immediately, it can prevent an otherwise inevitable death from an overdose.

Most controversial are facilities called “safe injection sites” where drug users can come and use drugs without fear of arrest. The staff provides clean needles to reduce the risk of HIV and hepatitis C infections and is prepared to resuscitate addicts who overdose. This approach is called “harm reduction.” The problem is that addicts must still buy drugs illegally and it is almost impossible to know what is in them. The proposed solutions to this epidemic range from “lock them up” to “drug abuse is no less a disease than cancer or diabetes.”

Marcia Angell cautioned that opioids have a legitimate purpose and are enormously important. They treat severe pain, often when no other treatment is effective. Patients suffering from cancer are sometimes completely dependent on opioids for relief, as are some patients with other forms of severe pain. The awful opioid epidemic is still outweighed by alcohol deaths, which are also increasing. In 2016, when there were 64,000 deaths in the USA from the drug epidemic, there were 90,000 from alcohol (including accidents and homicides caused by inebriated people as well as direct effects, mainly cirrhosis of the liver). Cigarette smoking is estimated to cause 480,000 deaths per year. Alcohol and cigarettes have no medical or practical uses of any kind, yet we permit their use if regulated. In contrast, opioids do have medical uses.

PARK TREATMENT

In March 2018, I moved into a high-rise condominium in the Turtle Creek neighborhood of Dallas. Surrounding Turtle Creek are wonderful walking trails and park areas, and I found that taking long walks on the weekend is extremely refreshing and uplifting. Recently, I read a piece in Time magazine about the “nature prescriptions” of Dr. Robert Zarr, a pediatrician in Washington, DC³ He prescribes spending an hour each week outdoors, in the fresh air of a local park, whether playing tennis or exploring the soccer fields. Zarr wrote: “There’s a paradigm shift in the way we think about parks: not just as a place to recreate, but literally as a prescription, a place to improve your health.” Dr. Zarr writes up to 10 nature scripts per day. In 2017, he founded Park Rx America to make it easier for more health professionals to write park prescriptions for patients of all ages, particularly those who are obese, have mental health issues, or have chronic conditions like hypertension or diabetes mellitus.

Dr. Zarr is part of a growing movement to bring the outdoors into medicine. Nobody claims that nature will cure diseases on its own, but physicians are capitalizing on the mental and physical benefits of spending time in green spaces. What are the benefits of going outdoors?

• Relaxation. Studies have shown that spending time outdoors decreases levels of the hormone cortisol, lowers blood pressure, and reduces other markers of stress.

• Physical activity. Exercise is an important pillar of health, of course, and going outside encourages one to get moving, whether by hiking, biking, gardening, or strolling.

• Social support. Parks are inherently social places. Seeing and interacting with others guards against loneliness, a major public health threat.

• Mental health. Several investigators have shown that spending time in green spaces can lift one’s mood and reduce symptoms of depression and anxiety.

• Awe. Soaking in the arresting beauty of nature has been found to lower levels of inflammation in the body and spark feelings of generosity, perspective, and selflessness.

• Fresh air. Pollution is linked to several illnesses, so breathing clean air may reduce the risk of respiratory problems, cancer, and possibly heart disease.

ADULT-ONSET FOOD ALLERGIES

A recent study found that 11% of US adults—more than 26 million—have a food allergy, and about half developed the food allergy as adults.⁴ Whether food allergies among US adults are increasing is not clear. A true food allergy is when the body’s immune system mistakes a food as harmful, triggering the immune system to release immunoglobulin E (IgE). When someone with an allergy eats that food, the IgE antibodies trigger the immune system to release histamine, a chemical that causes symptoms such as hives, itching, and, in extreme cases, anaphylaxes. The cause of food allergies is unclear. Some investigators theorize that they could be related to the increasing use of antibiotics, rising rates of cesarean sections that affect the microbiome of babies, and, increasingly, sterile environments. All of these appear to change the good bacteria in the intestinal tract, which alters the immune system. About 8% of children have a food allergy. About 25% of children outgrow their food allergies by age 5, particularly those allergic to milk, eggs, and soy. The most common adult-onset allergy is shellfish, affecting about 3.5 million US adults, followed by milk, wheat, and nuts, each of which affects about 1 million adults. About twice as many women develop a food allergy as adults as men (7% vs 3%). Though a tenth of adults have a food allergy, about twice as many (19%) think they have a food allergy but do not report symptoms consistent with a diagnosable IgE-mediated allergy. Some adults who think they have a food allergy often suffer from other food-related conditions, such as lactose intolerance, oral allergy syndrome, eosinophilic esophagitis, or food protein–induced enterocolitis syndrome.

CANCER DEATHS

For most of the 20th century, cancer deaths rose, driven mainly by men dying from lung cancer.⁵ Since its peak in 1991, the death rate has steadily dropped (1.5% a year) through 2016, primarily because of long-running efforts to reduce smoking, as well as advances in detection and treatment of cancer at earlier stages. Cancer remains one of the leading causes of death among Americans, however. In 2019, an estimated 1.76 million new cases will be diagnosed and close to 607,000 cancer deaths will occur in the USA. Men die in the greatest numbers from lung, prostate gland, and colorectal cancers, and women die primarily from lung, breast, and colorectal cancers. In the last 25 years, men have had a 34% total decline in cancer mortality compared to a 24% decline for women, largely due to trends in smoking rates. The lung cancer incidence is declining twice as fast among men as women, which in part reflects the fact that women historically took up smoking in larger numbers in later decades and are slower to quit. Among adults <55 years, the incidence of colorectal cancer has continued to increase, almost 2% a year since the mid-1990s. Obesity might be a factor. The gap in cancer mortality between blacks and whites has narrowed, mainly due to a drop in cigarette smoking among black teenagers from the late 1970s to the early 1990s.

Incidence rates of melanoma and liver, thyroid, uterine, and pancreatic cancers also continue to rise. In both men and women, the incidence of liver cancer is increasing more rapidly than any other cancer. Possibly 71% of liver cancer cases can potentially be prevented through lifestyle changes, such as not smoking, increasing physical activity, losing weight, and preventing hepatitis B and C viruses. About 24% of liver cancer cases result from chronic hepatitis C infection, with a threefold rise in reported infections from 2010 to 2016 because of the opioid epidemic.

TATTOOS

In 2017, the dermal ink industry generated an estimated $1.6 billion in revenue.⁶ Over the next decade, the industry expects to continue to grow at an annual rate of about 8%. The expansion is attributed not only to the increasing popularity of tattoos but also to the fact that younger people, who are driving the trend, prefer expensive custom work over cheaper predesigned images, and those who get inked once tend to return for more. Not only has the customer base expanded, but per-customer profits also have increased, with millennials leading the pack. An estimated 47% of that group, which ranges in age from 18 to 35 years, has at least one tattoo; 37% have at least two, and 15% have five or more. In contrast, 36% of Generation X and 13% of baby boomers are inked.

The proliferation of the supposedly permanent markings has led to a second boom: tattoo removal. The American Academy of Dermatologic Surgery reported that 687,000 tattoos have been removed since 2010, a tiny fraction of all tattoos. The removal process is expensive. The state-of-the-art method uses lasers to break up ink with rapid pulses of light that reach temperatures as high as 1652°F. The Kirby-Desai Scale helps people estimate how many treatments might be necessary based on tattoo location, number of colors, skin type, and other information. Most are cleared in 3 to 12 sessions. The price per square inch per laser treatment ranges from $49 to $300. Thus, at $50 per square inch, removing a 3 × 5-in. tattoo requires eight laser treatments, with a cost of $5900. At $300 per square inch, the cost would be $36,000.

The FDA reports that tattoo artists use more than 50 different shades of ink, and none are approved for injection into the skin. Because the inks are intended for professional use, they are exempt from the mandatory ingredient labels required of cosmetics sold directly to consumers, and the Centers for Disease Control and Prevention cautions that they may be made from products, such as calligraphy ink, drawing ink, or printer ink, that were never intended for tattoos. Though the pigments are subject to premarket approval under the federal Food, Drug, and Cosmetic Act, the FDA has never exercised this authority.

The rate of complications appears to be low, although no government agency systematically tracks that. The FDA urges consumers and health care providers to report adverse reactions through its MedWatch system, and the agency does investigate problems.

The absence of federal oversight has left states and localities to grapple with regulations on their own. At least eight states specify that tattoo ink must be sterile, nontoxic, or unadulterated. Most states have rules regarding the tattooing of minors. Although infections are less likely in licensed parlors, fewer than half of the states require certification or licensing of tattooists or their establishments.

HISTORY OF EXERCISE

America’s number one New Year’s resolution is to get fit. Consequently, there is a predictable surge in gym memberships in January of each year, and by February memberships subside. According to Keith Blanchard, the business model of the $80 billion global health club industry depends on this annual triumph of hope over experience.⁷

Exercising is a modern indulgence. For early humans, fitness was a requirement if one wanted to stay alive. With civilization came regular physical training in the form of continually prepping for war. Ancient Greece’s original Olympics were nominally about games, but the military’s focus was clear: chariot racing, wrestling and boxing, throwing the javelin and the discus, and footraces run with armor and a shield. For nonsoldiers, work became less physically demanding as the centuries rolled on. Technological improvements gradually shifted the civilian workforce away from farming and blacksmithing and toward minimal physical activity.

From 1750 to 1950, the new leisure time, in the lucky parts of the world that could afford it, started to weigh heavily on the average person’s health. Physicians began stressing the value of exercise in combating diseases of decadence. Ernest Hemingway and Teddy Roosevelt stressed its role in proving one’s mettle. As Blanchard said, “Wrestlers and bare-knuckle boxers drew crowds; circus strongmen pulled train cars full of flappers with their teeth; … and college coeds deemed athletes the absolute dreamiest.”

By the 20th century, the publishing industry was busy extolling the benefits of working out to regular people. In the 1920s, Charles Atlas built an empire targeting “97-pound weakling” boys through ads in the back of comic books. He was succeeded as America’s buffest gym coach by Jack LaLanne, who created what may have been our first health club infomercial (“The Jack LaLanne Show”), which LaLanne produced from 1953 through the 1980s when a young Arnold Schwarzenegger took the baton.

In the 1960s to the 1980s, gyms were on the rise. In 1968, Kenneth Cooper introduced the benefits of aerobic exercise. About the same time, a widely popular book called Jogging introduced a New Zealand phenomenon to Americans. Entrepreneurs adapted early inventions, like the treadmill, an 1800s gargantuan paddlewheel designed to punish dozens of prisoners at once to generate power or grind grain (hence “mill”). Similarly, exercise bikes, around since at least 1796, became smaller and modernized, giving them relevance in a new world where their punishing monotony could blend seamlessly with attractions like TV. The gyms’ new machines, like the Nautilus, endorsed by football running backs and tennis stars, were built on a logarithmic spiral-shaped pulley wheel that provided variable resistance throughout a single exercise motion. Bowflex featured a similar variable resistance in the form of “power rods.” The two companies are now one.

From the 1990s to the present, Jane Fonda’s Workout Video (1982) was the first wildly popular exercise tape, but many others followed: Billy Blanks, Olivia Newton John, Richard Simmons, Tony Horton, and Suzanne Somers.

Today, home exercise equipment continues to proliferate in an ever more bewildering array. There are specialized rowing and skiing machines, and exercise bikes have flowered into spin machines. It is clear, however, that machines are not the answer; motivation is.

VENEZUELA’S MEDICAL CHAOS

Ryan Dube reported that nearly 2 million Venezuelans have fled their country since the late Hugo Chávez took office in 1999 and put his country on the path to socialism.⁸ The number has accelerated since President Nicolás Maduro took over in 2013, with businessmen, university professors, farmers, and oil workers abandoning a country ridden by authoritarian rule and protest. Venezuelans are flooding into neighboring Columbia and Brazil and to the Caribbean islands. In the USA, their asylum requests have surged.

The exodus of physicians is exacerbating the already serious strain on Venezuela’s public health system, which has been crippled by dilapidated hospitals and shortages of medical supplies. Figures released in May 2017 by the health ministry showed that maternal mortality increased 66% in 2016, and infant mortality, which rose 30% in 2016, is now higher in Venezuela than in war-torn Syria. Malaria and diphtheria rates are soaring amid shortages of insect repellents, vaccinations, and public health funding.

The Venezuelan Federation of Doctors estimates that about 16,000 doctors have left Venezuela in the last 12 years, moving as far away as Spain and Australia. In 2016, 1313 Venezuelan-educated physicians, more than any other foreign group, took a test to work in Chile’s public health system, up from just 16 in 2011. In 2016, 88% of medical students in their final year at four Venezuelan universities said that they hoped to emigrate after graduation. And the emigration of physicians from Venezuela continues to accelerate.

TELEMEDICINE

Eighty percent of mid-size and large US companies offered telemedicine services to their workers in 2018, up from 18% in 2014.⁹ Only 8% of eligible employees, however, used telemedicine at least once in 2017. The price is right. Walmart workers can now see a physician—a virtual visit—for only $4. The retail giant recently rolled back the $40 price on telemedicine, becoming the latest big company to nudge employees toward a high-tech way to get diagnosed and treated remotely. Although most patients still prefer to visit their physician face-to-face, the practice gains fans once the patient tries it. Stay tuned.

HUMAN ORGAN TRANSPLANTATION IN CHINA

According to Benedict Rogers, China does more transplants than any other country.¹⁰ The number of voluntary donors does not match the number of organ transplants done in the country, indicating that most organs are removed from involuntary donors. Death-row inmates cannot account for these discrepancies. China executes more people than the rest of the world combined but still only a few thousand a year. Chinese law requires prisoners sentenced to death to be executed within 7-days, not enough time to match their organs to patients and have them ready on demand, as is China’s practice. That discrepancy led investigators to conclude that many prisoners of conscience—Falun Gong members, Uighur Muslims, Tibetan Buddhists, and “underground” Christians—have been subjected to medical testing and their organs forcibly removed. Experts around the world have testified to China’s crimes of involuntary donors. Israel, Taiwan, and Spain have banned “organ tourism” to China. United Nations rapporteurs have called China to account for the sources of their donor organs but have received no response.

COSTS OF EYEGLASSES

I recently purchased new eyeglasses: the cost, $800! Why are eyeglasses so expensive? David Lazarus tried to answer that question.¹¹ The Vision Council, an optical industry trade group, estimates that about 75% of US adults use some sort of vision correction. About two-thirds of that number wear eyeglasses. That is roughly 126 million people. The average cost of a pair of frames is $231. The average cost of a pair of single-vision lenses is $112. Progressive, no-line lenses can run twice that amount. According to Lazarus, the true cost of a pair of acetate frames—three pieces of plastic and some bits of metal—is as low as $10. Lenses require precision work, but they are almost entirely made of plastic and almost all production is automated.

When we buy glasses, we are paying a markup that is enormous. The soaring eyeglass cost should be a part of the country’s overall health care debate; at least there should be some transparency about how much eyeglasses cost to manufacture. The Vision Council will not release any eyeglass cost numbers. The council does not want us to know that for years a single company, Luxottica, controlled much of the eyewear market. Its own licensed brands include Armani, Brooks Brothers, Burberry, Chanel, Coach, DKNY, Dolce & Gabbana, Michael Kors, Oakley, Oliver Peoples, Persol, Polo Ralph Lauren, Ray-Ban, Tiffany, Valentino, Vogue, and Versace. Italy’s Luxottica also runs EyeMed Vision Care, LensCrafters, Pearl Vision, Sears Optical, Sunglass Hut, and Target Optical.

In 2018, Luxottica merged with France’s Essilor, the world’s leading maker of prescription eyeglass lenses and contact lenses. Virtually all Transitions^® lenses are made by Essilor. The combined entity is called Essilor Luxottica. The new company will not give its costs. It does not want to explain why customers are paying 10 to 20 times more than what the frames and lenses cost to manufacture. Online retailers, whose prices can be much lower, make up just 4% of the total eyeglass market, according to Forbes.

The eyeglass makers argue that there have been numerous technological advances in the last 20 years. Nevertheless, with about 126 million American adults wearing prescription glasses and replacing them every few years, it does not take long for frame and lens makers to recover any costs of research and development. In contrast to the frames, the lenses are the “health care” component of vision correction and as such should be affordable to all.

CHANGING US DEMOGRAPHICS

In 2015, the Pew Research Center conducted an analysis of immigration to the US from 1965 to 2015.¹² That 50-year wave decreased the USA’s median age and changed the demographics such that by 2015 the US was 62% white, 18% Hispanic, 12% black, and 6% Asian. The total population in Texas in 2010 was just over 25 million and was 45% white, 38% Hispanic, 12% black, and 4% Asian. Among Texas’s three largest racial/ethnic groups (2017 figures), births per 1000 women were as follows: white, 1708; black, 1828; and Hispanic, 2136. A fertility rate of 2100 births per 1000 women is considered enough to replace the population.

PHOTOGRAPHY

Books published in the 19th century and, for the most part, in the first 50 years of the 20th century contained few photographs. Medical articles published before 1950 contained with few images, figures, or tables. In my career, I have spent hours most weeks involved in photographing the heart. Recently, Paul Lowe produced a book entitled A Chronology of Photography: A Cultural Timeline From Camera Obscura to Instagram.¹³ The book contains approximately 320 images to illustrate almost 200 years of photography. Lowe and his contributors detailed the medium’s swift progression from the purview of the scientists who invented it (noted astronomer John Herschel coined the term “photograph” in 1839, combining the Greek words for “light” and “drawing”) to its adoption by entrepreneurs who established thousands of photographic studios to meet the growing demand among members of the middle class for images of themselves, something previously available only to the wealthy. In the decade following its invention, photography rapidly established itself as the dominant form of recording the world, and its dominance has increased ever since, with an estimated 1.3 trillion images taken in 2017 alone.

Some artists used the medium as more than a simple recording device, producing images that can only be termed fine art. Louis Daguerre had been a painter and architect before inventing the photographic process that bears his name, and a haunting still life of objects in his studio is the earliest known example of a daguerreotype. The equipment for early noncommercial photography was generally within the means of only the well-to-do, and a surprising number of practitioners were women. The new craft was deemed as acceptable a pastime among ladies of British society as embroidery and watercolor painting had been for previous generations.

Continuing innovations through the 19th and 20th centuries made photography more and more a part of daily life. The invention of processes that allowed images to be reproduced in newspapers without first being engraved made illustrated journalism common. Kodak made its first camera intended for casual use by the middle class in 1888, and its introduction of the Brownie camera in 1900 made it possible for anyone to be a photographer. The advent of 35 mm rolls of film and interchangeable lenses for the compact camera, such as the Leica, made it possible to take photographs almost anywhere. The debut of Kodachrome in 1935 set a standard for color photography that would last until 2009, when, overtaken by digital cameras, Kodak announced that it would cease production of the film.

The last chapter in the book is titled “What Is a Photographer?” When anyone with a smartphone can snap and post an image on a worldwide platform, what rules do professionals have? Lowe wrote, “As the 21st century continues, and the number of images increases exponentially, what becomes increasingly important is not who took the photograph, but how it can be used and to what end.”

William Clifford Roberts, MD
February 15, 2019