Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Loneliness Can Be The Death Of Us

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A little over 100 years ago, a small band of Italians left Roseto Val Fortore, a village in the foothills of the Apennines, in hopes of a better life amid the slate quarries of eastern Pennsylvania.

Naming their new village Roseto, the group soon recreated the strong community ties they had nurtured in Italy. They lived in three-generation households, centered their lives on family and built their houses so close together that all it took to have in a neighborly chat was a walk to the front porch.

By the 1960s, Roseto stood out like a distinctly un-sore thumb, becoming a magnet for researchers. While Roseto shared the same water supply, doctors and hospital with nearby villages, the town had only 40 percent as many heart attack deaths.

At first, researchers thought the Rosetans might carry some special, protective genes. But this was not the case, for Rosetans who moved away — even to the nearby village of Bangor — lost whatever magic the town possessed against heart disease.

That magic, now known as “the Roseto effect,” is as simple as it is elusive in America today: Close ties to other people.

A growing body of data shows that closeness with other people has a strong protective effect against illness and death. And that the lack of such ties — social isolation — can kill just as surely as smoking, obesity or high blood pressure.

That is one of the conclusions of a new book, “Overcoming Loneliness in Everyday Life,” due out in June by a husband and wife team of McLean Hospital psychiatrists, Jacqueline Olds and Richard Schwartz, and journalist Harriet Webster.

Loneliness is no longer just a painful experience, but a “major public health problem,” says Schwartz, “and most psychiatrists haven’t registered the strength of the medical data on this.”

In 1950, only 10 percent of households consisted of just one person, according to census figures. By 1994, this number had soared to 24 percent. That means 12 percent of the adult population now lives alone.

And this trend is particularly strong among older people, who are more likely than ever before, and more likely than younger people, to live alone. While fewer than 10 percent of people aged 25 to 44 live alone, census data show, nearly a quarter of those 65 to 74 do, and 40 percent of people 75 and older.

While some people certainly maintain a high level of happiness — about three in 10, in fact, according to surveys by University of Chicago researchers cited in the May issue of Scientific American — others are clearly lonely. A 1990 Gallup poll found that more than 36 percent of Americans are lonely.

For many people, the worst part of loneliness is that it is often accompanied by shame. It is not okay in this culture to feel lonely, Olds and Schwartz write in their book, “because American culture prizes self-sufficiency above all else.”

“Our notion of success is being able to purchase what you need and not be obligated to anyone,” Schwartz explains in an interview.

“Yet in other cultures,” Olds adds, “people have always accepted leaning on each other as part of life.”

The mere fact of living alone, of course, does not mean a person is destined to be lonely, though it probably does increase the odds, notes Dr. Gene Cohen, director of the Center on Aging, Health and Humanities at George Washington University in Washington.

Nor should loneliness be confused with depression, he says, though both involve feelings of sadness. Loneliness is a state “you can pull out of,” says Cohen, “and you often maintain the motivation to get involved with other people.”

With depression, “you may lose the motivation to be involved,” he says, and while social support can help assuage depression, some people also need professional help, including “the talking therapies or the judicious use of medication.”

Certainly, the ability to spend time alone happily — creative solitude, if you will — is one of the great joys of life, and a hallmark of a mature personality.

But the evidence is now overwhelming in two directions: Social isolation — having few, meaningful interpersonal ties –can have severe medical consequences, and close ties with people can significantly increase health and longevity.

Consider:

– People who are isolated but healthy are twice as likely to die over a period of a decade or so as healthy people who are not isolated, according to a 1988 review of studies on 37,000 people in the United States, Finland and Sweden. Among adults of working age, the more-isolated men are one to four times more likely to die of all causes at any age than less-isolated men, and more-isolated women are one to three times more likely to die than less-isolated women, says sociologist James House, of the Survey Research Center at University of Michigan.

– Living alone after a heart attack significantly raises the risk of subsequent cardiac problems, according to a 1992 study of more than 1,000 people by Columbia University researchers published in the Journal of the American Medical Association.

– People with heart disease have a poorer chance of survival if they are unmarried and do not have a confidant than if they are married, have a confidant, or both, according to a study of 1,368 people by Duke University researchers in the same journal.

– Women with advanced breast cancer who join a support group live twice as long as those who do not, according to a study several years ago by Dr. David Spiegel, a Stanford University psychiatrist.

– Similarly, people with malignant melanoma who participate in group intervention live longer than those who do not, according to a 1993 study by Dr. Fawzy I. Fawzy, a UCLA psychiatrist.

– While chronic stress, such as taking care of a spouse with dementia, leads to marked declines in immune response, having a strong network of friends offsets this decline, according to studies by Ronald Glaser, an Ohio State University microbiologist, and his wife, Janice Kiecolt-Glaser, a psychiatrist.

“Primates, which we are, are a social species,” says Glaser. “We run in packs, in troops. Social interaction between individuals” is an important “buffer to the physiological changes that stress is inducing.”

And this may be particularly true for older people, whose immune systems decline with age.

“The research clearly shows that social isolation is a major health hazard for elderly people. Socially isolated elders have higher rates of physical and mental illness and even death. . .” said Karl Pillemer, director of the Applied Gerontology Research Institute at Cornell University, in an e-mail interview last week.

An older person who is isolated is also at increased risk of being abused, according to Pillemer’s studies, which show that older people who were abused had less contact with friends and family than those who were not, in some cases because the abuser forbad such contact.

Many Americans, young and old, turn to therapists, self-help groups and medications to combat isolation, but there may be a better way, and it’s not just seeking friends for friendship’s sake.

“The idea is that you need to be willing to enter into relationships of mutual obligation,” says Olds.

“The really naive notion of our time is that the way you make friends is just by being fascinated with someone, that you are drawn by pure attraction,” says Schwartz.

“But the fact is, people’s lives are so hectic that those purely fun relationships often don’t get sustained. It’s the relationships where people are really useful to each other that do get sustained, that deepen and that therefore fulfill people’s needs for longterm intimacy,” Olds adds.

If that has an old-fashioned ring to it, they say, so be it. After all, old wives’ tales often endure precisely because they do contain gems of hard-won wisdom.

Like this one: To have a friend is to be one

Winners

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Heaven knows that every one of the 38,500 official entrants (and even the 10,000 “bandits”) in today’s Boston Marathon should get some kind of a medal just for getting out there and doing what the rest of us can’t – or won’t.

But for many on the sidelines, it’s the athletes with handicaps – 106 in wheelchairs, 31 who are visually impaired and three with organ transplants this year – who elicit the biggest lumps in the throat.

We cheer them on with all our hearts, as well we should. But along with the cheers, there’s often a sense of surprise, maybe even shock.

There shouldn’t be, at least not anymore.

In recent years, athletes with disabilities have been competing ever more visibly in both mainstream and special events, burning up the track and the basketball courts, the ski slopes and the cycling paths, often pushing well beyond the limit of what many able-bodied folks would attempt.

This summer, for instance, after the traditional Olympic Games in Atlanta, 3,500 people from 127 countries will compete in the Paralympic Games for elite athletes with physical disabilities, including paraplegics and quadriplegics, people with cerebral palsy, amputees, blind athletes, and others.

And that’s just the beginning. There are games galore for people with all kinds of disabilities, including competitions for people who have had life-saving organ transplants.

So on this day when all hats are off to the raw power of mind and body, here are the stories of a few people who have become star athletes, despite the most overwhelming obstacles.

Mary Pierce, 49, cyclist, lung transplant recipient

Like 100,000 other Americans, Pierce was born with alpha-1 trypsin deficiency, which causes potentially fatal liver problems in infants and lung disease – emphysema – in adults.

“I was 30, just out of college. . .when I began to notice changes in lung function,” says Pierce, of St. Joseph, Mich. “I had shortness of breath with minimal exertion, I got frequent colds and lung infections.”

A smoker since age 16, she said she “watched little bits of my life disappear around me. I stopped skiing. I couldn’t play tennis. The last thing to go was my motorcycle . . I couldn’t close the face shield because I got so claustrophic.”

By her 40th birthday, her breathing problems had made eating so difficult that she had lost 50 pounds. She had only 17 percent of her lung function. When her genetic defect was finally diagnosed, Pierce began taking medication to replace the missing enzyme and supplemental, intravenous nutrition.

But by 46, she was in a wheelchair, tethered to an oxygen tank and so near death that she could no longer avoid the “scary” decision to have a double lung transplant.

Within hours of surgery, Pierce recalls with delight, her husband told her she looked “pink and rosy.” Two days later, she began working out on a stationary bike in her room.

She quickly gained weight and began spending all her time at the gym, lifting weights and working out. “For the first time in my life,” she exults, “I lived in a body that worked.”

She bought a fancy bike, and a year after her transplant she began cycling competitively. She hasn’t stopped since. Last year, Pierce was one of 700 athletes with transplants at the World Transplant Games in England. She won a gold medal.

This spring, if the Michigan snow ever melts, she’ll be back on the roads, training 25 miles a day for the US transplant games this summer in Salt Lake City.

“You have to be resilient,” she says. “Nobody has any promises in life. You have to be ready for everything. Just know life is going to change, and that you’re going to survive.”

Rene Kirby, 41, skier, gymnast, skateboarder born with spina bifida

Kirby, 41, skis on his hands because of a birth defect in which the spine doesn’t close completely around the cord, causing weakness or paralysis.

Kirby, a retired IBM “failure analyst” from Burlington, Vt., was born with such a severe defect that he never walked.

But he’s “done just about everything,” he says cheerfully – skateboarding, roller-blading, ice skating, canoeing, kayaking, tricycle riding, downhill skiing, gymnastics and handball.

“I’ve been an athlete all my life. It’s nothing new to me,” says Kirby. “I walk on my hands and if people don’t like it, it’s their problem. I just get around the way I want to.”

The only problem, he says, roaring with laughter, “is going to a place with a lot of miniskirts.” Women are disconcerted, he laughes, to see a guy looking up at them from ground level.

Until an injured shoulder forced his retirement, he rode a tricycle at work: “I’d fly down the corridors, I’d get that baby really whipping. I used to see people jump out of my way.” In high school, he was state gymnastics champ. Then he took up skiing, his hands jammed into size 12 boots and his legs either stuck out in front, dragging behind or up in the air.

He gets onto the chair lift by “standing” on the tails of his extra-long skis and falling back onto the chair. To get off, he says, “I just jump forward and land on my hands.”

Asked if he’s felt he’s had a disability, he scoffs, “Nah. . ..

“All these people who walk around on legs – how many times did they fall to learn it? So what? Yeah, you’re gonna fall. You’ve got to take the first step and get out there.”

Jean Driscoll, 29, wheelchair marathoner with spina bifida

Driscoll, who lives in Champagne, Ill. was born with spina bifida, though she was able to walk until she was 14. That year, she had five hip surgeries in an attempt to keep her hips aligned properly and spent the entire year in a body cast.

For a while afterwards, she walked with crutches, but began spending more time in a wheelchair. By the time she was 23, her knees gave out and she gave up walking for good.

It hardly slowed her down. In fact, she’d been recruited at 21 to play wheelchair basketball at the University of Illinois and soon began wheelchair racing as well.

She now trains 100 to 120 miles a week in her special, 17-pound aluminum wheelchair. Her shoulders are so powerful that, though she weighs just 110 pounds, she can bench press 200.

She’s won the Boston Marathon six times, and today is racing for her seventh straight victory.

“I am not a disabled athlete,” she says. “When you are actually competing, it’s not a disability thing, it’s an athletic event.”

Her motto is, “Dream big and work hard. . . .You have just as good a chance of doing what you want as anybody else.”

Joe Quintanilla, 19, marathon runner, visually impaired

“Being blind really hasn’t caused any real problems,” says Joe Quintanilla of Cambridge, who has been nearly blind since birth. “I’ve lived this way for a long time, so it’s nothing new.”

At Boston College where he is a sophomore, Quintanilla’s poor vision means he must study with books on tapes or have classmates read to him. He tape records his classes and takes his exams orally.

When he’s training, he runs with other athletes who give him verbal cues or guide hime with their elbows. He’s running today’s marathon, his fourth, with a friend, Stacey Clements, and hopes to run in the Paralympics as well.

“If you really want to do something, nothing should stop you,” he says. “Even if you can’t achieve it, you should give it everything you have and be proud of yourself.”

Linda Bolle, 33, marathoner, visually impaired

Linda Bolle of Reading was born with a genetic defect that left her partially blind since birth.

“My parents were protective because I was a girl, but not because I didn’t see as well as other kids,” says Bolle, a supervisor at Lotus Development Corp.

“They permitted me to go out and do what my friends were doing. They never treated me as though I had an impairment. That had a lot to do with how I thought of myself.”

Although Bolle has been running for 10 years, this is her first marathon, and she’ll be running with her husband Ned to give her verbal cues.

She rarely thinks of her disability. “It’s just part of who I am,” she says. “I don’t really know life any other way. . . You can achieve anything you set your mind to do.”

Larz Neilson, 49, skier, biker, amputee

Thirty-two years ago, Larz Neilson lost his left leg below the knee in a motor scooter accident when he was 18.

“I’ve been to college, I’ve done a lot of things,” says Neilson, who has indeed – including editing a newspaper in Wilmington, Mass., publishing a real estate magazine and managing a gift shop in Boothbay, Maine.

But skiing is “the most energizing thing I’ve ever done,” says Neilson, except, as his wife points out, for getting married three and a half years ago.

Through skiing, softball, bicycling and canoeing, Neilson has also met other athletes who “put demands on their prostheses and limb makers. Handicapped athletics has been driving a lot of wonderful improvements in prosthetics in the last dozen years.”

He speaks with pride of his new leg with its fancy suspension system. “I step in and it goes click, click, click,” he says. “I can actually run with this thing. For years and years, I was having to run like step-and-hop. I can now run step over step.”

Beyond good prosthetics, he says, the key is “to believe in yourself and try. Attitude is everything.”

To learn more

For more information about athletic programs for people with disabilities, call:

–  US Sports and Fitness Center for the Disabled, 617-581-7775.

–  US Association for Blind Athletes, 719-630-0422.

–  Handicapped Athletics Program of the MDC (Metropolitan District Commission), 617-727-9547 X450.

–  Wheelchair Sports USA, 719-574-1150.

–  Paralyzed Veterans of America, 1-800-424-8200 X752 or 508-660-1181.

–  Wheelchair Sports and Recreation Association, 617-773-7251.  – 1996 Paralympic Games, 404-588-1996.

–  Massachusetts Association for the Blind, 1-800-682-9200 or 617-738-5110.

–  Boston Self-Help Center 277-0080

–  New England Handicapped Sports Association, 1-800-628-4484

–  Transplant games and organ donation, 1-800-622-9010, organized by the National Kidney Foundation.

–  Alpha-1-antitrypsin deficiency, 1-800-4-alpha-1.

–  Community Boating on the Charles River, 617-523-1038.

 

A battle plan for surviving the repetitive strain wars

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Jeff Del Papa’s hands and forearms gave out five years ago, after 15 years of pounding keyboards as a computer programmer for a company in Wilmington.

Today, Del Papa, a 38-year-old Watertown man who once played medieval muscial instruments and opened jars with a flick of the wrist, is back working as a programmer, only now he has to dictate every thought into a voice-activated computer.

It recognizes 50,000 words — provided Del Papa puts complete pauses between words. . .so . .that. . .he. . .ends. . .up. . . speaking. . .like. . . this. Naturally, this drives anyone within earshot nuts in 15 minutes, he says, and it means his e-mail is about as private as a TV news broadcast.

And while Del Papa’s hands no longer ache at the end of the day, his voice sometimes does, “because all of a sudden you’re talking all day.”

Beth Baron, too, is a casualty of the repetitive strain wars. Baron, 25, of Somerville, was typing away as a secretary at Children’s Hospital two years ago when her forearms suddenly felt too heavy to move and her wrists began to tingle.

Within three weeks, she went “from being totally fine to having to dial the phone with my feet,” she says. “It hurt to brush my teeth, to wipe my own behind, to do my laundry.”

Del Papa and Baron are among the walking wounded, the 332,000 Americans whose work has left a trail of injured fingers, hands, wrists, forearms, shoulders, necks and backs, according to 1994 Bureau of Labor Statistics.

Their troubles go by many names — cumulative trauma disorder, work-related musculo-skeletal disorder of the upper extremities, RSI or repetitive strain injury, carpal tunnel syndrome, tendonitis, tension neck syndrome, thoracic outlet syndrome — even tennis or golf elbow (epicondylitis). Sad to say, you can also get the last two by typing, not just by swatting at balls for fun.

Whatever you call it, the number of people with such injuries today is more than 10 times higher than in 1982, says Dr. Lawrence Fine, director of the division of surveillance, hazard evaluation and field studies at NIOSH, the National Institute for Occupational Safety and Health.

To be sure, many of these cases probably involve just greater recognition and reporting of injuries, says Fine.

But while many doctors, workers and even corporations now take RSI more seriously — and some companies aggressively adapt work stations to prevent such injuries — there is still resistance in some quarters to the mere idea that a person can get hurt just by typing or other repetitive work.

This is partly because some RSI diagnoses are based on a doctor’s clinical judgment, not objective tests. And partly, because of looseness in the medical definitions themselves.

Last July, for instance, a review article in the Journal of Hand Surgery concluded that not one of 52 relevant studies had established a true cause-and-effect relationship between work and well-defined medical conditions, partly because the criteria for accurate diagnosis are so fuzzy and overlapping.

But others, among them Hilary Marcus, co-program director of the Massachusetts Coalition on New Office Technology, an advocacy group, insist that the increase in RSI cases — probably spurred by growing computer use at home and at work — is real.

So is the toll, she says, in both human and economic terms.

At one recent meeting of her group, grad students who had planned on long careers in computers spoke, sometimes tearfully, of injuries that now threaten their dreams and livelihoods.

It costs $17,582 on average for each worker’s compensation claim for repetitive trauma disorder, including carpal tunnel syndrome, says Letitia Davis, director of occupational health surveillance at Department of Public Health.

That, not surprisingly, scares the you-know-what out of Congress and Big Business, which have teamed up to stomp out efforts by the Occupational Safety and Health Administration to establish workplace standards to prevent such problems.

Corporate lobbying has been so intense that OSHA can’t even get its new standards “out the door,” says spokeswoman Cheryl Byrne, and won’t until “hell freezes over.” (The good news, is that you can get the standards, which detail methods of prevention and ways to track injuries, through the Internet.)

While injuries vary with the type of motion a worker does — punching data into a computer is different from stabbing beef 20,000 times a day in a packing house — the biomechanics are similar.

When you type, for instance, you use muscles that are attached to bones by tendons, which slide around in tubes called synovial sheaths. Repetition of this motion can cause inflammation, says Dr. Rose Goldman, director of occupational and environmental medicine at Cambridge Hospital.

And if inflammation or blocked blood flow occur in a tiny space like the carpal tunnel — the passage in the wrist made of bones and a ligament through which tendons and a nerve pass — the result can be nerve compression, which leads to tingling, numbness and pain.

There are two ways to attack this — by preventing it in the first place or treating it later. Prevention wins hands down.

Sometimes, all that takes is more work breaks. One NIOSH study showed that workers are just as productive and have fewer symptoms if they take a 5-minute break every hour instead of a 15-minute break every few hours.

But prevention usually involves ergononics, too, the science of fitting the workplace to the worker, not vice versa.

For people who bang away at computers all day, this means typing with wrists in “neutral” position, that is, with your hands neither flexed up nor drooping down, and with wrists not angled either left or right, says Bryan Buchholz , an ergonomist at the University of Massachusetts at Lowell.

Your chair and keyboard height should also be adjusted so you can type with your feet on the floor — or on a footrest — with about a 90 degree angle at your knees, hips and elbows. Pull-out keyboard trays and adjustable chairs may help achieve this.

The key “is to keep the keyboard low enough that you can relax your shoulders,” adds Dr. David Rempel, director of the ergonomics lab at the University of California in San Francisco. And if you talk on the phone while typing a headset is essential, ergonomists say, if you’re prone to neck spasms.

Beyond that, though, the gurus disagree.

Fine, for instance, is a firm believer in resting the elbows on padded arm rests to prevent neck spasms while you type.

Dr. Emil Pascarelli, professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York, advises just the opposite. In fact, he says, “You’re probably better off not having arm rests. The problem is you can’t adjust the height of the arm rests, and if your shoulders are too high you’ll get neck and shoulder pain.”

Wrist rests are another bone of contention. Some people swear by them, but Pascarelli says they “transfer all the activity of keystrokes to the much more vulnerable forearm muscles.”

“If you must use a wrist rest,” adds Rempel, “don’t use it while you’re typing, but only while you’re resting.”

Keyboards, too, are a subject of debate. Some ergonomists advocate flat keyboards, not those that slope up toward the back. Others advocate split keyboards or tent-like keyboards, but these are too new to have been fully evaluated.

Generally, the pros agree that if you use a mouse or other pointing device, you should keep it near the keyboard, not grip it too hard and not “drag” it too much. But they disagree on whether clickable mice or track balls are easier on the body.

If you think you already have RSI, your best ally may be common sense. With carpal tunnel syndrome, for instance, rest, ice, anti-inflammatory drugs and cortisone shots may help.

Some self-diagnosed sufferers also try wrist splints, which may help. But if you try to type with them on or leave them on too long, you may make things worse, specialists say.

Some people also get relief from massage and acupuncture, but for many, specialist say, physical therapy helps the most.

With physical therapy, the goal is to “teach people how to gently stretch and strengthen” muscles in the forearm, neck and shoulder blades, says Kathi Fairbend, a Weston therapist.

And if all this fails, surgery may be the answer.

In carpal tunnel surgery, the goal is to “release” — that is, slice — the transverse carpal ligament on the “roof” of the tunnel so that pressure inside the tunnel is diminished.

This used to mean a two-inch incision from the palm to the wrist, says Dr. W.P. Andrew Lee, a hand surgeon at Massachusetts General Hospital. Recently, doctors have turned to endoscopic surgery, which involves smaller incisions and tiny TV cameras, and Lee and a colleague have now devised an operation to combine the best of these two techniques.

But it makes no sense to go through surgery — or even less invasive remedies — then go back to the same old, work station.

Sooner or later, you have to fix your work station so you don’t get hurt, which may mean getting political.

At least, that’s how Beth Baron sees it. “You have to act up,” she says.”Fight for your health. Fight for your rights.”

SIDEBAR 1

To learn more about RSI

For more information, call:

  • The Massachusetts Coalition on New Office Technology, 617-776-2777 begin_of_the_skype_highlighting              617-776-2777      end_of_the_skype_highlighting.
  • The Massachusetts Department of Public Health, Occupational Health Surveillance Program, 624-5624.
  • The National Institute for Occupational Safety and Health, 1-800-35-NIOSH begin_of_the_skype_highlighting              1-800-35-NIOSH      end_of_the_skype_highlighting, or 1-800-356-4674 begin_of_the_skype_highlighting              1-800-356-4674      end_of_the_skype_highlighting.
  • You might also read:
  • “Repetitive Strain Injury,” by Dr. Emil Pascarelli, published by John Wiley & Sons, Inc., New York.

You can also get information on the Internet at: http://www.princeton.edu/uhs/hi_ergonomics.html

or, for both the OSHA standards and proposed California standards at: http://www.tifaq.com/ergonomics/standards.html

SIDEBAR 2

YOU COULD HAVE RSI IF YOU:

  • Do things with your non-dominant hand that used to be easier with your dominant hand (dialing the telephone or punching your codes into the automatic teller machine at the bank with your left hand when you are right-handed, or vice versa).
  • Use your forearm, feet, or shoulder, instead of your hand, to push open doors, or find yourself shaking out your hands because they have gone numb.
  • Avoid wearing or buying certain kinds of clothing because it is too difficult to put them on.
  • Keep dropping things.
  • Find you can’t peel or chop food.
  • Experience trouble tying ties, buttoning collar buttons, hooking bras or putting on jewelry.
  • Have problems with keys or brushing teeth.
  • Feel overly protective of your hands (won’t to shake hands, for instance.).
  • Don’t hang on to the handrail, subway strap, or bus pole with the hand you usually use.
  • Have difficulty holding a book or newspaper.

Source: “Repetitive Strain Injury: A Complete User’s Guide” by Emil Pascarelli, MD and Deborah Quilter.

Trying everything, more and more cancer patients seek out ancient Chinese remedies to augment modern medicine

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For Ingrid Schorr, 36, an actor and writer who lives in Arlington, the bomb dropped last September: a totally unexpected diagnosis of breast cancer.

The diagnosis was traumatic enough, she says, but she also felt “desperate and sad” about having to undergo chemotherapy. She knew it would leave her weak and drained.

Her instincts were clear. She agreed to fight cancer with the harsh tools of Western medicine, the so-called “slash, burn and poison” approach of surgery, radiation and chemo.

But she also vowed to try to protect her body against that onslaught with what she hoped would be the gentler, more supportive tools of ancient herbs and modern nutrition as well.

And she didn’t want some do-it-yourself, East-meets-West patchwork of ideas culled from books, friends and herbalists who didn’t consult with oncologists. What she wanted, she says, was “a complete program of nutritional support and detoxification with herbs, and I wanted it from an oncologist.”

That proved a tall order, at least in this medical mecca.

So Schorr commutes monthly to Evanston, Ill., where she sees Dr. Keith Block, an internist who has put together a staff of oncologists, herbal chemists, dieticians and others who offer a combined program of chemotherapy, herbs, diet, psychological support, exercise and stress management.

Schorr may be unusual in the lengths to which she went to find a good blend of Eastern and Western medicine. But her inclination to augment – not replace – Western medicine with reputable alternatives is anything but unusual.

Cancer patients today, like AIDS patients a decade ago, are pushing outside the traditional frontiers of medicine, demanding that doctors take seriously their desire to combine Western medicine with other remedies, especially medicinal herbs used for millenia in China.

To be sure, even Block warns that there is more art than science in blending of the two traditions.

“There simply haven’t been enough carefully-controlled human studies to know how much good many of these traditional herbs can do,” he says. “But most of evidence to date, which is admittedly anecdotal, suggests there is little to no harm in herbs prescribed by practitioners who know what they’re doing.”

Good, bad or indifferent, herbs are clearly in demand.

“In the past, doctors would have tried to discourage patients from using anything alternative while undergoing cancer treatment. But today, you don’t see discouragement. You see some indifference and some interest,” says Alexandra Todd, a Suffolk University medical sociologist. That’s “because the public is doing it, not because the medical profession wants to.”

Indeed, many cancer patients do not tell their oncologists when they take herbs on the side, though they should. But “the more you ask, the more you find out that people do it,” adds Dr. Karen Krag, an oncologist at the Dana Farber Cancer Institute. “There’s more of it out there than oncologists would like to believe.”

And although Americans don’t equal the Germans, the leaders among Western nations in using and studying herbs, we now spend $ 2 billion on them yearly, and the market is growing 20 to 30 percent a year, says Mark Blumenthal, executive director of the American Botanical Council, a nonprofit research group.

“Business is booming,” adds acupuncturist-herbalist Michael Broffman of the Pine Street Chinese Benevolent Association in San Anselmo, Calif.

“When we first came to Marin County in 1983, there were only three of us practicing Chinese medicine. Now there are 100 in this county alone, and about 6,000 nationwide,” says Broffman, a leader in the art of trying to tailor herb use to the various types and stages of standard chemotherapy.

It is no easy task.

There are dozens of types of cancers, thousands of herbs and thousands upon thousands of herbal combinations. Patients also vary in gender, age, stage of disease and susceptibility to the effects – good and bad – of herbs. And, practitioners say, an herb that seems to work at one stage – such as in the middle of chemotherapy – may be useless when the patient is in remission.

For example, one chemotherapy regimen often used for breast cancer is CMF – cytoxan, methotrexate and 5-fluorouracil. To go with this regimen, Broffman often uses herbs like astragalus and a Japanese formula called JT-48, JTT or Juzentaihoto.

But that’s just the beginning. Because CMF is given in 21-day cycles, some herbs are given on days 1 through 4, in hopes they will enhance circulation and boost the effects of chemo. Others are given on days 5 through 10, the idea being to clean up dead cells, and others on days 11 through 21, to build strength and immunity.

For other cancers, the recommended remedies are different. For non-Hodgkins’ lymphoma, Block uses the Chinese herb Dan Shen, also called red-rooted sage or salvia miltiorrhizaCQ, citing research suggesting that it can boost the remission rate of standard chemotherapy.

Because choosing the combination and timing of herbs is complicated – and because herbs can be toxic – herbalists stress that you should not fool around with self-medication. Chances are you won’t know what you’re doing.

The trouble is, you can’t be sure your herbalist knows, either.

“There is no quality control for herbalists,” says Blumenthal of the botanical council, though many herbalists are also acupuncturists, who often take training in herbal medicine.

Last year, the National Commission for the Certification of Acupuncture, which administers the national exam for acupuncturists, developed a separate exam in Chinese herbal medicine. Increasingly, many states, including Massachusetts, are beginning to demand that acupuncturusts show proof of training in herbs if they use herbs in their practice.

But the issue of training raises a deeper question: How solid is the research on herbal medicine to start with?

“I do believe that empirical observation by astute Chinese healers has identified active compounds over the past 3,000 years,” says Dr. Jerome Groopman, chief of hematology and oncology at Deaconess hospital.

But Groopman worries that sometimes “neither the herbalists nor the physicians really know what’s in these compounds.”

Beyond the question of what’s really in those funny little packages of twigs, dried flowers and curly, brown things is the question of research standards.

“Clinical trials in China are frequently not randomized controlled clinical trials,” warns Michael Lerner in his cautious book, “Choices in Healing.”

“And even when they are,” he writes, “the methodology is often suspect by Western scientific standards.”

There is quality control for herbs themselves, says Blumenthal, but it’s “variable from one company to another.”

So far, the US Food and Drug Administration has stayed on the sidelines. Legally, the FDA says, herbs are classed as dietary supplements and do not need its approval before they hit the market. Once a product is marketed, however, the FDA can have it removed if evidence accumulates that it is is dangerous.

All this, of course, leaves patients like Ingrid Schorr fending for themselves and eager for physicians like Dr. Keith Block.

“I get more than 50 calls a day from people looking for doctors who do what we do,” says Block, vice president the American Cancer Society chapter in Chicago and medical director of the cancer program at Edgewater Medical Center, a hospital affiliated with the University of Illinois School of Medicine. “As far as we know, we’re the only place in the country trying to put it all together, to combine the best of both worlds.”

Based on his early data – presented at a conference in 1994 and published in the proceedings of that meeting – Block thinks his individualized program “buys patients better odds.”

Ingrid Schorr hopes so, too, and so far things look good. Despite all the chemo, she has not lost her hair or her monthly periods. She also has a good appetite and has had little nausea.

Of even greater importance, she says, is her peace of mind.

“The main benefit I’ve had from finding a doctor who could put it all together for me is that I don’t feel so scrambled,” she says. “I was trying to do it all myself before and that was making me crazy.”

1 If you are considering herbs

  • If you want to take herbs while in the care of a mainstream doctor, there are several things you can do to bridge the gap between East and West.
  • The first is to get a list – in your own language – of all the herbs you are taking or that have been recommended. Give this list to your doctor and ask if he or she recognizes any of the herbs and knows of any ill effects.
  • You might also ask your doctor to keep your list on file and compare your experience on herbs with that of other patients. This may not help you directly, but it can lead to the slow accumulation of anecdotal evidence that, with further research, can become genuine science.
  • This approach has already helped boost knowledge of alternative remedies for AIDS, says Dr. Calvin Cohen, research director for the Brookline-based Community Research Initiative. Through CRI, 700 Boston-area patients with AIDS or HIV have joined a Canadian-American study of 15,000 patients aimed at keeping track of how patients fare on alternative treatments.
  • “This is not a prospective study, but it is a first step,” he says. “Unless we start to acknowledge these anecdotes, people get cynical. They think doctors don’t care.”

 2 Licensing herbalists

  • At the moment, there is no licensing of herbalists in Massachusetts, which means that anyone can hang up a shingle and hand out herbs.
  • But there are ways to protect yourself, and the best is probably to find a licensed acupunturist who has been trained in using herbs, as many have. Acupuncuturists are licensed – by the committee on acupuncture of the state Board of Registration in Medicine.
  • Beginning in January 1998, acupuncturists who use herbs will have to submit evidence that they have been trained in herb use in a nationally accredited program in acupuncture and Oriental medicine, or an equivalent state-approved program.
  • To learn if your acupuncturist is licensed and is trained in herbs, call 727-3086 ext. 363 on Wednesdays, 2-4 p.m., and Thursdays and Fridays, 9 a.m.-4 p.m..

3 For more information

For more information, you might read:

  • “Choices in Healing,” by Michael Lerner; MIT Press, Cambridge.
  • “Double Vision,” by Alexandra Todd; University Press of New England, Hanover, N.H.
  • “Herbs of Choice: The therapeutic use of phytomedicinals,” by Varro E. Tyler; The Haworth Press, Inc., Binghamton, N.Y.
  • “HerbalGram,” a quarterly journal of the American Botanical Council. For a ($ 25) year’s subscription, send name, address and check or credit card number to P.O. Box 201660, Austin, Tex. 78720.

For general information on alternative therapies, call:

  • Commonweal, a research and environmental research institute in Bolinas, California, 415-868-0970.

For information on finding herbalists, call:

  • National Holistic Health Directory & Resource Guide, 1995-1996. No referrals by phone, but guide lists practitioners by specialty and region. Call 800-782-7006 for the $ 5.95 guide. The guide is also available at newstands and online at: http://www.spdcc.com/home/newage
  • Herbal treatments are available through the teaching clinic of New England School of Acupuncture, 617-926-4271.

All vision problems are not equal

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After 33 years in the rough and tumble of Cambridge politics, including several stints as mayor, Walter Sullivan, 73, has developed a new — albeit unwanted — preoccupation during retirement: eye troubles.

In fact, there are four major vision problems that often plague older people — cataracts, glaucoma, macular degeneration and diabetic retinopathy — and Sullivan has them all.

His first brush with blindness “scared the hell out of me,” he said last week by phone from Florida. “I was walking along the Charles River at 6 a.m. one day when I went blind in both eyes briefly. . . I didn’t know what the heck was happening. I thought my sight was gone.”

It wasn’t. In fact, by the time Sullivan walked home — very slowly — hisvision had returned as mysteriously as it had disappeared, a phenomenon his doctors still can’t explain, despite his multiple eye problems.

With four different diseases, of course, Sullivan’s case is unusually dramatic. But the fact is that, for all of us, the odds of having eye problems — from the merely annoying to the sight-threatening — increase sharply with age.

People 65 and older constitute only 12 percent of the population but account for more than 50 percent of all cases of blindness, according to the American Academy of Ophthalmology. By age 65, in fact, one in every three people has some form of vision-limiting eye disease.

And with the aging of Baby Boomers, now fumbling with bifocals and trying to read with arms that are suddenly too short, the number of older people with eye problems will soar to more than 66 million, according to Dr. Carl Kupfer, director of the National Eye Institute.

To be sure, some of the problems of aging eyes are nearly universal — and little worse than bad bifocal jokes.

At midlife, almost everybody finds it harder to read or do close work, to see at night, to adjust to sudden changes in illumination and to judge the speed of moving objects, says James Fozard, associate scientific director of the Baltimore Longitudinal Study of Aging, one of the longest-running and most detailed studies of the biology of aging.

One reason is that as we age, the pupil, the black part of the eye, no longer expands as readily in dim light. That means, among other things, that the older you get, the more crucial it is to have good light for reading and close work.

Aging also affects light-sensing cells called rods and cones in the retina, the tissue in the back of the eye. Cones are sensitive to color and bright illumination like daylight; rods are sensitive to movement and dim light.

With age, it takes longer for the rods to activate, which means, Fozard notes wryly, that it takes you longer at 60 to find a seat in a darkened movie theater than it did at 15.

It’s also normal to find glare more troublesome as you get older and to need starker contrast — very dark letters on a very white page — to read well.

But the most obvious normal change is presbyopia, the decreased ability to focus close-up because of changes in elasticity of the lens and in the eye’s focusing muscles. This ability peaks at age 12 — and, sad to say, goes downhill from there.

At some point between 38 and 50, we find “our arms are not long enough to read the phone book. This is absolutely inevitable,” says Dr. Edward Murphy, director of the general eye service at the Massachusetts Eye and Ear Infirmary.

Even people who’ve been nearsighted all their lives aren’t immune from presbyopia. For them, it means taking off glasses or contacts to see up close.

One solution is to wear bifocals with clear glass on the bottom and prescription lenses on top. Another is to adjust contact lenses so one eye sees well at a distance, the other, close-up.

But these annoyances “pale beside the serious, sight-threatening eye diseases of later life such as cataracts, glaucoma, macular degeneration and diabetic retinoapthy,” says Tony Cavallerano, director of the New England Eye Institute.

“All these diseases develop slowly and insidiously, which means early detection through regular eye exams is crucial,” adds Dr. Carmen Puliafito, director of the New England Eye Center and chairman of ophthalmology of Tufts University School of Medicine.

A cataract is a clouding of the lens caused by the buildup of yellow and brown pigments. Eventually, this clouding can become so severe that light cannot pass through.

So far, drugs have proved ineffective against cataracts, but surgery often works extremely well, says Puliafito. In the surgery, performed 1 million times a year in America, doctors make a tiny incision at the edge of the cornea, then use high-frequency ultrasound to break the lens into millions of pieces that can be sucked out through a tube.

Once the old lens is gone, a lens of acrylic or silicone is slipped in. ”The patient goes back to normal activities the next day and vision gets better in a few weeks,” he says.

Glaucoma, too, is an insidious problem.

In a normal eye, there is a slow, constant flow of fluid from the middle of the eye to the bloodstream though a network of drainage cells. In glaucoma, which affects about 2 million Americans, this drainage system becomes blocked, leading to a buildup of pressure inside the eyeball. Untreated, the pressure can damage the optic nerve and eventually cause blindness.

Often, there is no pain or other symptoms, which unfortunately means glaucoma can go undetected until some damage is done.

Once glaucoma is detected, further damage can be prevented with eyedrops containing beta-blockers (the same kind of drugs used to control bloodpressure) to improve outflow of fluid, or with drops such as Trusopt, which contain drugs that decrease the production of fluid.

If drugs don’t work, laser surgery often does. In a procedure that takes about 10 minutes, a laser beam is used to create tiny holes to improve drainage. If this fails, a last resort is non-laser surgery to create a larger drainage channel.

The leading cause of legal blindness in older people is age-related macular degeneration, which strikes about 500,000 people a year. It develops when something, probably dangerous oxygen molecules called free radicals or the buildup of fatty deposits, damages the macula, a tiny spot in the center of the retina.

Typically, it does not affect peripheral vision, but macular degeneration, which often affects both eyes, makes it harder to read, drive and recognize faces. Some controversial research suggests it may be prevented with anti- oxidant vitamins and minerals such as vitamin E and beta-carotene, selenium and zinc.

Once you get it, there is little doctors can do, although magnifying devices and computer-enhanced TV projections may help focus images on healthy cells around the macula.

On the other hand, if the degeneration is complicated by new blood vessels growing underneath the retina and by leakage of fluid from these vessels into the macula, there is a solution: once again, laser surgery, which can shut down the new vessels.

Leaky blood vessels are also the culprit in diabetic retinopathy, a major problem for millions of older Americans with diabetes. In diabetic retinopathy, blood vessels grow into the retina itself, where substances leaking from the vessels can cause swelling. Blood may also leak into the rest of the eye, blocking transmission of light.

In many cases, says Puliafito, laser surgery helps by stimulating the eye to absorb the fluid and by getting rid of abnormal blood vessels.

Walter Sullivan, the veteran of three surgeries at the New England Eye Center, can now see well enough to drive, walk, read and lead a normal life. He counts himself a lucky man.

“I’ve had great results,” he says. But it would have been better to have caught his problems even earlier.

His advice is simple: “Keep getting your eyes checked.”

SIDEBARTO LEARN MORE

 

– New England Eye Center at New England Medical Center, 1-800-231-3316 or 617-636-4600.

– Massachusetts Eye and Ear Infimary, 617-573-4199.

– New England Eye Institute, 617-262-2020. The institute also runs a mobile van for outreach toolder people, at 617-236-6317.

– National Eye Care Project, 1-800-222-EYES (1-800-222-3937). If you’re 65 or older, this service will help you find an ophthalmologist who will do an exam free if you have no insurance, or who will waive the co-pay or deductible if you have insurance, including Medicare and Medicaid.

– American Foundation for the Blind, 1-800-232-5463, for referrals to a low-vision specialist.

– Massachusetts Commission for the Blind, 617-727-5550 or 1-800-392-6450, if you are legally blind (10 percent vision or less). If you use a telecommunications device for the deaf, call 1-800-392-6556.

– Vision Foundation Inc., 617-926-4232 or 1-800-852-3029 (Massachusetts residents only).

– Prevent Blindness America, 617-489-0007 or 1-800-331-2020.

– Massachusetts Association for the Blind, 617-738-5110.

– Carroll Center for the Blind, 617-969-6200 or 1-800-852-3131.

 

For more information or referrals, call: 

SIDEBARTO LEARN MORE

 

– New England Eye Center at New England Medical Center, 1-800-231-3316 or 617-636-4600.

– Massachusetts Eye and Ear Infimary, 617-573-4199.

– New England Eye Institute, 617-262-2020. The institute also runs a mobile van for outreach toolder people, at 617-236-6317.

– National Eye Care Project, 1-800-222-EYES (1-800-222-3937). If you’re 65 or older, this service will help you find an ophthalmologist who will do an exam free if you have no insurance, or who will waive the co-pay or deductible if you have insurance, including Medicare and Medicaid.

– American Foundation for the Blind, 1-800-232-5463, for referrals to a low-vision specialist.

– Massachusetts Commission for the Blind, 617-727-5550 or 1-800-392-6450, if you are legally blind (10 percent vision or less). If you use a telecommunications device for the deaf, call 1-800-392-6556.

– Vision Foundation Inc., 617-926-4232 or 1-800-852-3029 (Massachusetts residents only).

– Prevent Blindness America, 617-489-0007 or 1-800-331-2020.

– Massachusetts Association for the Blind, 617-738-5110.

– Carroll Center for the Blind, 617-969-6200 or 1-800-852-3131.

 

For more information or referrals, call:

We may be putting too much stress on stress

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You spend months, maybe years, trying to get pregnant, watching in despair as friend after friend accomplishes this most elemental of biological tasks with apparent ease.

Sooner or later, one of these blissfully fertile souls will look you in the eye and, with the best of intentions, diagnose your problem: Stress.

Or perhaps you cough a bit too much on the phone one night, or let loose with a few impressive sneezes. Chances are, your telephone buddy will pause in mid-sentence to say, “That sounds like a bad cold. You must be under too much stress.”

Worse yet, you may do this to yourself, perhaps at the worst possible time, like when you’ve just been told you have cancer. Even as the doctor tries to explain the problem, you may tune out and leap to your own “obvious” conclusion: Stress.

In the last decade or two, we seem to have swung from a technocentric culture that barely acknowledged the possiblity of a mind-body connection to the nearly mindless assumption that everything that goes wrong in our bodies is caused by our minds.

Stress has become our hypothesis of first resort, an oversimplified worldview that is not just an insult to rationality but a not-so-veiled way of blaming the patient, of at least seeming to say, “You brought this on yourself.”

Now don’t panic, mind-body fans. We’re not about to throw out the baby with the bathwater. In fact, there’s growing evidence that stress can play a role in some medical problems, including raising the risk that you’ll catch a cold.

Nor is anybody suggesting that we should abandon useful stress management tricks that make many people feel better, including meditation, relaxation training, yoga or exercise. Quality of life counts, and anything that enhances it is all to the good.

But the complex truth is that while stress — and just defining that is difficult because one person’s stress may be another’s gratifying challenge — does appear to be linked to some health problems, but not to others.

Last week, for instance, University of Wisconsin researchers led by Felicia Roberts published an intriguing study on stress and breast cancer. Newly-diagnosed breast cancer patients, Roberts says, are often convinced their cancer is linked to a stressful time in the recent past — a messy divorce, perhaps, or a husband’s death.

In fact, last December, British researchers thought they had found such a link, though their study involved only 100 women, looked at negative life events for just one year prior to diagnosis and had other methodological flaws.

In the Wisconsin study, researchers gave a modified version of a common stress questionnaire to 258 breast cancer patients and 614 women without cancer who were selected at random.

The questionnaire asked whether any of 11 events had occurred in the past five years, including the death of a husband, family member or close friend; a divorce or retirement, and also positive but stressful events like marriage or moving in with a new partner.

To her surprise, Roberts says, the team found no significant difference in stress levels between cancer patients and healthy women.

This is music to the ears of Barrie Cassileth , a Duke University psychologist and medical sociologist whose editorial accompanied the Wisconsin study last week in Cancer, a journal of the American Cancer Society.

“This is the era of stress causing everything in the world. It’s very unfortunate,” says Cassileth. “There certainly is a mind-body link, but I don’t think the mind causes cancer and I don’t think the mind can cure it.”

In fact, there’s plenty of evidence that people can suffer tremendous stress with no increased cancer risk.

In military studies, for instance, soldiers discharged for neuroses during World War II had no higher cancer rates 24 years later than their mentally healthier comrades. Nor have POWs studied turned out to be more cancer-prone than other soldiers. Even concentration camp survivors show no excess cancer many years later, says Cassileth.

All of which means it is “absolutely foolish” to attribute complex medical problems to a single factor like stress, says Dr. Herbert Benson, president of the Mind/Body Medical Institute at Deaconess Hospital.

In treatment as in diagnosis, what makes more sense, he says, is to “view health and well-being as akin to a three-legged stool. One of the legs is pharmaceutical, a second is surgery and procedures, and the third is self-care, which includes nutrition, exercise, stress management and the mind-body belief stuff.”

But while stress does not appear to cause cancer, there is evidence it may contribute to some problems.

A 1993 Framingham Heart Study of more than 1,000 people, for instance, showed that high levels of anxiety predicted future high blood pressure for middle-aged men, though not for women.

And a 1991 study of nearly 400 people by researchers in Britain and at Carnegie Mellon University in Pittsburgh showed that psychological stress raises the risk of getting a cold. Volunteers filled out a stress questionnaire and were assessed on personality traits. Researchers also took samples of their blood, then gave volunteers either nose drops containing one of five viruses known to cause respiratory infections or harmless salt water drops.

After the volunteers were quarantined for a week, the results were clear: The more stress in a person’s life, the higher the risk of catching a cold, regardless of other factors, such as age, sex, education, personality, quality of sleep, smoking, alcohol consumption, exercise, diet, even baseline counts of white blood cells in the immune system.

Other researchers have come to similar conclusions, including an Ohio State University husband-and-wife team, Janice Kiecolt-Glaser, a psychologist, and Dr. Ronald Glaser, an immunologist.

Last fall, in a study published in Lancet, the Glasers compared the rate of wound healing in 13 family caretakers of dementia patients and 13 control subjects. Other research by the Glasers had previously shown that caring for someone with dementia is stressful and has measurable effects on immunity.

Under anesthesia, all 26 subjects in this study were given small puncture wounds on their arms. The difference in healing was “much bigger than we expected,” says Kiecolt-Glaser. Wounds took an average of 47 days to heal in the caretakers, versus 38 days in the controls, a huge difference.

To be sure, not every temporary dip in immunity, whether triggered by stress or not, translates to a decrease in health.

But evidence is growing, Kiecolt-Glaser says, that stress can affect resistance to disease, especially among older people, whose immune systems often decline with age anyway. The best way to offset this stress, she adds, is to maintain strong emotional relationships with other people.

And what of the controversial link between stress and infertility? That’s a tough one.

About 90 percent of infertility is caused by physical problems such as blocked fallopian tubes or problems with sperm or eggs, says Alice Domar, a psychologist at Deaconess Hospital.

“But there is a subgroup of patients in whom stress may play a role,” she says. One Belgian study of women receiving healthy, donor sperm found that the more anxious a woman was about conceiving, the longer it took to get pregnant.

Another study showed that infertile women who finally did conceive had a spontaneous decline in anxiety before conception.

The bottom line is that it’s still “a chicken and egg question” whether stress is a cause or a result of infertility, she says. But whichever way it goes, stress management — including relaxation techniques, “cognitive restructuring” to gain a more positive attitude and other approaches — may help.

In a study at the Deaconess, for instance, Domar followed 284 long-infertile women through a stress management program. After six months, 36 percent conceived and went on to have a baby and another 6 percent conceived but lost the baby — a better track record than probably would have occurred otherwise, she says.

But more important, she says, was the other finding from that study: “Even the women who did not get pregant dramatically decreased their levels of distress.”

SIDEBAR:

Health Sense and Aging columns on line

Selected Health Sense and Aging columns are available by sending e-mail to request(AT SIGN SYMBOL)globe.com and writing the document number in the “subject” field:

You can also find selected Health Sense and Aging columns on line by using the keywords: Column Corner.

  • 029021 The agony of the feet Jan. 29
  • 022016 Fine-tuning the Pap smear Jan. 22
  • 015014 High-fat diet fights epilepsy Jan. 15
  • 008018 Drink up – or not? (women and alcohol) Jan. 8
  • 001008 Exercise appears to boost immune system – to a point Jan. 1
  • 353010 Sex — the morning after Dec. 18, 1995
  • 332004 For shingles sufferers, 2 new drugs Nov. 27
  • 325160 Living right: What matters most (cholesterol control) Nov. 20
  • 304019 We’re eating ourselves to death (obesity) Oct.30
  • 276113 What to do if a health plan says no Oct. 2
  • 255010 I’ve got what? How to research a diagnosis Sep. 11
  • 192135 Navigating the maze of the estrogen replacement debate July 10

 

The guru does lunch: hold the fat — all of it

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Dr. Dean Ornish, the California guru whose radical approach to diet has been shown to reverse heart disease, settles in at the corner table at the Ritz cafe, facing Temptation.

Temptation, his luncheon partner one recent winter day, points to the lobster bisque, the special Ritz cheeseburger with aged cheddar, the Boston cream pie.

“They sound good, but I think I’ll try something different,” says Ornish, 42, whose tastes — and recommendations — run to fruits, vegetables, grains, beans, nonfat dairy products, egg whites and not a whole lot more.

With no added oils of any sort, this amounts to a diet that is 10 percent fat, with almost no cholesterol.

As the maitre d’ hovers, Ornish, clearly unconstrained by conventional expectations or printed menus, begins the serious negotiations.

“Can you make me a cup of minestrone with no cream and no butter? Can you make up just some pasta, angel hair pasta, and can you make a marinara sauce without any oil, not even olive oil? And grill up some vegetables?”

(Temptation orders the penne with portobello mushrooms and cepes, swimming in olive oil.)

Ornish settles back, takes a hefty swallow of water and launches into a plug for his latest book, “Everyday Cooking with Dr. Dean Ornish,” and his new program at Beth Israel Hospital, where for $7,000 or so each — some insurers cover it — about 100 people this year will try Ornish’s approach to reversing heart disease.

Just as Ornish is warming to his tale of healthy hearts, legumes and yoga, the waiter swoops over. Would it be all right to add just the tiniest bit of oil to cook the onions for the marinara sauce?

It would not.

“Why not just leave the onions out?” suggests Ornish. Heads nod: Of course.

Eating the way he does, says Ornish, who is 6 feet tall, weighs 170 (he’s gained 15 pounds pumping iron) and has a total cholesterol level of 130, is ”not a moral issue.”

“This is just a choice I prefer. Once you start categorizing food as good or bad, soon you’re a good or bad person,” he says, noting that he grew up eating meat five times a day in Texas but now loves his plant-based, meat-free diet.

Once you get used to it, he says, food tastes better, you feel better fast, and you even come to prefer healthful things like skim milk. Besides, he contends, making big, radical changes in lifestyle and diet is easier and more effective than chipping away at the problem with small, incremental changes.

Over the years, Ornish’s approach has been controversial. At first, other doctors doubted that clogged arteries and chest pain could be reversed by something as low-tech as diet and behavior modification. Lately, critics have worried that his program is just too tough for the average person to stomach.

But it seems to work. Several years ago, Ornish published a study of 48 people that showed that blockage of coronary arteries was significantly reversed in 82 percent of patients after one year on the diet and a behavior modification program.

Last fall, he published a five-year followup on the same people. Using scans that measure blood flow to the heart, he found that 99 percent of patients were able to halt or reverse progression of heart disease.

Nationwide, about 1,000 patients so far have enrolled in Ornish programs at eight hospitals, and many, he says, have been able to avoid expensive bypass surgery or angioplasty to open their arteries. In fact, Mutual of Omaha insurance company, which has followed more than 40 Ornish patients, has saved $5.55 for every dollar it spent on the program, he says.

The heart of the regimen, says Ornish, who is director of the Preventive Medicine Research Institute in Sausalito, Calif., is its multidisciplinary approach.

At Beth Israel, for instance, patients exercise — that is, walk — a minimum of half an hour a day, or one hour three times a week. They also spend an hour a day doing yoga, relaxation exercises and meditation, and have regular cardiac checkups and group counseling.

Richard Murphy, a 54-year-old plumber from Hanover who has been in Beth Israel’s pilot program since September, attests to both the rigor of the program, and its results.

After a heart attack seven years ago, Murphy says, he stuck to a healthful diet and exercise program for a few years, but gradually slipped back. Last year, he began having angina, the chest pains that are a hallmark of clogged coronary arteries.

When his insurer, John Hancock Co., offered to foot 90 percent of the bill for the Ornish program, Murphy jumped at the chance. Since September, he has lost 15 pounds, feels “excellent” and says he has “a bounce to my step I didn’t have before.” And his angina is gone.

Back at the Ritz, lunch arrives, and Ornish is thrilled.

“Doesn’t that look good,” he says. “You did a very nice job. My compliments to the chef.”

His plate is filled with grilled vegetables that glow with health and color atop a pile of pasta. There is not a droplet of oil.

“You can go out to eat and order this,” says Ornish, relishing every bite. People hesitate to ask restaurants for what they want, he says, because ”they don’t want to look weird or different — but my plate looks better than yours.”

It does.

“And if you eat low-fat all the time, you begin to prefer it,” he says.

Temptation eyes the oil at the bottom of her plate.

Finally, the dessert menus arrive. “Tiramisu?” asks the maitre d’.

At first, Ornish hangs tough. “What kind of sorbet do you have?” Then, saying he’d “rather eat chocolate if I’m going to eat fat,” he caves: “Do you have any chocolate desserts?”

Invited to split a chocolate mousse, he agrees to have a taste.

It’s OK, he says, because he knows he’s free of heart disease. Besides, the real reason to stick to a healthful diet, says the guru, is that “you’ll feel better. It’s the joy of living, not the fear of dying, that sustains you.”

The mousse arrives. It’s gorgeous. Ornish slips his fork into it, puts a tiny bit into his mouth. Conversation stops. It is the moment of truth.

He closes his eyes to savor it. No wonder. It’s the only bite he takes.

Wax, pluck, zap. Hair today, gone tomorrow

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Middle age is a time of many ironies – like increasing wisdom amid shrinking job options – but one of the most medically bizarre is this: At midlife, we start losing hair where we want it and start growing it where we don’t.

Many men, especially those with genetic bad luck, start growing hair on noses and ears just as they lose it on top.

Many women, smooth-faced for decades, look in the mirror one menopausal morning and discover – gasp! – a mustache, enough chin hairs to make up a small beard and maybe even sideburns.

To be sure, too much hair or hair in the wrong places is a problem for millions of Americans, regardless of age. In fact, we seem to be on constant hair alert.

We shave. We pluck. We bleach. We wax. We zap. We slap on creams that turn hair to jelly. Soon, those of us with a lot of both hair and money, may explode away those pesky hair follicles a new way – with lasers.

This obsession – and the booming hair removal business it supports – will likely sprout new growth as Baby Boomers hit midlife and discover hairy ears and unladylike beards.

Doctors have long known that women can develop excessive hairiness, or hirsutism, early in life from genes that cause high levels of male hormones or from diseases like polycystic ovary syndrome that make them overly sensitive to normal, low levels of male hormones in their bodies.

But nobody really understands what triggers the crazy hair growth of midlife – for men or women.

For men, the most important predisposing factor for hairy ears or nasal hair is probably genetics, says Dr. Howard Baden, a dermatologist at Massachusetts General Hospital, though nobody knows why this tendency kicks in as a man ages.

For women, the leading theory is that declining levels of female hormones at menopause trigger the sprouting of facial hair.

But “the fact that female hormones drop is not a real good explanation for why postmenopausal women have more hair on their faces, because they’re also losing pubic hair,” he says.

So what can you do if you find yourself growing hair in the wrong places faster than those Chia pets on TV?

Lots.

–  Shaving. This is the cheapest and simplest solution, and, contrary to widespread belief, does not make hair grow back faster or thicker, the American Academy of Dermatology says. For best results, soak skin with warm water, use a shaving gel or foam and shave with, not against, the grain of hair growth.

–  Plucking. This is also cheap, safe and simple but it can hurt and take time. For the brave and technologically inclined, there are mechancial plucking devices with rotating springs.

–  Bleaching. Over-the-counter bleaches makes hair less visible but don’t get rid of it. In general, dermatologists say, bleaches are safe, but if you bleach facial hair, be sure to use products designed for the face.

–  Depilatories. These over-the-counter chemicals break the disulfide bonds inside hair, turning hair to a jelly that you wipe off. Again, be careful with your face – body depilatories are too strong. Depilatories may also cause allergies.

–  Waxing. In this age-old method, a thin layer of warm wax is applied, then allowed to cool. When the wax is ripped off, hair comes with it, which – no surprise – can hurt. Waxing lasts several weeks because the hair is yanked from under the skin.

But waxing can cause folliculitis, inflammation of the follicle from which hair grows, and may – rarely – trigger skin damage, as Amy Macdonald of Cambridge found, to her horror.

Thirteen years ago, a day before she was to be a bridesmaid in a wedding, Macdonald decided to have her legs waxed.

“My skin came off,” she says. “It was a bloody mess.” It hurt . . .and there were scars on it for a year and a half.”

–     Electrolysis. This is the only safe way to remove hair permanently, according to the dermatology association. But whether it is truly permanent is debatable and the US Food and Drug Administration, which regulates medical devices, is re-evaluating its policy on the matter.

During electrolysis, sterilized needles are passed down the hair shaft to the follicle. It can be painful, though Cambridge electrologist Judy Feiner says, “I have people who can fall asleep during treatment.”

When electric current is applied, the hair root is destroyed.  But because hair grows in cycles and the needle doesn’t always reach the root, the process can take many treatments.

Success also depends heavily on the skill of the operator; in the wrong hands, electrolysis can cause scarring and infection, which is one reason that Massachusetts and some other states require that electrologists be licensed.

And because electrolysis destroys hairs one by one, costs are high. This year, Americans are expected to spend $ 1 billion on electrolysis, and per patient costs can run to hundreds or thousands of dollars.

One 44-year-old Newton woman, for instance, began growing a mustache during pregnancy, as many women do. In one year alone, she spent $ 500 on electrolysis – to little avail.

“They give you the impression that after five growths of the same hair, you can kill it,” says the woman, who requested anonymity. “But it was still growing in after a year.”

–  Lasers. The hair removal trend of the future, at least according to laser scientists, is lasers because “large areas of hair can be treated at once,” says Dr. Roy Geronemus, director of the Laser and Skin Surgery Center in New York.

So far, the FDA has approved only one hair removal laser, a device made by ThermoLase in San Diego, and clients must go to a special salon, Spa Thira in La Jolla, for treatment. Other spas are expected to open this year, though not in Boston.

In the ThermoLase system, hair is removed by waxing to open a path to the follicle. Then a black, carbon-based cream is spread on the skin. The carbon seeps into the follicle, the laser heats the carbon and the follicle explodes.

Not a pretty process, and not a entirely pain-free one either – for the skin or the wallet. In fact, laser removal of a woman’s mustache costs $ 1,400, according to the company price list, and zapping away her chin hairs costs $ 2,300.

There is also a theoretical concern that lasers could destroy the pigment in skin, leaving white spots, laser researchers say, though this risk is probably only about 1 percent.

One client who has tried laser hair removal, a California man named Paul who did not want his last name used, says he has spent $ 1,500 for three treatments on his upper back and neck.

Because he had a lot of hair, the waxing “was painful,” he says. “You don’t pass out, but it’s not fun.”

By comparison, he says, the laser treatment itself didn’t hurt much. In most spots it merely tingled or felt like a rubber band snapped on his skin.

So far, he says, each treatment has kept about 50 percent of his hair from growing back – roughly the success rate that Dr. Rox Anderson, research director for the Massachusetts General Hospital Laser Center, has found in two pilot clinical trials.

In one study of 13 people, Anderson found that a ruby laser made by Spectrum Medical Technologies in Natick produces a delay in hair regrowth of about six months. In another study, Anderson got similar results with a different laser, plus a cream containing ALA (aminolevulinic acid), a natural substance that makes cells, including hair cells, sensitive to light.

So far, he says, laser hair removal has not been directly compared to electrolysis or proved to be permanent.

But Dr. Melanie Grossman, research director at New York’s Laser and Skin Surgery Center says the hope is that “lasers will prove to be more efficient than other methods of hair removal, though we don’t have the answer to that yet.”

Laser treatments do appear safe, however, have not caused scarring or permanent changes in skin pigment and should get cheaper with time, says Anderson. And if the Spectrum laser under review by the FDA is approved, the technique could be available in Boston soon.

Still, he cautions, laser hair removal, like electrolysis, is not an intrinsically gentle process. Both methods are designed “to destroy living cells in hair follicles. . . God did not intend this to happen.”

So does this mean Boomers who sprout hairy ears and postmenopausal beards should just go back to shaving?

No, he says. If you’re sure you never want that hair again, go ahead and zap it – one way or another – forever.

But if you’re not sure, simple solutions like shaving may be the answer. After all, he says, “shaving is elegant, and it’s kind of fun.”

To learn more

To check whether your hair removal specialist is licensed, you may call:

–  For electrolysis: The Board of Registration of Electrologists, 727-3080.

–  For waxing: The Board of Registration of Cosmetologists, 727-3067. (This board also licenses estheticians).

–  For lasers: Rules vary from state to state, but laser hair removal usually must be done physicians, nurse practitioners or physicians’ assistants. A state board cannot tell you whether your health care professional has had special training in lasers; it can tell you whether he or she is licensed.

The Board of Registration in Medicine (doctors) may be reached at 727-3086; the Board of Registration in Nursing (nurses and nurse practitioners) at 727-9961; and the Board of Registration of Physicians’ Assistants at 727-3069

In medical laboratories, garlic is coming up roses

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Garlic, the “stinking rose” beloved by gourmets and health gurus for nearly 4,000 years now, is finally getting respect from the mainstream medical establishment.

First mentioned in 1550 B.C. in an Egyptian medical papyrus, then given a whiff of credibility in 1858, when Louis Pasteur discovered that its juice kills bacteria, garlic is now one of the hottest phytochemicals – plant compounds – in medical research.

In cancer centers, government labs and dietary supplement factories, garlic in all its many forms – raw and raunchy, stewed and sweet, deodorized and dandified – is being hungrily studied, not to mention munched, by eager scientists.

But the more they tease apart the 60-to-100 compounds in garlic’s crescent-shaped cloves, the more complicated its chemistry turns out to be.

In fact, the chemistry is so ridiculously complicated – you definitely don’t want the details – that garlic supplement manufacturers could almost, but not quite, be forgiven for all their glaring omissions, spurious claims and misleading ads.

Such sins aside – for the moment – there’s no question that garlic research has become mainstream and that scientists are starting to understand how garlic may help fight cancer, heart disease and other ills, just as old wives’ tales have long said.  Several months ago, for instance, the National Cancer Institute, long interested in the potential of some foods and herbs to prevent or treat cancer, threw its weight behind a study of 3,600 people in Shandong province in China. In 1988 and 1989, epidemiological studies of thousands of people in Shandong had shown that the risk of stomach cancer was lowest among people who ate the most garlic.

To find out if garlic can actually prevent cancer in high-risk people, NCI epidemiologist Linda Morris Brown and others have begun a randomized clinical trial in which Shandong residents will get supplements of aged garlic extract and others, a look-alike placebo.

While it might have been better in some ways to let some people simply eat more garlic than others, says Brown, supplements were necessary to ensure that the trial subjects didn’t know who was getting the extra garlic and who was not, lest those expectations – the placebo effect – influence the results.

And that’s just one sliver of a growing body of research, some of it paid for by supplement manufacturers, on garlic’s medicinal potential.

Several months ago, Pennsylvania State University researchers found in a randomized, double-blind study of men with high cholesterol that aged garlic extract has a “mild cholesterol-lowering effect.”

Brown University researchers found much the same thing in 1994. Nine 700-mg capsules of aged garlic extract a day lowers cholesterol by a modest 8 percent, says Robert I-San Lin, a co-author of the study. Lin is also director of nutrition at the Nutrition International Co. in Irvine, Calif., which sells vitamins and meal supplements and helped support the study.

At a garlic conference in Berlin last fall, British and Australian researchers pooled data from 16 studies on cholesterol and found that garlic has a small beneficial effect.

In similar work involving eight pooled studies on blood pressure, they found that garlic lowered systolic blood pressure (the top number) by about eight points and diastolic pressure (the bottom number), by 5 points.

Garlic may also fight cardiovascular disease in yet another way – by reducing the tendency of platelets in the blood to clot and stick to artery walls.

And emerging data suggest garlic can fight cancer as well.

Dr. Manfred Steiner, a hematologist at East Carolina Medical School in Greenville, N.C., has found that SAMC (S-allyl mercaptocysteine, a consituent of aged garlic extract) can stop the process by which cells divide and grow in both normal and cancerous cells, at least in the test tube.

“You add these compounds and you can watch what happens,” he says. “Cell growth slows and cells die off.”

Like Steiner, John Pinto, a biochemist at Memorial Sloan-Kettering Cancer Center in New York, has documented the ability of garlic to slow cell growth and says it may help fight cancer in other ways as well.

SAMC, for instance, may keep cancer from getting started by protecting the genetic molecule DNA against damage from free radicals, the destructive forms of oxygen that are formed as food is burned. In test tube experiments, Pinto has found that SAMC protects against this damage by boosting glutathione, a natural free radical fighter.

SAMC and its chemical cousins may also act as chemical pumps, Pinto adds, pushing into overdrive a complex family of enzymes that detoxifies carcinogens and drugs, the so-called cytochrome P-450 system.

By activing these enzymes, garlic seems to help keep carcinogens away from DNA and then, using other molecules, to escort the carcinogens out of cells, Pinto says.

Microbiologist Michael Wargovich at the M.D. Anderson Cancer Center in Houston, who is also studying garlic’s effects on the P-450 system, agrees. In fact, his latest project, presumably awaited with bated breath by backyard chefs, is to find out whether garlic can detoxify the carcinogens created when hamburgers are burned.

And other recent studies, including two supported in part by Wakunaga of America Co., the world’s leading manufacturer of garlic supplements, have shown that garlic constituents may retard bladder and breast cancers in rodents.

All of which, of course, is music to manufacturers’ ears.

The public is so ga-ga about garlic, in fact, that the world market for supplements is now $ 250 million a year, says William Sterling, director of sales and marketing for Wakunaga, which has the lion’s share, $ 200 million a year.

But the mere fact that sales are booming does not mean that supplements are any better than natural garlic. And you certainly won’t find much enlightenment on the labels.

Many labels don’t even say which compounds are in the product, much less how they may help or harm you, because supplements are not tightly regulated by the US Food and Drug Administration, as drugs are.

And labels often make little sense, like some touting a garlic component called allicin. Some products may not even contain active allicin because allicin breaks down so easily, says biophysicist Lin of California.

And even those with allicin “potential,” which are supposed to creat allicin in the body when mixed with water, may not do so because stomach acids block allicin formation, he adds.

Besides, even if you could get lots of allicin into your system, it might not be a good idea because allicin can irritate the digestive tract, just as raw garlic can. In fact, the nutritionists who run the Garlic Information Center in New York say supplements without allicin may be safer than raw garlic.

The real problem, though, is not that supplement makers are making a bundle on our garlic gullibility, but that researchers, despite recent progress, still don’t have the answers.

“We still don’t know precisely which constituents of garlic work best or whether it’s better to eat real garlic or take supplements,” says Dr. Richard Rivlin, program director of the clinical nutrition research unit at Sloan-Kettering.

Nor does anybody know how much garlic we should consume, though Lin of California, is willing to offer his best guess.

He recommends a daily dose of 10 grams (or three cloves) of natural garlic, which is equivalent to 4 grams of garlic powder or 40 milligrams of garlic oil, though cloves, powders and oils all have different constituent chemicals.

(There’s no way to translate natural garlic into aged extract equivalents because some compounds in the extracts are not in raw garlic.)

However you take it, the bottom line, as Pinto of Sloan-Kettering puts it, is that “some garlic is better than none.”

A garlic chemistry primer

The main component in raw garlic is alliin. But as soon as you crush or cut a clove of garlic, an enzyme called alliinase is released, converting alliin into allicin.

Allicin, which gives garlic its odor, is a strong oxidant, that is, a chemical that creates free radicals, which in excess, can be dangerous. Allicin can cause stomach irritation and, in rare cases, hemolytic anemia, destruction of red blood cells. If if placed directly on the skin, allicin can cause blistering.  During cooking, allicin produces ajoene, DADS (diallyl disulfide) and other compounds that may help keep blood from clotting.

During aging, alliin and allicin are converted to water-soluble compounds such as S-allyl cysteine and S-allyl mercaptocystine, which have little odor, are stable and survive cooking. These are among the ingredients in “aged garlic extract” supplements and may help combat cancer and protect against heart disease.

Garlic also contains oil-soluble compounds like DAS (diallyl sulfide) and DADS which may have beneficial effects on blood pressure, lipids and clotting and may help prevent cancer.

 

Where to call

For more information on garlic, you may call:

  • The Garlic Information Center hotline, 1-800-330-5922, The line was set up last year by researchers at Cornell University Medical College.

Fear of aids is no reason to avoid dentist

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At 2:30 on a Monday afternoon in the summer of 1989, James Sharpe, a convenience store owner from Northampton, settled back in the dentist’s chair to have three teeth extracted.

AIDS was, presumably, the last thing on his mind, and he certainly had no risk factors for the disease.His dentist, Dr. Anthony E. Breglio, was not infected with the AIDS virus, quite unlike Dr. David Acer, the Florida dentist who was infected and passed the virus to six patients.

Furthermore, no other patients Breglio had treated earlier that day are known to have had AIDS.

Breglio practiced the type of infection control that most dentists used at the time – soaking his drills and other similar tools in chemicals, says Dr. Alfred De Maria, director of communicable disease control for Massachusetts, who looked into the case in 1991.

Today, Sharpe has AIDS, and he blames it on poor sterilization of dental equipment by Breglio, whom he is suing in Hampshire County Superior Court. Seven weeks after his dental visit, Sharpe developed flu-like symptoms; when other tests came back negative, he had an AIDS test. It was positive.

Whatever the outcome of the Sharpe case, which is expected to go to the jury this week, it has revived one of the nagging fears of the AIDS epidemic: that you can catch it just by going to the dentist.

How realistic are those fears?

Not very, say many infection-control specialists. And whatever the odds were in 1989, they are even tinier today.

In fact, if you’re looking for an excuse to avoid the dentist, you’d be better off with the old “My dog ate the appointment card” line.

But fear is a notoriously stubborn thing, and in the case of invasive medical procedures, not irrational. So like a diligent dentist picking around with that nasty little “explorer” tool, let’s take a close at the evidence.

With the Sharpe case still unresolved, there has been not one documented case in which a person has caught AIDS from dental equipment, even though Americans make nearly 500 million dental visits a year. If you want to calculate the risk ratio since the AIDS epidemic began in 1981, that’s zero cases over a denominator in the billions.

In fact, even if all 32,381 AIDS cases in which the mode of infection is unknown were actually caused by dental equipment – which is unlikely – the risk would still be vanishingly small.

Furthermore, Acer’s six patients are the only documented cases of AIDS transmission from a dentist infected with HIV. Federal health officials have never been able to pinpoint whether Acer cut himself and then accidentally exposed patients to his blood, failed to sterilize his equipment properly or infected his patients intentionally.

“There were some problems with his infection-control methods,” acknowledges Dr. Harold Jaffe, associate director for the HIV-AIDS National Center for Infectious Diseases at the federal Centers for Disease Control in Atlanta. “But we didn’t prove the route of transmission.”

The Acer case aside, there have been zero – count ’em, zero – documented cases of HIV transmission from infected health care workers to patients. And this holds true even after “look-back” studies involving 22,000 patients, though critics note that there were some methodological flaws in these studies.

By contrast, at least 40 health care workers have been infected by patients.

Still, there’s no question that, under pressure from nervous patients, dentistry been getting safer.

In 1989, when Sharpe believes he was infected, American Dental Association guidelines recommended sterilization by autoclave (which uses intense heat and steam under pressure), but said disinfection with chemicals, a less surefire germ-killing method, was also adequate, says Dr. Richard Price, a Newton dentist and ADA spokesman.

In 1992, the ADA toughened its stance, recommending that all metal instruments, including drills, be heat-sterilized after each use by autoclave, dry heat or chemical vapors. It also said chemical disinfection was no longer adequate.

This proved difficult, however, because many handpieces had to be taken apart to be sterilized or could not withstand heat, prompting some dentists to continue using chemical disinfectants instead.

Even today, some dentists don’t heat-sterilize as they should. The ADA’s own survey last year found that 92.5 percent of dentists heat-sterilize handpieces before each use – up from 25 percent in 1990 – but that still leaves 12,000 who don’t.

And some specialists, like David Lewis, a microbial ecologist at the University of Georgia, contend that only 50 to 80 percent of dentists heat-sterilize tools after each patient.

The technology has improved so much that dentists “can sterilize handpieces in toto now, without taking them apart, because manufacturers have made all the components heat-resistant,” says Price.

In 1993, the CDC issued its own infection-control guidelines, which don’t carry the force of law but are generally followed. These call for sterilizing with an autoclave, dry heat or chemical vapor all instruments that penetrate soft tissue or bone, like the burs used for drilling, as well as instruments that contact oral tissues, like mirrors.

Because the internal surfaces of high-speed handpieces and other devices can become contaminated, the CDC concluded that “soaking in liquid chemical germicides” is not acceptable infection control.

In practice, though, some dentists still use chemicals to sterilize equipment that is not heat-resistant, like the tabs that hold X-ray films.

“Cold sterilization with chemicals obviously only works for surfaces that the chemicals can reach – not for instruments with tiny nooks and crannies or hollow tubes – but it does work well for these solid surfaces,” insists Price of Newton.

“But things are evolving even as we speak, and as of this week, because of questions remaining in patients’ minds, I am doing away with cold sterilization myself.”

Increasingly, he adds, dentists are turning to materials they can use once and throw away, like devices used to polish teeth and the tubes that suck saliva out of the mouth.

So does this mean all risk of AIDS in dentistry is gone?

Not quite. A small risk will remain as long as there is any dentist out there who does not heat-sterilize or throw away after use everything that goes in your mouth.

That’s because, as Lewis showed in studies published in 1992 in the journal Lancet and last year in Nature Medicine, the AIDS virus can get into dental equipment and survive “up to several days” in the lubricating fluids inside the instruments.

Lewis, who testified last week for Sharpe, took blood from AIDS patients and mixed it with lubricants, then immersed the lubricants in a 2-percent solution of glutaraldehyde, a disinfectant. The virus survived.

“And if glutaraldehyde couldn’t kill the AIDS virus, then no chemical disinfectant used would be effective. Only heat effectively kills the AIDS virus in dental devices,” he said in a telephone interview. “But if the equipment is properly sterlized, there should be no concern.”

Dr. Sanford F. Kuvin, who also testified for Sharpe last week, charging that “dirty dentistry” was involved, agrees “there is no risk if the dentist or other invasive dental health care worker is HIV-negative and if sterilization is proper.” If not, he said, “there is a risk that’s somewhere between infinitessimal and small.”

So how can you tell if your dentist is doing the right thing?

“Ask questions and don’t stop until you’re satisfied,” advises Price, though for many patients, that’s easier said than done, especially with a mouth full of dental hardware.

Still, you could start by asking how much your dentist has spent to meet infection-control guidelines, including guidelines to protect dental employees. Many dentists have spent $ 24,000 a year to comply and may be quite happy to tell you so.

Ask if your dentist uses an autoclave, and if you’re in doubt, ask to see it. Then ask how often your dentist checks to be sure it’s working.

After that, you might as well relax because, as Price puts it, “There’s got to be some trust.”

Dr. Martin Hirsch, director of clinical AIDS research at Massachusetts General Hospital, agrees.

“I hate going to dentists,” says Hirsch, “but I think the risk of spread of HIV is infinitessimally low in that setting and people shouldn’t avoid dentists for that reason.”

 Look and ask questions

Things to look for and ask about at the dentist’s office:

  • Is the room clean and orderly, and do surfaces and equipment appear clean?
  • Is the staff willing to answer your questions?
  • Do the dentist and other dental workers practice “universal precautions,” including wearing gloves and other protective gear during your treatment?
  • Are needles and other sharp items disposed of in special puncture-resistant containers?
  • Is everything that goes in your mouth heat-sterilized or disposable? (If you’re worried about non-heat-resistant items like the gadgets that hold X-rays, ask. American Dental Association guidelines say it’s acceptable, though not preferred, to use chemicals to sterilize these.)
  • How often is the autoclave machine checked? (Federal guidelines say it should be checked at least weekly.)

    If you’re still worried, call the state Board of Registration in Dentistry (617-727-7368 begin_of_the_skype_highlighting              617-727-7368      end_of_the_skype_highlighting).