Tobacco Free Hospitals 150 Years Ago!

As a physician and psychiatrist, I have never been a smoker although I have ironically known two oncologists who were heavy smokers (go figure!).

When I am admitting patients to any hospital I have worked within, for the last 30 years, I always answer somewhat bluntly, “I am a doctor, I am death on smoking,” when patients (even now still!) ask me if they could smoke in the hospital.

All joking aside, I trained at Duke Hospital decades ago. I became curious about the history of the tobacco industry as tobacco was grown everywhere in North Carolina and a huge part of the agricultural economy back in those years. I read up on the history of Duke Hospital, its origin with the Duke family and the incredible monopoly the Duke family had on the tobacco industry that was one of the strongest monopolies in this country until the mid 1900’s. I learned that one of the “Duke boys,” my faulty memory says it was James Buchanan Duke III, early on realized they apparently had unleashed a desecration on the nation’s health and dissolved the Duke family’s monopoly breaking up the then American Tobacco Company and moving the family out of the business. That prescient move many decades ago, would be kin to the Royal Saudi family moving the royal family out of oil production!

The many billions that they had earned in those days made the Duke Foundation one of the largest in the world at the time and it still is. From then on the Duke Family and Foundation devoted itself to philanthropy often in health care. For instance the Foundation funded the hospital for the Eastern Band of Cherokee Indians in western North Carolina, and, has continued to fund health care initiatives such as the Women’s and Children’s health services and a beautiful health clinic for just that patient population.

Ironically, I chanced upon a book from an obscure eReader book compendium which I thought would be entirely about my current interest in the history of the state psychiatric hospital movement in this country. [To warn the readers, that will start to be one of my subjects I will cover over time in this blog in the coming months, in order to set the stage for an ongoing discussion and analysis of the failed historical [and present efforts at mental health reform in this country].

The book I downloaded is an oldie entitled: Rules and Regulations of the Insane Asylum of California Prescribed By The Resident Physician, August 1, 1861. Stockton; Armor and Clayes, Printers, 1861.  Believe it or not that is apparently how some book titles were required to appear following some arcane long lost “style rule set” that I think is quite cool, neat, concise and tells you everything you need to know.

A bit of explanation is in order. We think of resident physicians these days as young apprentice physicians who have graduated from medical school and are pursuing their specialty training, such as in internal medicine, surgery, pediatrics, psychiatry, etc. But a “Resident Physician” in those state hospital days were the head boss doctor who LIVED at the out of the way state psychiatric hospital. So the “Resident” was today’s chief of staff. To quote: The Resident Physician, who shall also be the Superintendent, shall be the chief executive officer of the Asylum…” (pg. 1-2).

If you were to obtain this rather quaint and frankly “cute” book as it is quite entertaining to read with all its formal language, you would be most favorably impressed by the comprehensive prescribed confidentiality rules who were most detailed and quite zealous thoroughness in the preservation of respect for the patients! But to the point at hand, on “point” 12, this amusing yet instructive document states:  “…the patients are not allowed the use of tobacco, within the Asylum, the employees are expected not to use it, in any form, in their presence.”

So there we have hit, “state hospital ‘asylums for the insane,'” were tobacco roughly 130 years before modern day hospitals moved ban tobacco and smoking from their premises. I was somehow historically pleased…

Sadly Misplaced Martyrdom Wishes Were Realized

Early this morning I felt compelled to write some middle of the road comments on the then still unfolding massacre and manhunt crisis in Paris. In it I expressed my views of different cultures than mine as not only worthwhile and worthy of respect but also long fascinating to me since childhood. I ended by expressing the hope that the mass shooters would be captured alive as I saw and still see little purpose in their being killed. Alas, and I really mean that, they were killed in a standoff of their own making and the news media are already attributing to them the wishes to be martyrs.

I realize my less punitive sentiments towards them is not shared by many and I may very well be in the minority. Keeping in mind that my humble young blog is quite unknown and certainly light years away from being influential, I thought I would dabble in “bloggology” and try to set up through the available handy dandy WordPress widget a poll on this issue. This will go down at least in my mind as the most unscientific poll every conducted since my blog tends to focus on esoteric, arcane subjects like mental illness treatment policy, a psychiatrist’s perspective on cultural and issues of the intellect and the world of “letters” as it used to be called in the days of scholarship. Also this blog appears to far to live up to my expectations and attract a very UNrepresentative of any population sample and is quite self selected comprised of persons with these not so common interests. But anyway here goes.

 

I Feel Like a “Charlie” Too

January 9, 2015

I grew up all over the world even in the Middle East for 3 years. I have long had a multi-cultural view of the world and even as a child a sense of wonderment at every new culture’s customs, beliefs, modes of dress, customs of behaviors, and of course their religions, ALL of which I can say I found interesting and useful in that they all, each and every one had some cosmic, transcendental idea that I adopted in my own way. I was fortunate to have ‘internationalist’ parents who unwitting or wittingly exposed me to all these different cultures through their work which were quite international in scope. In my own workplace, a significant part of our medical staff are Muslim or Hindu. I, intereestingly enough in this mixture, am a long ago converted Jew. Socially I love to mingle with, talk with and learn from those professionals and truly count them as some of the most wonderful friends I have met and been privileged to permit to get to know.

I went to college and medical school in the turbulent late sixties and early seventies on a truly tumultuous and radical campus, the University of Michigan. I lived in “co=operative” housing in which students owned and maintained the housing. This attracted the poorest, most brainy and most motivated students on campus and some of the most radical. So I lived in the midst of much of the political anti-establishment turmoil this country went through in the Johnson and Nixon Presidencies. I was a centrist, a fascinated observer. One of theses in my several specialized Honors Programs I was enrolled in, concerned the similarities between the far left radicals, true (not Communist) Bolsevik, anarchists in the Russian Revolution of the early 1900’s leading up to Lenin’s takeover of Russia, which was not idealistic as the student radicals believed but a bloody totalitarian murderous winner kill all revolution, and, finally the themes of the American Young Leftists, Radicals in SNCC, the Weathermen, Tom Hayden, Rennie Davis, Eric Chester and many of the other radicals of that time many of whom I ‘met’ by going to meetings public and ‘underground’ and listening to their ideologies. I was truly the naive student researching for my paper and my friends always teased me as the sexually backward student ‘researching’ prostitution in the seamy sides of town in order ‘to get laid.’ Instead my mind got ‘blown.’ {No pun intended!]

I have never forgotten those lessons. All fascists, radicals, fundamentalists, terrorists, fanatics, zealots are more of less the same. An echo I saw early this moring on MSN news before 5 a.m. was a video on the similarities between Boston Marathon Bombers and the current Paris Charles Hebdon satire magazine massacre’ists. Disempowered people, often ‘losers,’ poor weak identies, alienated from really any stable social system/family, angry, blaming the system, etc. They are ALL the same no what the specific ideology. They always see the solution as best being implemented in the most firm dictatorial authoritarian manner possible, through terrorist violence and ‘revolution.’ Their system of belief is always superior all others. Free speech is dangerous, letting people become educated and to think for themselves is dangerous. Does the Taliban come to mind? How about even in this country the ultra-right (or also the ultra-left liberals) who all think their educational systems with rigid tenets that are more “anti” than evidence based are RIGHT. All else is heresy, blasphemy, science gone bad, a ‘hidden agenda,’ all the code phrases in all parts of the world where the struggle between the modern and the feudal, totalitarian, anti-progress, anti-knowledge movements are in play for control of their regions, even of the world. Nazi Germany, apartheid, American racist ideology of slavery, American subjugation of Native Americans, our current anti-immigrant hysteria, our anti-intellectualism embodied in the Bush administration’s condemnation of stem cell research, which incidentally saved my life from multiple myeloma, all are manifestations of this malignant modern day knowledge struggle as I call it.

I remember the many slogans of the American Radical student movement, most of which I thought were ridiculous. Abbie Hoffman even parodied them in his unforgettable title of his book Steal This Book which incidentally was hiliarious. And this leads to my main point: authoritarian radical fanatics have no sense of humor. This may sound trivial and dumb but it is one of the most telling of their attributes. It is currently embodied in the reasons behind the bombing in ?2011 of the Charlie Hebdon offices and the walk in massacre of the 12 staff just three days ago. That satirical magazine’s parodies were funny to many even within Islam. We have our own running gag about Jesus in the national running joke with a million variations of: “What Would Jesus Do?” I haven’t seen anyone struck down by lightning by constructing and telling their own variation of this. I am Jewish so I do not make such jokes as but I make goofy Jewish Rabbi jokes and Bubbe jokes and such. I feel that I should only joke about my kind but I RESPECT the right of others to poke fun at my religion and when the joke is a good and pointed one, on the satirical Mort Sahl plane of discourse, I laugh as hard as I feel like it. Radicals do not laugh and they react in predictable ways that do not fit their view of things, of how things should be. A corollary to this is that they cannot tolerate ambuigity. I am a psychiatrist, and as I like to say, in my profession I live in ambiguity. Those who cannot do so, react with rigidity, fear of the unknown, of what may become known that may upset or challenge their world view. So satire, humor, parody is dangerous for them.

I subscribe to a monthly old style paper newsletter of comedy and satire, a subscription originally given to me as a gift by a dear long term friend who also shares an affection for satire, humor and keeping ourselves honest through humor. It is called Funny Times and it would not be well received in any rigid, anti-modernistic, anti-science, fanatic community or society. But it is free to poke fun in our society with our long cherished values of freedom of opinion and speech. Those set us apart from the fanatics of the world.

So for now the name Charlie means to me the embodiment of self awareness, humor, useful satire that makes us examine anything and everything that needs review, our politics, our sacred cows, laws that make no sense, even beliefs that need examination, meditative development to the highest compassionate plane, and a tolerant person and society.

In keeping with that, I fervently hope the two terrorist brothers in Paris are captured alive. I know many want revenge and would be happy to see them killed in an out of control suicidal shoot out. I do not. As I heard yesterday in an interview on NPR with a mother who was injured severely and lost part of a leg in the Boston Marathon bombing, nothing would be improved or changed by use of the death penalty. It would only satisfy base and primitive urges and in my view does not serve much good purpose if any at all.

 

The Perfect Storm of Psychiatric Safety Dilemmas

A just published article caught my eye, or rather one of my targeting search bots for topics for blogging. It involves that dilemma of what to do with a ‘mental patient’ in Canada who has been ‘detained,’ i.e., involuntarily committed/hospitalized in a public [read “state hospital” in the United States] psychiatric hospital for nineteen (19) years with virtually no treatment.

He has the near perfect combination of unfortunate frightening [to the public] denominators of: 1) possible intellectual deficit and consequently, 2) lessened capacity to take in, utilize, internalize, understand and retain change from mental health treatment other than use of psychotropic medications, 4) deafness with poor knowledge, facility and use of sign language, making the enterprise of conveying concepts of treatment based healthy change and knowledge of the “wrongness” or inappropriate nature of his socially unacceptable behaviors almost impossible, and worst of all the history of and baggage of being a pedophile!

He is now is in his 50’s and has spent 19 years of his adult life in an institution under legal constraints that I assume from my own experience with just such patients as legally preventing him from “re-socialization” into the community on a long term basis to prepare for re-entry into society. Most of these patients are under near perpetual court orders keeping them under lock and key inside state hospitals as “a danger to the community.” Why, even when they go to specialty medical centers for sophisticated medical care [as they DO develop chronic medical problems just like the rest of us] they have to go in police custody. Never mind that they often have the minds of children and almost never would the capacity to escape, rob banks, kidnap persons, pull off sophisticated white collar crime scams or make an attempt on the President’s life! Unlike obviously dangerous sociopathic savvy career criminals they would not have a clue as to where and to whom to go to for purchasing an automatic rifle and even a Saturday night special cheap pistol.

So they languish in ‘interminate’ lengths of stay in hospitals ill equipped to meet their complex social, rehabilitative and psychiatric needs. And forget community speciality based supervised structured based housing for them outside the secure hospitals. Such exist only in rare enlightened communities and largely not in my bailiwick of practice. With all these ‘barriers to discharge’ as they are called in inpatient mental health jargon, they are often adjudicated “incompetent to proceed,” to trial on their charges, because they are “non-restorable” [to competency to stand trial] and no professional is going to stake their license on releasing them with the thin possibility of an adverse event of such an impaired person, say for instance, approaching a child on a school playground.

So now in Canada, comes a judicial ruling that puts a six month cap on such detaining hospitalizations altogether. As this ruling comes to be cited in the near inevitable and expectable wave of advocacy attorneys in Canada and in the US citing this as binding precedent, we could see a revolution in forced discharges for such impaired patients into the public world of communities large and small that have no place, no staff, no infrastructure, no funding, to accommodate them. Perhaps they will all end up in bankrupt empty motels and flophouse abandoned hotels as we have seen in large cities where the chronically mentally ill are housed in convenient never-ending, stopgap solutions, a contradiction in terms if I ever heard one. I sincerely doubt that our unenlightened legislatures across the country will rise to the need with the billions of dollars in funding to house and care for these very impaired, needy patients with vast multiplicity of care needs. Or will they  just dumped onto their families, abandoned military bases or sent to the other great current dumping grounds, the nation’s jails, already overflowing with disturbed mental patients.

For the report on this little noticed but potentially revolutionary, if not cataclysmic article on this ruling, please read: “Court places six-month cap on involuntary detention of mental health patients,” by Sean Fine, Justice Writer, The Globe and Mail, Published Tuesday, Dec. 24, 2014.

 

The Treatment of Multiple Sclerosis as a Metaphor for Schizophrenia

Multiple sclerosis, or M.S., is a devastating, chronic, debilitating illness, that has defied until recently most treatment approaches. It hits the young adult in the prime of life typically, more young women than men. It is like ALS though much slower, and not quite as destructive neurologically as ALS but well bad enough. Only in the last two decades or so, have treatments started to be even minimally effective. I have followed M.S. patients in my decades of psychiatric practice since I started in the neurosciences, brain science as a collegian, then aspired to go into neurosurgery before I decided on psychiatry as a medical student. I have long enjoyed practicing medical centers and general hospitals on the “psychiatry consult liaison services,” almost specializing in seeing neurology patients and M.S. patients most of all.

M.S. is like many other chronic illnesses. For decades we had only paltry symptomatic treatments. That is to say, our treatment only treated symptoms, or brought episodes to a close and did not treat the etiological, causative basis of M.S. When one had a flare of M.S. with “shorting out,” loss of a sense, use of a limb, sight, balance, etc., then one was given intravenous treatments with whatever immunosuppressant was in vogue at the time. These over the last 40 years or more have included ACTH, prednisone, methotrexate, bee venom (which like many other briefly popular treatments, did NOT work) and other agents de jure.

Then the advent of more scientifically based, more specific anti-immune system based medications came out in the 1990’s, the family of the interferons. These were much better for many M.S. patients at stopping an episode in its tracks than the previous agents. But they had like so many modern medicines in all branches of medical practice, enormous side and adverse effects. Betaseron based medicines tended to be given by injection shallowly into the subcutaneous tissues every other day and would cause in the vast majority of persons, a day of in-the-bed-flu like syndrome. “Flu without the flu” as many called it. And on an every other day schedule, you got the shot, had the flu and then the next day when the flu like aches and low grade fever and fatigue passed, you got your next shot and braced yourself for starting to feel bad physically that evening…it was awful and many many patients tolerated this for years and then en masse stopped the interferon based therapies. A newer, slightly different family of agents came out nearly a decade ago but were no better.

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