Pricing Insulin out of Reach of Diabetics in the United States

"Our survey confirms that globally, rationing insulin is all too common. It also confirms what many already know: respondents from the U.S.A., one of the wealthiest countries in the world, had the highest degree of rationing of insulin and supplies compared to other high-income countries."
Elizabeth Pfiester, head, T1 International

When Professor Frederick Banting and his assistant Charles Best completed their research in insulin in 1921 at their University of Toronto laboratory -- a lifeline was thrown to the millions of people around the world whose inability to produce insulin naturally spelled a gruesome and swift death sentence -- the world sat up and took notice. Dr. Banting and his supervisor, J.R. McLeod were recognized as Nobel recipients, an award that Dr. Banting shared with his colleague, Dr. Best. 

Dr. Charles Best (left) Sir Frederick Banting (right)

The University of Toronto, acknowledging the vital importance of the discovery of insulin in saving the lives of millions and for its future usefulness in saving untold numbers of peoples' lives, made the decision that the patent was priceless. That being the case, it was 'sold' for the princely sum of $1. The formula for producing insulin was made widely available to ensure that it could be accessed wherever people required it, at a low and reasonable cost as one of the most important advances in medical science of the time.

In Canada, insulin is available to insulin-dependent diabetics at a reasonable price. Insulin itself must have a mode of delivery, so there is the added cost of hypodermic syringes. And to ensure that people with diabetes know how much long- and short-acting insulin they require at any given time, blood-testing strips as well as a 'reader' are also required. None of this paraphernalia supporting diabetes management is inexpensive; added together the monthly costs are substantial.

A woman fills a syringe to give herself an injection of insulin.  (Reed Saxon/The Associated Press)

In the United States, it appears that the most basic element of diabetes therapy, insulin, is now sold at an astronomical price. In Canada a vial of insulin is roughly $30. In the United States people with diabetes are charged over ten times as much for the very same insulin. What irony. Canadians have traditionally travelled across the border to the United States for purchases of all manner of goods whose cost has always been less in the U.S. than in Canada. Now, when it comes to pharmaceuticals, and particularly insulin, the trend has reversed.

Diabetes is a particularly pernicious chronic condition; it must be carefully monitored and dealt with. Managing diabetes properly equates with a total lifestyle overhaul. Diet, exercise, proper footwear, precise insulin measurements to match blood-sugar levels ascertained through monitoring must be adhered to. Diabetic neuropathy, retinopathy, heart problems are all conditions associated with long-term and/or improperly managed diabetes.

A new survey in the U.S. has found that too many people must struggle financially to be able to afford this vital medication, that while 18 percent of people with diabetes worldwide take to rationing insulin because of cost; bad enough. Worse is that close to 26 percent of people living with diabetes in the United States are forced through financial difficulties to ration their insulin. Half-measures, in other words, where carefully calibrated amounts of insulin are required for maximum outcomes in health.

Of those interviewed, 70 percent reported some cost coverage while two-thirds had no financial support for their out-of-pocket costs. In the U.S. 89 percent of diabetics did have health care coverage while 79 percent had no other assistance, and 5.5 percent received assistance from government. The problem here is that in the U.S. there are no longer any vials of insulin available for $30. In high-income countries other than the U.S. rationing was reported by 6.5 percent of people living with diabetes; 11 percent in low- or middle-income countries.

Over 29 million Americans (9.3 percent of the population) have some form of diabetes, according to the American Diabetes Association -- in a country where the free enterprise system was born and pharmaceutical companies charge to the hilt for their prescription formulas. Between 2002 and 2013, the average list price for insulin tripled; where 15 years ago a 20-milliliter vial of Humulin R U-500 had a price tag of $175.57, currently the cost is a staggering $1,487.

In excess of 1,400 patients and caregivers over 90 countries responded to answers in the survey by T1 International, a patient advocacy group focusing on Type 1 (formerly called Juvenile-Onset) diabetes. Without insurance, the costs associated with insulin are financially ruinous for a great many people; even those with some level of insurance are hard put to pay their out-of-pocket costs. And since insulin sells for one-tenth the price in Canada, Americans are increasingly heading north for their insulin needs.

According to one study, the estimated cost in production of a vial of human insulin ranges between $2.28 and $3.42. Most analog insulin production costs are between $3.69 and $6.16. As a result of rising prices and a growing contingent of patients, Medicare Part D costs in diabetes treatment rose 840 percent between 2007 and 2017, from $1.4 billion to $13.9 billion, while average costs per person increased by 358 percent in the same period, from $862 to $3,949.

A group of about 25 Americans from Minneapolis headed to London, Ontario this past week to buy their non-prescription insulin. Quinn Nystrom, one of the group's organizers, paid $21 a vial for insulin when she was diagnosed with Type1 diabetes two decades earlier; now it costs $445. Canada regulates drug prices through a review board to ensure that this kind of industrial-level gouging is prevented. It's past-time for the wealthiest nation on earth to do the same for its citizens.

Honouring One's Conscience

"It shows that when we make a decision whether to be dishonest or not, it's not only 'What can I get out of it versus what's the punishment, what's the effort'?"
"It actually matters that people have morals and they like to think of themselves as good human beings."
Nina Mazar, behavioral scientist, Boston University

"The evidence suggests that people tend to care about the welfare of others and they have an aversion to seeing themselves as a thief."
Alain Cohn, assistant professor of information, University of Michigan

"[A survey found that] without money, not reporting a wallet doesn't feel like stealing."
"With money, however, it suddenly feels like stealing and it feels even more like stealing when the money in the wallet increases."
Christian Zund, study co-author

Wallets with cash, a key, a grocery list and business cards were used to test honesty.  (Christian Zünd via Associated Press)

A new study appears to confound the generalized theory that people finding a wallet with money in it are unlikely to return it to its owner, intact. This three-year study considered to be the most all-encompassing world-wide test of peoples' inherent honesty came to the conclusion that people are, after all, inclined to want to do the right thing and return a lost wallet they find. The finding was a surprise to the researchers and it goes a long way to confirming that people in general tend to be mindful of ethical conduct to the extent of actually practising it.

Not only was the discovery made through this study that people value honest behaviour in themselves which will benefit others, but that the incentive to respond honestly is enhanced when a greater amount of money found in a lost wallet is involved. Published in the journal Science, experts in the field of human behaviour feel on the basis of the study and its finding that business and lawmakers might take notice that dishonesty can be prevented through moral expectation absent punitive reactions.

No fewer than 17,303 wallets were used in a giant research ruse that took place in 355 cities on every continent. Wallets complete with transparent business card cases and visible contents containing three business cards reflecting male names identifiable with the country they were distributed in were used to seed the experiment. Each of the business cards came complete with an email address, the wallet owner identified as a freelance software engineer.

A key, a handwritten grocery list in the language of the country the wallet was used in also occupied the wallet, along with in most instances a modest amount of cash in local currency, while others had no money in them at all. They were distributed by research assistants entering post offices, hotels, police stations, banks, museums and other public arenas to approach someone in authority with the spiel: "Hi, I found this on the street around the corner".

'The evidence suggests that people tend to care about the welfare of others, and they have an aversion to seeing themselves as a thief,' said Alain Cohn of the University of Michigan, one author who reported the results. (Christian Zünd via Associated Press)

The research assistant would then hand the wallet over to the individual they had addressed, perhaps someone behind a reception desk, with the additional explanation: "Somebody must have lost it. I'm in a hurry and have to go. Can you please take care of it?" Most people emailed the purported wallet owners with a view to returning the wallet. Peru and Mexico were the two countries where fewer wallets were returned than in any other.

An average of 40 percent of people into whose hands cashless wallets were placed reported them while 51 percent of people given wallets with money, did the same. The experiment was repeated in three countries, just to make certain of the outcomes. In Poland, the United Kingdom and the United States the routine was given a second round and this time greater amounts of cash were added.

Where the initial experiment used around $13.45 in local currency, the repeat performance upped the ante considerably, adding $94.15 in cash. The response to the lost wallets was even more dramatic, when greater numbers of people dutifully emailed the presumed owners to return the wallets; 72 percent compared with the 61 percent attempting to return the wallets with $13.45, and 46 percent of the cashless wallets.

The gender, age and friendliness of each wallet recipient was recorded by research assistants, including how busy they happened to be at the time; whether they had instant use of computers to enable swift response, and whether co-workers, security guards, or cameras could have recorded the exchange in possession of the wallet, from the 'finder' to the individual taking responsibility for its return.

The theory that any of these potentially compromising details could influence the person to feel compelled to return the wallet appeared not to make a difference at all. As Alain Cohn, one of the study's authors noted, "the psychological cost of the dishonest act" in withholding the wallet with cash seemed to propel people toward honesty and the wallet's return.

And how did the experiment end? In a way that acknowledged people's positive decision making by informing those reporting lost wallets through emails by thanking them and advising that the wallet's owner had left town, and the 'finder' could feel free to retain the money, or if preferred, donate it to charity.

"[Our team] would go into these various institutions ... like a bank or a post office, and they would go to the receptionist at the front and they would say, 'Hey, I found this wallet on the street around the corner. I have to leave right now. Can I just leave this wallet with you?'"
"And then we were interested to see how often people would return these wallets, or at least report to us that they found these wallets."

"When the wallet doesn't have money inside of it, it feels like stealing. But when the wallet has money inside, you start to question: 'Hey, if I don't turn this in, what does that say about me?'"

"And so there is this aversion to viewing yourself negatively and that's part of what's motivating people."

"That's not valuable to the person who we turned the wallet in to, but it is valuable to the owner [keys inspiring people to return wallets to their owners]."

David Tannenbaum, social psychologist, study co-author 

If you came across a lost wallet containing cash, would you return it to its rightful owner? Researchers were surprised to find that a majority of people would indeed return it rather than pocket the cash. (Justin Tallis/AFP/Getty Images)

Our Ultimate Consuming Culture

"Unlike drugs or alcohol, from which we can be totally abstinent if we want to be, shopping and eating have to be done."
Dr. April Benson, psychologist

"Here's how it works: The initial pleasurable experience -- ooh la la, that bag! -- releases the neurotransmitter dopamine in the nucleus accumbens, a part of the brain that plays a major role in our neural reward circuitry. Each time we do this pleasurable thing, dopamine is released faster, more intensely. The bits of the brain charged with memory encoding record the purchase as a nice experience, thus generating a conditioned emotional response to the cue."
Linda Rodrigues McRobbie, freelance writer, London

"Over time, the pleasure associated with an addictive behaviour subsides, but because the memory of the desired effect and the need to recreate it persists, desire becomes compulsion."
Dr. Carolyn Mair, psychology consultant

"[Corporate interests and marketers exploit our acquisitiveness desires to convince us that specific foods, porn, alcohol are desirable, their language steeped in self-reward.] That's part of the strategy to normalize and make innocuous these things that really aren't."
"Their revenue streams are really dependent on the heavy consumers. Corporations, especially those that market temptation goods, depend on excessive consumption for their bottom line."
Dr. David Courtwright, emeritus professor of  history, University of North Florida

"With more materialistic attitudes and more marketing, it's making it harder in general for people to deal with this stuff."
"We have all this media, and yet we're supposed to be able to control our shopping and we're looked down upon if we don't."
Dr. Ricardo Rieppi, psychotherapist

The shopping compulsion: it teases and attracts and compels us to respond to all the advertising we're exposed to on so many levels that have become commonplace and an adjunct to our lives. Everywhere we go, everything we tune into from radio to television, videos and social media make it all so accessible and so interesting, piquing our already-heightened sense of acquisitiveness in a consumer-oriented society. So many items become 'must-haves'. All the more so when they're being flogged by celebrity figures.

Shopping once entailed a physical presence; you deliberately embarked on a mission to go downtown to a shopping area to look about at what was on offer. Now you know what's on offer, advertisements pop up each time you're on line, every time you use your smartphone, everywhere you look while out driving and billboards beckon. And really, it's no longer an effort to shop. In days gone by shopping was carried out in rural areas by the use of mail order items. Now people don't have to haul themselves to shopping centres, the Internet makes it all so simple.

We are indoctrinated and geared through social media influence to want to shop, to acquire the most up-to-date fashions, the latest technological gear, the current home fashions, so readily accessible, all we do is click and it's in the virtual shopping basket and payment is remote, no handing over of cash. In excess of 197 million people buy goods through Amazon monthly. According to Walmart, the largest retailer in the world, $500-billion in sales last year alone beefed up their bottom line. Their top-selling items? laptops, crayons, Instant Pots....really!



In the United States last year, American credit card debt represented a record $870-billion; that's a lot of 'stuff' and it's linked to "compulsive buying disorder"; at least the 19 million Americans who represent the obsessive purchasing segment of the population falling into the category of buying-stuff-they-don't-really-need grouping. German psychiatrist Emil Kraepelin originated the term "oniomania" (buying mania) in 1915 to identify a compulsion he thought of as close to kleptomania.

One survey identified 64 percent of Americans who bought items on impulse later regretted that indiscretion, a condition we call buyer's remorse. So many things that aren't needed, aren't even wanted or particularly liked, but purchased in response to a compulsion to buy items that will later end up being donated to thrift shops, original tags and all. It all began in earnest in the 1980s with the proliferation of malls alongside an increase in disposable incomes. According to experts in the field, compulsive shopping affects a minimum of six percent of the population.

What may be even more surprising is that it isn't only women but men too who tend to compulsion-shop. Researchers point out that shopping helps many people over rough spots in their lives; coasting over depression as a distraction, however temporary. We are tempted by dissatisfaction with life, by feelings of anxiety to elevate our emotions to a more tractable and pleasant position by pleasing ourselves with new acquisitions; a band-aid solution to whatever ails us. It is an addiction that is difficult to regulate and discipline.

Stem Cell Infusion : Youthful Miracles

"[YouTube's one billion audience reaches more people than any television network] and presents a formidable platform to market unproven SCTs [stem cell therapies]."
"Providers often use misleading claims, hard sell promotional techniques, an base efficacy claims on patient testimonials."
New Study, published journal Stem Cell Reports

Terry Storm, shown in 2012, works in a Stanford University lab funded by the California stem cell program, which will soon come to the end of its $3 billion in state funding. (Paul Sakuma / Associated Press)

"[The power of the personal-story narrative] often overwhelms the data. It becomes very clear that patient testimonials, patient narratives, are a huge part of the marketing strategy."
"But despite all of the pop culture representations, despite all the excitement around these therapies, there are very few ready for the clinic. If  you see a stem cell therapy being marketed in your newspaper, on YouTube, it's almost for sure an unproven therapy and, at best, experimental."
"Of course testimonials are powerful, because there's a story being told."
"I think we need health-care professional organizations like the College of Physicians and Surgeons to stop their members from operation unproven stem cell therapies."
"Sometimes patients may see studies that have been done. These are generally observational studies, they're not well-controlled studies. So, they’re just asking patients, ‘how do you feel?’ You know placebo effect can play a big role. Especially when there’s a ‘placebo theater’ when there’s fancy technology and someone in a lab coat and people are paying a lot of money and we know that studies tell us, expensive placebos work better."
Timothy Caulfield, Canada Research Chair, professor of health law and policy, University of Alberta

A doctor at a stem cell clinic in Beverly Hills, Calif., collects fat from a patient's back as part of a stem cell procedure in 2014. The U.S. has experienced a boom in for-profit clinics marketing stem cells to patients for a wide range of ailments. Critics say they have flourished because of a lack of oversight. The U.S. FDA recently sent warning letters to two clinics and said it will take a firmer approach to stem cell clinics. (Raquel Dillion/The Associated Press)

Dr. Caulfield, who collaborated on this new study with American and Canadian colleagues, searched through YouTube to find videos relating to five medical conditions, focusing on ALS, cerebral palsy, multiple sclerosis and spinal cord injury, whose sufferers had sought out stem cell therapy, none of which would have been approved for therapeutic purposes. The study team focused on 159 videos for analytical purposes which (with the exception of three) were published by clinics whose therapies were unproven.

Most of the clinics, unsurprisingly were located in India. Next up, the United States and Mexico. Most of the people who sought out this type of stem-cell therapy were Americans -- the next largest groups were East Indians followed by Canadians. The videos featured people describing the process of injections with adult, bone marrow-derived umbilical, fat, placental or fetal stem cells. While effusively praising the therapy, mention of risks appeared an afterthought with merely ten percent of the videos speaking of downplayed risks.

One video alone has seen two-and-a-half million viewers watch an interview by comedian Joe Rogan of actor Mel Gibson, speaking about his 92-year-old father's miraculous regeneration following a double dose of stem cells extracted from umbilical cord blood injected into Gibson's father's hip. He began walking again, his eyesight improved, "cognition power" improved, his prolapsed heart valve healed -- according to Gibson -- in response to Rogan's skepticism. This one interview alone attracted more viewers than any other single YouTube topic.

The stem-cell clinics convincingly inform prospective clients that their therapies -- priced from several thousand at Canadian clinics to six thousand and steeper at those in the United States -- that an infusion of stem cells at their clinics can succeed in dramatically decreasing inflammation, and regenerate diseased or damaged organs and tissues. It's a sales pitch that people are eager to embrace, and to try out for themselves, envisioning an entirely changed self, a renewal of life's prospects in extending quality of life and a more enduring life.

At a Florida clinic, on the other hand, after stem cells were injected into the eyes of three women, the therapy left them blind. And while legitimate research scientists do believe in the potential of stem cells to grow new tissue -- replacing diseased or worn-out ones -- not all therapies are created equal, nor do they have the required experimental research to back up their quality and effectiveness claims. Some that do have papers to bolster their claims for success reporting improvements to some of those treated by them.

In Canada, although Health Canada has failed to involve itself in regulating the industry, it has issued warnings of unlicensed clinics offering unauthorized cell therapies, stating unproven claims that may in the final analysis pose serious risks to people anxious to give them a try. In videoed testimonials people are seen to describe their therapies and how their stem cell treatments have led them to increased appetite, strength, movement and flexibility. Some, on the other hand, also mention such changes to be of short duration.

Some claim to owe the new quality of their lives to the clinics treating them. Others speak of how swiftly the therapy's improvements in their function kicked in: "I started walking straighter. My energy came back and I'm amazed at how quick it happened." Dr. Caulfield is of the opinion that science must work harder at communicating both its promise and its limitations to people. That the same kind of communication strategies used by stem cell clinics who operate for profit, not science, would be useful in educating people.

"We need to use narratives, we need to use interesting videos in order to get across the good science. It's starting to happen. But we need more of it to fight this", he explained. Popularizing science in the field of health sciences so that people can have a more realistic understanding of just what it is they are so quick to submit their bodies to, in the hope that the therapy will work, because those selling it to them assure them it would.

"They are experimental [stem cell therapies]. We don't know if they work, and we don't know how safe they are."

"If a patient called me up to say they are thinking of getting the therapy from a practitioner offering it like this for a fee, I would say that I don't think that's wise."
"I don't think they know they are going to get any benefit. I think they are taking a potential risk, and all of these therapies should be offered within the context of a properly designed clinical trial."

"It is kind of scary because there is theoretical risk that there could be tumours that form. There is a theoretical risk of blood vessels forming where you don't want them to form — for instance, the back of the eye or other places, so all of these things could happen."

Dr. Duncan Stewart, scientific director, Ontario Institute for Regenerative Medicine

Researchers examined the training background of clinicians at 166 companies advertising unproven stem cell therapies in California, Florida, and Texas. (Spencer Platt/Getty Images)

The Daily Weigh-In

"We were somewhat surprised since our instructions were to maintain weight and not lose weight."
"It is possible that [overweight and obese] adults were less aware of their actual body weights at the beginning of the study, and seeing their weight on the scale perhaps prompted them to make some healthier choices or behaviours which led to actual weight loss."
"Daily self-weighing is quick, easy, and relatively low cost."
"For example, if someone likes to exercise, they can use that and adjust exercise levels to maintain weight. For a different person who doesn't like to exercise, they can use a different strategy." 
"Maybe they exercise a little bit more the next day [after seeing a weight increase] or they watch what they're eating more carefully."
"The subjects self-select how they're going to modify their behavior, which can be effective because we know that interventions are not one-size-fits-all."
"Vacations and holidays are probably the two times of year people are most susceptible to weight gain in a very short period of time. The holidays can actually have a big impact on someone's long-term health."
Jamie Cooper, nutrition researcher, University of Georgia

"The fact that we have a US$70 billion weight-loss industry in the United States is a testament to the fact that weight loss is very hard."
"What works for one person may not work for another ... I would suggest that [daily weighing] is one more tool that can be added to the arsenal of behaviours people consider around the holidays to help prevent weight gain."
Sarah Bleich, Harvard T.H.Chan School of Public Health, Boston

"Having defined goals of metrics and feedback toward goal achievement is often motivating to those who are engaging in weight management."
Dr. Nanette Steinie, endocrinologist, nutrition expert, University of Maryland School of Medicine, Baltimore

Associate professor Jamie Cooper shows graduate student Liana Rodrigues how to take height and weight of a subject for clinical health measures with undergraduate Allison Jones in Cooper's clinical lab in Dawson Hall.  Photo: Andrew Davis Tucker/UGA

"People are really sensitive to discrepancies or differences between their current selves and their standard or goal."
"When they see that discrepancy, it tends to lead to behavioral change. Daily self-weighing ends up doing that for people in a really clear way."
"It works really well in the context of people's busy lives. The idea that people might already have all the resources they need is really appealing."
Michelle vanDellen, associate professor, UGA Department of Psychology

A newly-published study out of the University of Georgia has concluded that a daily weigh-in at home could prevent weight gain occurring during the winter holiday season, from mid-November to early January, coinciding needless to say with Christmas and New Year's  and just about everyone's tendency to over-indulge in holiday food of the season. What inspired nutrition researcher Jamie Cooper and her colleagues to examine the issue of seasonal weight gain was that it was known that this winter period disproportionately contributes to annual weight gain.

And even people who regularly exercise and who also indulge, are not spared. The results of their study published in the journal Obesity showed that participants who weighed themselves on a daily basis, thus receiving graphical feedback of weight changes, either managed to maintain, or even lost weight. Their study counterparts who failed to weigh themselves daily on the other hand, gained an average of around six pounds (2.7 kilograms) in that same period.

What their study emphasized was that people who began with a weight in the normal range for height remained within that range when they took the time to weigh in daily, to observe the results of their indiscreet eating during the holiday season. The study enlisted 111 adults between the ages of 18 and 65 who were instructed to maintain their weight throughout the 2017 - 2018 holiday season. Half of the study participants were randomly assigned to the weigh-in group, the other half abstained. After 14 weeks, researchers did a follow-up to determine who had succeeded.

According to Sara Bleich at Harvard, it would be difficult to ascertain whether the results owed entirely to daily self-weighing, since the instruction to maintain weight might have affected the behaviour of the participants. Though not involved in the study, she believes the data could represent a simple method whereby people could remain conscious of their weight during the holidays. And according to Dr. Steinle in Baltimore, the results suggest that using a scale daily could represent an intelligent way to boost adherence to a "healthy living" plan.

As for the study leader, Dr. Cooper feels the daily weigh-in could have popular appeal within the general public at large, since it is indeed a simple yet effective way to encourage people to remain fit during times when they are most likely to relax the standards of their normal eating patterns alongside their exercise regimen, leading them to consume more calories than they normally would at a time of seasonal lowered inhibitions. 

For many, the holiday season is synonymous with indulgence and overeating, which can lead to weight gain. (Shutterstock/File)

The paper, "Daily self-weighing to prevent holiday-associated weight gain in adults", can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/oby.22454

Everything Old is New Again

"We've known that cannabis is one of the oldest cultivated plants in East Asia, primarily for making oil and hemp."
"Now we know the ancients also valued the plant for its psychoactive properties."
"[The plant was placed there] to probably allow this man to use this to go into the spirit world."
"There is a very deep history of a relationship between cannabis and humans for many uses -- fibre, seed, oil, food, medicine and psychoactive or spiritual or other uses."
Mark Merlin, botany professor, University of Hawaii, Manoa 

"[The location of those artifacts suggests cannabis smoke was] being used during funeral rituals, possibly to communicate with nature or spirits or deceased people, accompanied by music."
"[The findings are consistent with what's known about cannabis use across Central Eurasia], possibly reflecting some kind of community of shared beliefs in the Eurasian mountain foothills."
Yimin Yang, archaeologist, University of Chinese Academy of Sciences 

Scientists exhumed 10 wooden braziers from eight tombs at the ancient Jirzankal Cemetery in what is now western China. Many of the braziers held stones that were apparently heated and used to burn cannabis plants.

Xinhua Wu/Science Advances

Cannabis is no relatively recent plant known for its mind-bending properties as well as for pain relief. The use of this plant as a substance whose properties lend to mind-altering experiences is assumed to be at least 2,500 years old in human experience and  use. A new study just published in the journal Science Advances whose conclusions are based on the chemical analysis of residues discovered in a western China burial site by archaeologists identify a substance whose charred remains were found in wooden braziers, as cannabis.

In the 5th Century B.C., the Greek historian Herodotus wrote of people in Central Asia who burned the plant, inhaling the resulting smoke within tent-like structures as ceremonial procedures during burial ceremonies. He appeared to find the ritual he described similar to what he had witnessed in Greek bathhouses. Evidently the cannabis plant was used back in ancient times just as incense is used now in many Asian ceremonies, the smoke meant to be inhaled, part of a tradition of spiritual practices.

Cannabis residue the archaeologists found at the western China site was located in wood containers or braziers holding stones that conceivably were heated to create smoke from plant material which laboratory tests identified to be cannabis with higher levels of the psychoactive ingredient THC than most wild varieties of the plant naturally contain. Which led to conjecture whether people of the time cultivated the plants to breed them for their higher THC properties or had simply come across rare varieties of the plant containing greater amounts of the chemical.

According to Robert Spengler, a scientist at the Max Planck Institute for the Study of Human History in Jena, Germany, and a co-author of the paper, "a solid, unequivocal data point for actual use of this plant as a drug" was derived from the research. That this was ceremonially conducted during a burial led the researchers to believe the ceremony participants made use of cannabis "to communicate with nature, or spirits or deceased people", concluded Yimin Yang, the paper's senior author.

Much further away in northern China at yet another burial site, a kilogram of chopped cannabis was discovered adjacent to the head of a man buried in a cemetery which dated to roughly the same period. According to Dr. Spengler, there were two phases of cannabis domestication; first it was cultivated in eastern China some 3,500 years ago, valued as a source of fibre, oil and food, the wild plant having very low THC content. No evidence exists that the earlier domestication was linked to inhalation of the smoke.

The site in Western China, however, indicates that people had by then discovered and valued yet another feature of cannabis; the presence of tetrahydrocannabinol (THC). Archaeologists had excavated eight tombs in a burial site called Jirzankal Cemetery, in the Pamir Mountains of western China in 2013, where four stones were found with burn markings. When the material was examined through a chemical analysis known as gas chromatography -- mass spectrometry (GC-MS) the presence of cannabis with relatively high levels of THC was revealed.

Tomb M12, where the wooden burner was found   Photo: Xinhua Wu

DCD (Donation after Circulatory Death) Heart Transplants 

"The thing that people need to get their heads around is that, in order to do DCD hearts -- heart transplants after the heart has stopped beating -- the heart has to start beating again."
"It can either beat again outside the body, in this perfusion system or it can beat again inside the body."
"And the question is, because it's a more complicated procedure, because there are biological realities and there are ethical issues, the question will be for Canada going forward -- and I don't have the answer for you now -- can we do normothermic regional perfusion in Canada for DCD hearts? And if so, how to do it consistent with existing pratices and the medical, ethical and legal safeguards that should be in place."
"But, I think conceptually, in the world, we're evolving toward a brain-based concept of death. Would it fulfill our criteria for death? I can't answer that yet. There's both research and policy work that needs to be done to answer that question."
Dr. Sam Shemie, critical care doctor, medical adviser, Canadian Blood Services

"We need to be certain that there is no brain perfusion following the resumption of circulation in the donor body. We also need to be certain that we have accepted that resuming circulation in the body does not invalidate the determination of death. And the critical-care community, in the large part, would accept that, I think. But more work is to be done before this can occur in Ontario."
"In culture, in a variety of symbolic ways, the heart means something special. Up until now, we've not been able to recover and transplant the heart in this donation, and many families have expressed disappointment in that."
"We are dealing with a group of people who consent to organ donation that are tremendously courageous and generous. They want to give the most that they can give."
Dr. Robert Truog, bioethicist pediatrician, U.S.

"So, it's probably a storm in a teacup [fears that] folks might wake up, or some such thing."
"And what we've seen is that we can restore that blood supply within four minutes of the patient arriving in the operating room after declaration of death."
Dr. Stephen Large, surgeon, Papworth Hospital, Cambridge, England

Up to the present time, the delicate issue of donor hearts for transplant have been obtained from people whom medical science has declared brain-stem dead, a condition under which they are considered to be both medically and legally dead, even as their hearts remain capable of beating. The problem arises with the shortage of transplant-capable hearts from brain-dead donors. And a new technique has arisen which has become feasible for increasing the number of hearts for transplant at a crucial time of shortage.

A portable device called a "heart-in-a-box" which is a perfusion machine somewhat similar in appearance to a mini-ICU where blood collected from the donor is pumped through an oxygenator and into the heart, has presented as part of another option. It is a technique whereby hearts from organ donors whose hearts have stopped beating, are restarted before transplantaton. Beating and "breathing", the disembodied heart can be viable inside the sterile box for up to 12 hours.

The method is in use in Australia and the U.K. In Britain doctors proceed once life support is withdrawn from a donor following that brief window when the heart no longer beats and doctors, having waited the obligatory five minutes before death is declared -- when no pulse, no heartbeat is detected, nor chance the heart may spontaneously begin beating again -- the body is removed to the operating chamber where surgeons cut into the sternum, clamp the main arteries and connect the body to a machine designed to take over the work of the heart and lungs.

This machine with its specialized engineering has been named ECMO, extracorporeal membrane oxygenation. This stage completed, an incision is made through the abdomen wall, blood is re-circulated to the thorax and abdomen, and the heart is "revived"; the person is dead, but the heart is once again beating. In twenty minutes' time the heart is taken from the machine pumping on its own while within the corpse. The heart is injected with a cooling solution, extracted, and placed within the perfusion device for transport to the hospital where the transplant patient is awaiting a new heart.

The Canadian Blood Services and Trillium Gift of Life Network in Ontario conferred to develop expert guidance in determining conditions where "donations" prepared in such a manner could be done in Canada. Where, once life support is withdrawn, the heart no longer beats, organ procurement commences. DCD donors account for 25 percent of all donations in Canada, resulting in a gratifying increase in donor kidneys, livers and lungs. Now, Canada awaits the addition of hearts to the new process, since one so successful with other organs fails with hearts.

The new process solves the problem of the heart contracting once life support is withdrawn, and starving of oxygen and blood. As the muscle cells begin to die, blood pressure drops leaving the heart to go into cardiac arrest; its response to a period without blood flow and oxygen. A conundrum has developed with respect to the new system called normothermic regional perfusion in that if death is defined as irreversible cessation of circulatory and respiratory function, once circulation is restored, how can the person be considered dead?

In response to which Dr. Truog notes that simply because a heart cannot restart on its own does not denote it cannot be restarted; that people are creating an imagined problem over the determination of permanence. Circulation to the brain, he argues along with other experts, is what most matters. If  you "reanimate" the heart, the query remains, is there a remote opportunity for the brain to be reanimated, even if major vessels are clamped, cut and tied off?

The very question of reanimating dead hearts elicits a squeamish response from many. Some argue that restarting the heart has implications of death never having occurred, or that retrieval of the heart would amount to a violation of the "Dead Donor Rule", holding that organs must not be procured until the individual is dead. Two Harvard doctors argue in the journal Circulation: Heart Failure, that the act of reviving the heart will not alter its biological condition at the moment that death was declared; that it would not "toggle the state of the donor between dead and alive".

Since major blood vessels feeding the brain have been clamped, "the donor can be considered brain-dead before the donor heart is reanimated", they concluded. About 25 percent of adults in Canada die as they wait on, or are removed from the waiting list, once they become too ill for transplant. Leaving about 150 adult heart transplants concluded annually in Canada. "So even if you increase it by ten or twenty percent, that's significant", stated Dr. Shemie.

"Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality." "Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided."
Circulation: Heart Failure

Single-Use Plastic Exceptions

"It would be hard to overemphasize the importance of plastics in modern society."
"Just think what our world would be like if we didn't have garbage bags. It's not a frivolous use -- it's absolutely necessary for sanitation."
"We were gyrating with hula hoops, going to Tupperware parties [in the 1960s], listening to vinyl records, playing with plastic toys and drinking from plastic cups through plastic straws. And we were paying for it all with plastic."
"[The current backlash against plastic is no all-or-none situation]: It never is in science. You have to evaluate each of these uses on their own merit."
"This business of having a plastic-free world, it's just nonsense."
Dr. Joe Schwarcz, director, Office for Science and Society, McGill University, Montreal

A surgeon holds a syringe prior to administering chemotherapy on June 7, 2019, at the Georges-Francois Leclerc centre in Dijon, central-eastern France.   ROMAIN LAFABREGUE/AFP/Getty Images

"Climate change is now a lot more real for more people than ever. To most, it falls under the umbrella of 'environmental harm', so it all gets lumped together."
"The problem is, being aware that something needs to be done about the environment, and actually doing something about the environment is a big leap. They have all the worry of climate change, and none of the control."
"That it might be negligible overall [to give up plastic straws and feel virtuous about it] is not really the issue, it's the feeling of making a difference, of being able to affect outcomes -- that is the main thing."
"[Politically, straws are easy targets], something that could be removed without much upheaval, for maximum political gain."
"The disposable plastic furor isn't bad, per se [but some objects will always require durable, flexible, sterile material for proper function]. Syringes, IV stuff. Could you make plastic alternatives that have similar properties but are more biodegradable? Maybe."
Dean Burnett, neuroscientist, author, Cardiff, Wales

Disposable plastic items in the health sector aren’t a major concern, experts say. Tim Boyle/Getty Images

A study conducted a few years back by researchers at Magee-Womens Hospital in Pittsburgh found that on average, a single abdominal hysterectomy was responsible for generating 9.2 kilograms of waste. Half of that waste was disposable gloves, thin film packaging, wrappers, hard plastic trays and other plastics. The idea of the study was to weigh the environmental impact involved in the second most common major surgery for women in the U.S. and Canada; a hysterectomy.

The team studied 62 surgeries where researchers immediately on the completion of each of the surgeries entered the operating theatre to carefully collect, sort, label and weigh the solid waste and recycling. When politicians announce that it is time for single-use plastics to be regulated against in view of the vast amount of plastics circulating as waste in our environment, in the world's oceans, they have a point; we do package consumer items much, much too much.

On the other hand, there are exceptions; nothing is ever as simple as it seems at first glance. Syringes, IV tubing, saline bags, plastic-wrapped drugs, catheters -- all are objects made of plastic without which modern hospitals would find it difficult to operate, ensuring adequate sterile conditions to contain bacterial contamination. Some  hospitals, cognizant of the ultra abundance of waste plastics have undertaken steps to make operating rooms and other patient care areas less wasteful.

According to an article published in the Canadian Medical Association Journal, up to 85 percent of hospital garbage is non-hazardous solid waste. Plastic packaging is a typical source of waste plastic where many surgical products are double-wrapped. Blue sterile wrap is used to cover surgical instruments, but it can be recycled into curbside blue boxes. Hospitals in Quebec sort plastics, to send them to recyclers.

Hospitals began their shift to plastic, single-use sterilized products a decade ago, transitioning from sterilizing reusable products in a bid for absolute sterility, and to ensure that pathogenic bacteria not be transferred from one patient to another through re-used instruments, when sterilization processes failed. "The shift has been done and, while it's not impossible, it's difficult to undo", stated Jerome Ribesse, director general of Synergie Sante Environnement and a member of the board of the Canadian Coalition for Green Health Care.

According to Vito Buonsante, plastics program manager at Environmental Defence (what a name to match with an enterprise!) disposable plastic items emanating from the health sector do not constitute a major concern. It is the unnecessary use of plastics for the production of cutlery, plates and take-out containers that would usefully be tackled first. Straws are symbolic for environmentalists, yet they account for little in terms of weight in total plastic waste.

Think in terms of plastics of merit and long-term use. Say, for example, flat-screen TVs, computers, water pipes. Indispensable to our modern way of life.

Operating room. - 123RF Stock Photo

Hypothesizing Teen Anguish

"What we found was that yes, incidents of self-harm are increasing, and so are emergency department visits with mental health concerns."
"But I don't think any of the study team members expected such a dramatic rise from 2009 to 2017."
"Engagement with social media could lead to increased rates of self-harm, at least for vulnerable adolescents. This could happen in several ways: by normalizing self-harm, by triggering it, by getting teens to emulate self-harming peers, or by exposing youths to cuber bullying."
"We have hundreds of kids coming to Ontario emergency departments with these problems. The rate is going up every year. The rate is not slowing down."
"But the number of child psychiatrists at CHEO [Children's Hospital of Eastern Ontario, Ottawa] and child psychologists hasn't changed over that period. The number of emergency department personnel hasn't changed. That is really a problem."
"Efforts should be made to increase the supply of and access to evidence-based treatments for adolescents who self-harm or have mental health problems."
"Where possible, it's important to deliver these services to youth before they need to come to an emergency department."
Dr. William Gardner, senior scientist, CHEO Research Institute

CHEO emergency entrance. Wayne Cuddington / Postmedia

The trend toward teenagers turning to self-harm as an expression of their mental health needs being unanswered by health services represents a challenge to any society. Obviously, understanding the motivation or the pathology behind this trend of teens self-harming should be recognized as one of urgent need, both for the medical community and society at large to involve themselves in, since the cost to young peoples' mental health is so grievous and the loss to society of well-adjusted youth is increasing should mark this as a health emergency.

Research, led by Dr. William Gardner and published in the Canadian Journal of Psychiatry, points out that self-harming teen episodes have over-doubled between 2009 and 2017. What, however, is the driver? And until that is understood and measures taken to ameliorate the situation, it is more than obvious that the condition will continue and continue to accelerate. Teens reacting to unidentified stressors have been cutting or poisoning themselves and they are recognized as being at risk for repeated self-harm, and possibly suicide attempts.

There are hints of the increase in self-harm being coincidental in timing with the iPhone's introduction, leading to the ubiquitous use of smartphones in society in general, and among young people in particular. Canada saw iPhones being sold from the summer of 2008 onward and the suspicion among many is that this marked the beginning of increased self-harm among teens. The increased use of iPhones appears to have matched the increase in teens self-harming, according to the research hypothesis.

"Having all these phones in your pocket could be very difficult" for teens who are self-conscious about their social status or appearance to begin with, making them more vulnerable to facing social rejection or being emotionally bullied on-line. The other side of the equation, suggested Dr. Gardner, was that some emotionally unstable youths could benefit through social media, providing them with a venue away from social isolation, encouraging them to look elsewhere for validation, or even realize that they could benefit from health treatment.

The research was based on data retrieved from emergency departments province-wide, between 2003 and 2017, relying on data revealing a trend seen at hospitals and in communities increasingly in recent years.  Rates of youth emergency visits for self-harm happened to decrease by 32 percent between 2003 and 2009, and then swerved dramatically upward by 133 percent between 2009 and 2017. Mental health visits to hospital emergency rooms increased by 78 percent between 2009 and 2017 for all youths, while those linked to self-harm and mental health visits were higher for females, increasing more steadily than for males.

The findings, according to Dr. Gardner, a professor of epidemiology at University of Ottawa, and senior research chair for child and adolescent psychiatry, raise concerns relating to treatment for adolescents who present at emergency departments with mental health issues, where those departments are not equipped to deal with the needs of the teens due to a shortage of appropriate medical personnel. A shortage echoed by child and youth mental health workers province-wide.

As far as the researchers are concerned, emergency departments which represent the first contact in mental health issues for families do not present as an ideal setting for adolescents in crisis, requiring mental health services. Mental health followup through community-sourced medical care where the needs of self-harming teens are the focus remain the most effective source of help. Such followups have been identified with a reduced chance of repeat self-harm by teens, speaking to the success of such community health groups whose critical shortage disadvantages the growing numbers of teens in need.

The Enigma of Dissatisfied Human Physical Ideals

"Many assessment tools that are currently standard practice to diagnose eating disorders are geared toward females and are based on weight loss behaviours with the goal to become thin."
"Exercise is an under-recognized component of eating disorders. Teenagers who excessively exercise can have energy deficits and become malnourished if they do not increase their food intake to match their energy needs."
"Disordered eating may develop when a boy becomes preoccupied with his appearance, body size, weight, food, or exercise in a way that worsens his quality of life. He may withdraw from his usual activities or friends because of concerns with body size and appearance."
Dr. Jason Nagata, University of California San Francisco

"We are basically not asking the right questions for boys."
"Consequently, boys do not get access to treatment and they do not themselves see their problems as an eating disorder."
Dr. Trine Tetlie Eik-Nes, researcher, Norwegian University of Science and Technology, Trondheim

Eating disorders in boys and men are not readily recognized as such, mostly because diagnosis is canted toward symptoms related to and common with eating disorders in girls and women. The popularly-recognized symptoms of eating disorders making diagnosis simple for a troubling pathology are all associated with the way that girls and women react to their eating disorders; the symptoms are not transferable to boys and men. Males focus on building muscle, as opposed to reaching a goal of appearing unhealthily thin.

Adolescent eating disorders exemplified by calorie restriction and purging represent the classic hallmarks of girls' illness, not that of boys. A recently published commentary in the Lancet Child & Adolescent Health, makes that quite clear, reflecting the work and conclusion of Dr. Nagata and colleagues. Pediatricians and parents may simply overlook eating disorders among teen-age boys; unlike the characteristic symptoms for girls, boys' disorders are linked with the over-consumption of proteins.

Boys will take to a rigid regimen of restricting intake of carbohydrates and fats, and indulging in periods of over-consumption and calorie cutting, convinced this will aid in building muscle, according to the doctors' commentary in the Lancet Child & Adolescent Health journal. The use of steroids or supplements to bulk up, or to compulsively exercise, is the type of focus that boys' eating disorders typically lead toward.

Positive body image

Medical community guidelines steering treatment for eating disorders in boys fail to offer recommendations for how best to proceed with patients who exercise excessively. Biohacking is yet another method that increasingly appeals to teen-aged boys with eating disorders as they attempt to optimize physiology for muscle building through episodes of intermittent fasting, elimination diets, supplements and multiple cycles of steroid use.

The issue of the use of unregulated supplements used by teen-age boys to bulk up, which can include a variety of ingredients not clearly labelled or approved for human consumption is yet another problem the doctors identify in their commentary. The most pressing issue to be considered at this juncture, given the increasing numbers of boys and teens presenting with eating disorders is that most research has been undertaken focusing on disordered eating patterns in girls and women; non-applicable to boys and men.

What is applicable however, to both genders, is the idealization of the human figure whereby the 'perfect' muscled male becomes an object of admiration and that of the thin but curvaceous female whom girls and women are anxious to emulate to fit the concept that anyone can aspire to -- the perfect male or female shape through dedicated sacrifices downplaying the need for healthy, balanced food intake and moderate-level exercising.

As the younger generation becomes more addicted to social media sites where the ideal figures for each sex is constantly flaunted, the onlooker's sense of perspective dims and anxiety mounts. What steps into the picture at that juncture is the implacable 'need' to achieve perfection. Accompanied by a willingness to force one's body into an unrealistic and ultimately harmful conception of the perfect male or female shape.

Boys who exercise too much can become malnourished even when they aren't restricting their calorie intake, the doctors write. Photo: Getty

Sex or Text?

"Several high income countries have recently reported a decline in the frequency with which men and women have sex. Sexual inactivity might not seem an obvious focus for public health attention—concern is generally reserved for sexual activity and its adverse outcomes such as unintended pregnancy, sexually transmitted infection, and sexual dysfunction—but regular sexual activity has benefits for health, well being, and quality of life."
"Research indicates that men and women who enjoy an active sex life are fitter, happier, and have better cognitive function and increased life expectancy. Evidence shows that sexual activity might help prevent infection by bolstering immune function; protect against cardiovascular disease by lowering heart rate and blood pressure; and reduce stress by increasing release of oxytocin."
Authors: Kaye Wellings, professor, Melissa J.Palmer, research fellow, Kazuyo Machiyama, assistant professor, Emma Slaymaker, associate professor, London School of Hygiene and Tropical Medicine study, British Medical Journal

"[There appears a connection between smartphone tyranny and the weakening of] the boundary between the public world and private life ... You get home and continue shopping or buy tickets -- everything except for ... talking."
"You don't feel close when you are constantly on the phone."
"Several factors are likely to explain this decline, but one may be the sheer pace of modern life."
"It is interesting that those most affected are in mid-life, the group often referred to as the ‘U-bend’ or ‘sandwich’ generation. These are the cohorts of men and women who, having started their families at older ages than previous generations, are often juggling childcare, work and responsibilities to parents who are getting older."
"What is important to well-being is not how often people have sex but whether it matters to them.
More than half of the men and women taking part in the study said they’d prefer to have sex more often, which could partly stem from unfavourable comparisons with what they think is the norm."
“Most people believe that others have more regular sex than they do themselves. Many people are likely to find it reassuring that they are not out of line."
Kaye Wellings, lead author, study Changes in, and factors associated with, frequency of sex in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles (NATSAL)

A study on mobile phone use while performing other activities was presented at a symposium on how digital technology is affecting relationships ( Getty )

A recently published major sex survey of 34,000 Brits points out the grip of the Internet has led the United Kingdom to join other countries ranging from Finland to Australia, in research validating that populations are less engaged in sexual union. One of the world's most thorough sex surveys -- The National Survey of Sexual Attitudes and Lifestyles (NATSAL) which has conducted surveys every decade since 1991, released its latest findings representing the period up to 2012.

That finding validates that sex life in Britain, as in many other countries of the world where the Internet has taken precedence over all other modes of communication, including face-to-face, is responsible for people fixating on social media and all manner of Internet searches and communications, at the expense of one-on-one relationships of an intimate order; namely sex or conjugal relations, which are steadily on a downward spiral.

In 2012, 13.2 percent of women in Britain reported having sex on ten occasions or more in the past month, as compared to 20.6 percent back in 2001. For men, the figure over the same period dropped from 20.2 percent in 2001 to 14.4 percent by 2012. Those are the numbers representing couples who have continued to engage in sex. In sad contrast both men and women who had not experienced any sex in the past month had risen to almost 30 percent whereas in 2001 the figure stood at 23 percent of women and 26 percent of men.

As far as the authors of this latest study are concerned, it is the rise of smartphone use (the ubiquitous and hugely popular iPhone was launched in 2007), where the Internet has made its way into all aspects of peoples' lives. Digital life for most people has become an endless 24/7 affair. The compulsion to endlessly check email, to scroll, to scrutinize alerts, to engage in games and tab-opening are all identified as playing their part in destroying peoples' personal, intimate lives and concentration on other day-to-day concerns.

It is the social life of millennials that has fixated the interest of researchers, who delve into their sex lives for data applicable to that demographic. They, after all, came of age online. As a result the social contract requiring face-to-face relationships to bloom has passed them by with the disinterest of those who have more interesting fish to fry. The gap that exists in social awareness and custom between people over 35 and those under 28 in the modern social construct is immense.

Yet, this most recent NATSAL survey identifies that the steepest decline in having sex appears not among the young and single, but rather within the over-age 25 demographic who happen to be in long-term stable relationships; married or cohabiting. In this group the odds of having had sex ten or more times by either men or women was about halved between 2001 and 2012. These are the people who bring the Internet into bed, where the tendency is to continue working, organizing, shopping, communicating.

The survey looked no further than 2012 for its conclusions. But no one doubts that the situation has only exacerbated as the public ever more fiercely embraced their indispensable iPhones, abandoning flesh-to-flesh contact. The Wall Street Journal conducted a poll, finding a rising number of Americans (36 percent of 28-to-38-year-olds, and 16 percent of those over 39), will make the inevitable choice of Internet over sex.