Katie Couric on a "60 Minutes" broadcast last month reported on the potentially dangerous diagnosis of bipolar disorder in children. At least one doctor at his clinic was prescribing off-label medications--those not tested on children--as a viable treatment for their behaviors that seem out of control. However, use of these medications does not come without side effects, including, as CBS reports, "major weight gain, hand tremors, shakes, drooling and muscle spasms." It also has an ultimate risk: death, as in the case of Rebecca Riley whose mother Carolyn is now on trial for allegedly killing her by over-administering the prescribed drugs. And when Couric asked her if she thought her daughter really was bipolar as the doctor diagnosed, she replied "Probably not" and instead, "Maybe she was just hyper for her age." Her conclusions unfortunately came too late.
This may be a long-winded introduction to a book review, but it clearly sends the message that the public, especially parents, should use a common sense approach to health assessment. The Illusion of Certainty by Erik Rifkin, Ph.D. and Edward Bouwer, Ph.D. discusses how to measure the risks and benefits of screening tests and drugs. In using a unique approach they hope to succeed in empowering people to make well-informed decisions about their own health and the health of those in their care.
While the public is barraged with information from the media regarding symptoms and outcomes stated in relative terms, the authors say that they really aren't provided with clear and unequivocal evidence. And unfortunately, based upon Wal-Green's success in putting a pharmacy on every corner comes the obvious conclusion that not all but too many physicians satisfy the notion that drug therapy is a cure-all for everything that their patients think ails them. Of course, the book for the authors' own protection comes with a disclaimer that it is not a medical guide to self-assessment.
Erik Rifkin is president of Rifkin and Associates of Baltimore, MD, an environmental consulting firm that addresses the nature and magnitude of environmental risks and potential remediation strategies. Edward J. Bouwer is professor of environmental engineering at Johns Hopkins University in Baltimore. He has provided guidance on managing human and ecological risks to Congress, regulatory agencies and the scientific community.
The purpose of the book, the authors say, is to provide individuals with the tools to interpret health benefit and risk values objectively. The authors define the difference between absolute risk, or an individual's chance of developing a disease over a given time, and relative risk reduction, the stats often used by the medical community and drug companies which the authors suggest present a distorted picture. They point out that absolute risk reflects the number of people who will get the disease compared to the total number of people in the study while relative risk reduction compares the total number of people who get the disease with those who benefit from intervention but neglects to consider the total number of people considered.
Get a second opinion is not unknown advice. Some patients, however, still blindly choose to disregard the human factor in their physician's decision-making. Actually, what the authors are saying is that a second or third opinion, although important information, is only part of the mix of information that a person should sift through to reach his or her own final decision.
In dealing with risk, Rifkin and Bouwer offer as an example the decision made by the parents of a young son who had developed a lump on his leg. The parents, opting against surgery in spite of the doctor's advice, apparently decided that the risks of surgery including nerve damage that the doctor mentioned outweighed the possibility that the lump was cancerous. They said they researched the total picture on their own and thought it was one that the physician should have provided.
Risk estimates, Rifkin and Bouwer say, also should be considered in evaluating the need for screening and preventative care, since individuals are constantly being encouraged to seek these services. In discussing one woman's very personal decision to have a routine breast cancer screening or not, they concluded that the medical community is lax in providing an accurate assessment of the harm and benefits from screening mammography even if it means acknowledging the overall uncertainty in assessing the health risk.
From The Illusion of Certainty
Tackling the fact that many individuals concerned with health risks have little or no medical or scientific background, the authors have developed a paradigm placing health risk and benefit information in a familiar format. They decided to use a theatre seating chart to show absolute risk reduction for the likelihood of contracting various illnesses as well as the percentages of benefits of popular screening tests. With 500 seats darkened out of 1,000 in one illustration they visually show that 50% of individuals develop AIDS within 10 years after being infected with the HIV virus, an acceptable medical conclusion. In contrast they show that only one seat out of 1,000 would be darkened for a woman likely to benefit from mammogram screening based on the results of a Swedish study in 2000. While this illustration and the statistic it represents is quite controversial, what the authors are suggesting once more is that educational material should be provided in this case regarding the risks of breast cancer compared to the possibility of radiation exposure.
A significant portion of part one of the book deals with risk assessment applied to environmental health. And it is in this section that environmentalists might question what appeared to be Rifkin and Bouwer's bias in discussing the effect of a California pulp mill's emissions, calling attention to a high degree of uncertainty in the research results and findings. The limitations of environmental risk analysis were discussed similarly with the Maryland Department of the Environment's attempt to place the blame for chromium and sediment toxicity on one particular company.
The topics in part two of the book deal with the connection between Vioxx and heart attacks, the benefits for screening for colorectal cancer and prostate cancer using prostate-specific antigen (PSA) testing, the significance of elevated cholesterol, the effects of smoking, residential radon and the risk of lung cancer, and the pros and cons of chlorinated drinking water. The final section attempts to evaluate ecological risk assessment. While the authors say, "The ecological problem needs to be defined, and the hazards need to be identified," whether this assessment ultimately will improve decision making and consequently protect ecological resources is not clear. Their discussion of whether gall flies should be brought into an environment to control invasive and toxic knapweed, whether the crown-of-thorns starfish should be controlled from attacking the coral in Australia's Great Barrier Reef or elsewhere or Asian oysters removed from Chesapeake Bay again illustrate the author's contention that there are often no right or wrong answers, just endless uncertainty.
Stats can lie no matter how clearly they are presented and by whom. The Illusion of Certainty should be read by anyone wanting more information about the difficulties in assessing health risks and benefits but still interested in taking charge of his or her own health decisions.
Title - The Illusion of Certainty [Health Benefits and Risks]
Author - Erik Rifkin, Ph.D. and Edward Bouwer, Ph.D. with guest author Bob Sheff, MD
Publisher - Springer (9-14-07)/244 pp./$29.95 (available from Amazon.com)
Versions in hardcover --ISBN-10: 0387751653 ISBN-13: 978-0387751658