Asthma is a big problem in the United States, and one which is growing annually. Somewhere between 3000 and 4000 people die from the disease in this country annually; this figure includes about 200 to 300 children. While I am unaware of confirmed asthma deaths in the setting of backcountry treks, the disease is so common it is inevitable that some folks with asthma will have difficulty in the wilderness.
Most specialists in asthma believe that the bulk of these deaths are unnecessary. Many of them result not from the lack of appropriate therapy but from failure to use well-established therapies in the appropriate fashion and time.
There is a major national initiative ongoing to improve all of this. One big component of it is the development of personal "asthma action plans" (AAPs). These are documents which are developed for individual patients with their physicians, which provide specific directions for treatment depending upon actual symptoms. There are several versions of AAPs, but all are predicated on the individual's assessment of his or her condition as "green" (good), "yellow" (not good), or "red" (awful). The plan provides specific medication suggestions for each zone. Here's a link to a nice example of an AAP:
http://cpnonline.org/CRS/CRS/pa_actionpl_art.htm
How does this relate to the wilderness? Although this system has become state-of-the-art for asthma care in the US, it has largely not penetrated first aid courses--any courses, not just wilderness ones. I recently reviewed over a dozen wilderness first aid textbooks and none even mentioned the AAP. Instead, they had a variety of generic recommendations regarding inhalers, perhaps enhanced by some attempt at explaining esoteric lung physiology, none of which were particularly useful. I guess that I shouldn't find this too surprising, since at a panel discussion in which I took part a while ago the representative of a major provider of wilderness first aid training commented that he had asthma himself and never heard of an asthma action plan!
Is there an "action item" for the wilderness educator here? You bet there is. Part of the pre-trek process in most programs is some sort of medical history/screening/release. I firmly believe that if any prospective participants provide a history of asthma, they must have an up to date personal AAP, a copy of which accompanies them on the expedition. Of course, there is also a need to be sure that the individual has an adequate supply of any or all drugs called for in the AAP.
What if someone does not have this? Although I hardly ever criticize fellow physicians (I know you'll find that hard to believe!), this is a time when it is appropriate to do so. Simply put, a physician caring for a patient with asthma in the 21st century who does not provide an asthma action plan is providing substandard care. This isn't just me--the Center for Medicare and Medicaid Services (CMS) has a standard for hospitals that patients with asthma must be provided with AAPs upon discharge. Failure to do so can actually result in hospital sanctions.
Therefore, I believe that programs have an obligation to their participants to notify them that they must discuss with their physician the development of an AAP and must bring one along with them.
Thursday, December 1, 2011
Wednesday, October 5, 2011
What do ticks, heart attacks, and protozoa have in common?
I recently did a column in my wilderness health series in Adirondac magazine on the topic of ticks (http://adirondoc.com/publications/ticked_off_072011.pdf). I warned the editor that as soon as the column came out, he would be receiving irate letters. He didn't believe me.
The ink on the magazine was hardly dry when the first complaint came across his desk.
I was taken severely to task for minimizing the problem of Lyme disease among users of the outdoors.
Read the piece and judge for yourself. Lyme disease is a nasty affliction, but virtually always treatable with a short course of a common antibiotic; deaths from Lyme in the US are virtually unheard of. "Chronic" Lyme disease exists mainly in the minds of a group of unfortunate folks with some sort of chronic pain syndrome and a group of "specialists" who make a living from them. Hikers in tick-infested areas should take some simple precautions, but not consume much mental energy worrying about them.
The whole thing got me thinking about the irrational way in which those of us in the outdoor education industry decide what to worry about. It isn't just ticks.
I spend a lot of time working with challenge course programs, especially around issues of "medical screening". There have been a few (actually very few) cases of sudden cardiac death involving users of these courses, although on a per-participant-hour basis the actual risk is statistically at baseline (http://adirondoc.com/publications/sudden_death_2002.pdf). (Remember, over 300,000 people experience sudden cardiac death annually, and every one of them was doing something at the time!) This has not stopped some in the industry from arguing for exhaustive (and completely unvalidated) screening methods to select out those at risk. This has reached the ludicrous point of some arguing that failure to implement such screening is "unethical"! Of course, experienced cardiologists will tell you that they cannot predict the risk of sudden death in any specific individual, but this has not stopped facilitators from implementing simplistic checklists--preventing nothing but also potentially depriving folks who could benefit from such a program from participating.
I have commented previously on the silliness which has inflicted many outdoor instructors regarding the risk of water-borne giardiasis. Although the scientific data on this problem are abundantly clear, there continue to be programs which enforce water treatment strategies which are entirely unsupported by data. Some of these are so bizarre (keeping utensils which are "dipped" in suspect water separate from "clean" ones; flushing out the microliters of water caught in screw-top water bottle grooves) they seem more suited for the Book of Leviticus than outdoor education materials.
The problem with this sort of thing is that there actually are some very good data which should inform our decision making in these areas. Sadly, most outdoor education programs do not seem to integrate such epidemiologic data into their policy development.
We worry needlessly about water quality, while rarely enforcing hand sanitation--a far better way to address the spread of intestinal infection on the trail. We push for wide availability of "Epi Pens" without prescription to trek leaders, with virtually no data pointing to anaphylaxis as an actual problem in outdoor education courses. Of course, those who push for Epi Pens are not the ones advocating flu shots and immunization updates--a vastly more important intervention for a group about to set out on a lengthy expedition. Many programs insist on lengthy "woofer" courses and refreshers for their leaders, in the face of absolutely no evidence that such programs meaningfully impact safety, even if a fraction of their skills could be retained. Epidemiologic data clearly point to automobile accidents and drowning as the major causes of death on treks--have you ever heard of a program with a mandatory driver education or water safety recertification requirement?
In my "day job" as an academic physician, I am constantly surrounded by the drumbeats of those insisting that everything we do be firmly grounded in evidence. When I step into the outdoor education arena, however, it appears that unsubstantiated opinion, anecdote, and dogma regularly trump evidence.
We must do better.
The ink on the magazine was hardly dry when the first complaint came across his desk.
I was taken severely to task for minimizing the problem of Lyme disease among users of the outdoors.
Read the piece and judge for yourself. Lyme disease is a nasty affliction, but virtually always treatable with a short course of a common antibiotic; deaths from Lyme in the US are virtually unheard of. "Chronic" Lyme disease exists mainly in the minds of a group of unfortunate folks with some sort of chronic pain syndrome and a group of "specialists" who make a living from them. Hikers in tick-infested areas should take some simple precautions, but not consume much mental energy worrying about them.
The whole thing got me thinking about the irrational way in which those of us in the outdoor education industry decide what to worry about. It isn't just ticks.
I spend a lot of time working with challenge course programs, especially around issues of "medical screening". There have been a few (actually very few) cases of sudden cardiac death involving users of these courses, although on a per-participant-hour basis the actual risk is statistically at baseline (http://adirondoc.com/publications/sudden_death_2002.pdf). (Remember, over 300,000 people experience sudden cardiac death annually, and every one of them was doing something at the time!) This has not stopped some in the industry from arguing for exhaustive (and completely unvalidated) screening methods to select out those at risk. This has reached the ludicrous point of some arguing that failure to implement such screening is "unethical"! Of course, experienced cardiologists will tell you that they cannot predict the risk of sudden death in any specific individual, but this has not stopped facilitators from implementing simplistic checklists--preventing nothing but also potentially depriving folks who could benefit from such a program from participating.
I have commented previously on the silliness which has inflicted many outdoor instructors regarding the risk of water-borne giardiasis. Although the scientific data on this problem are abundantly clear, there continue to be programs which enforce water treatment strategies which are entirely unsupported by data. Some of these are so bizarre (keeping utensils which are "dipped" in suspect water separate from "clean" ones; flushing out the microliters of water caught in screw-top water bottle grooves) they seem more suited for the Book of Leviticus than outdoor education materials.
The problem with this sort of thing is that there actually are some very good data which should inform our decision making in these areas. Sadly, most outdoor education programs do not seem to integrate such epidemiologic data into their policy development.
We worry needlessly about water quality, while rarely enforcing hand sanitation--a far better way to address the spread of intestinal infection on the trail. We push for wide availability of "Epi Pens" without prescription to trek leaders, with virtually no data pointing to anaphylaxis as an actual problem in outdoor education courses. Of course, those who push for Epi Pens are not the ones advocating flu shots and immunization updates--a vastly more important intervention for a group about to set out on a lengthy expedition. Many programs insist on lengthy "woofer" courses and refreshers for their leaders, in the face of absolutely no evidence that such programs meaningfully impact safety, even if a fraction of their skills could be retained. Epidemiologic data clearly point to automobile accidents and drowning as the major causes of death on treks--have you ever heard of a program with a mandatory driver education or water safety recertification requirement?
In my "day job" as an academic physician, I am constantly surrounded by the drumbeats of those insisting that everything we do be firmly grounded in evidence. When I step into the outdoor education arena, however, it appears that unsubstantiated opinion, anecdote, and dogma regularly trump evidence.
We must do better.
Saturday, July 30, 2011
A "game changer" in grizzly territory?
You may have heard about the recent grizzly attack involving a group of NOLS students in Alaska's Talkeetna Mountains. A good rendition of the story is in this article from the Alaska Dispatch:
http://www.alaskadispatch.com/article/alaska-bear-attack-nols-kids-did-phenomenal-job
The story hit home, as this is a part of Alaska in which I have led scores of students during WEA courses over the past decade. The story is of particular interest to those of us who take groups into grizzly country, as it appears to be the first example of an exception to a rule we all hold as gospel: grizzlies do not attack large groups. Is this a "game changer" for outdoor educators?
Although the mantra appears in various forms, it is best stated by David Smith in his estimable book Backcountry Bear Basics. Smith reports that there has never been an injury to a group of six or more, nor a fatality in a group of four or more. He believes that this is because such a group is more likely to be noisy, to be seen early by the bear, and to give the bear pause before initiating a charge.
As best I can tell, this statement has never been challenged by anyone knowledgeable. The Alaska Department of Fish and Game apparently believes it. I discussed this the other day with Bill Porter, a friend who is a senior wildlife biologist at Michigan State University, who also concurs.
So, what happened? Obviously, we will probably never know for sure, but from the report in the paper I have a theory. Although the group size was sufficient to be protective, I have to wonder about how close together they were. Apparently, they were walking in a creek--a particularly dangerous place in the Talkeetnas in late July--when they came upon the sow and her cub. I suspect that the group was spread out somewhat, and that the mother thought she was being challenged by a single individual. She attacked, and it was only after that that the rest of the group wandered into the location.
Fortunately, the student had the knowledge and wits to do exactly the right thing: play dead. This worked, as the bear then left him for another student. Obviously, the vaunted NOLS bear procedure training saved the boy's life.
So, what is the lesson here for the outdoor leader in grizzly territory? I believe that we can continue to say with integrity that there is safety in numbers. What we must reinforce to our students, however, is that only applies if the group is tightly together--close enough to be seen as one. This is easier said than done--groups tend to spread out, and many resent being told to keep together. This incident, however, reminds us that this must always be the practice in bear country.
http://www.alaskadispatch.com/article/alaska-bear-attack-nols-kids-did-phenomenal-job
The story hit home, as this is a part of Alaska in which I have led scores of students during WEA courses over the past decade. The story is of particular interest to those of us who take groups into grizzly country, as it appears to be the first example of an exception to a rule we all hold as gospel: grizzlies do not attack large groups. Is this a "game changer" for outdoor educators?
Although the mantra appears in various forms, it is best stated by David Smith in his estimable book Backcountry Bear Basics. Smith reports that there has never been an injury to a group of six or more, nor a fatality in a group of four or more. He believes that this is because such a group is more likely to be noisy, to be seen early by the bear, and to give the bear pause before initiating a charge.
As best I can tell, this statement has never been challenged by anyone knowledgeable. The Alaska Department of Fish and Game apparently believes it. I discussed this the other day with Bill Porter, a friend who is a senior wildlife biologist at Michigan State University, who also concurs.
So, what happened? Obviously, we will probably never know for sure, but from the report in the paper I have a theory. Although the group size was sufficient to be protective, I have to wonder about how close together they were. Apparently, they were walking in a creek--a particularly dangerous place in the Talkeetnas in late July--when they came upon the sow and her cub. I suspect that the group was spread out somewhat, and that the mother thought she was being challenged by a single individual. She attacked, and it was only after that that the rest of the group wandered into the location.
Fortunately, the student had the knowledge and wits to do exactly the right thing: play dead. This worked, as the bear then left him for another student. Obviously, the vaunted NOLS bear procedure training saved the boy's life.
So, what is the lesson here for the outdoor leader in grizzly territory? I believe that we can continue to say with integrity that there is safety in numbers. What we must reinforce to our students, however, is that only applies if the group is tightly together--close enough to be seen as one. This is easier said than done--groups tend to spread out, and many resent being told to keep together. This incident, however, reminds us that this must always be the practice in bear country.
Tuesday, June 28, 2011
Hand sanitizers work!
As is often the case, the best new wilderness medicine news is not in the outdoor or the wilderness medicine literature. Instead, it can be found in rigorous studies reported in major peer-reviewed journals. A recent study reported in the Pediatric Infectious Disease Journal is a case in point.
With the recognition that poor personal hygiene, not drinking water, is the real culprit leading to gastrointestinal distress among backpackers, more attention is being paid to hand sanitation. Although good ol' soap and water is the tried and true approach to this, it is not always practical in the backcountry. Lately, a lot of folks have been using alcohol-based hand sanitizers instead. Although I have admired their attention to hygiene, I have wondered if this approach was effective.
A group of French investigators have studied the hand sanitizer intervention in a group with a huge susceptability to hand-to-mouth transmission of gastroenteritis: 5 to 10 year old kids. Basically, the intervention was quite simple. In one school, all students underwent supervised use of hand sanitizers several times a day. In another school, they did not. The numbers of children developing diarrhea and/or vomiting during the study period were compared between the schools. The "intervention" school experienced about half of the number of GI infections as the control school. There were similar differences demonstrated between the schools in doctor visits, days lost from school, and working days lost by parents. There were no complications associated with the use of the gel.
Other studies have looked at the biology of this (effectiveness of gels in killing organisms in the lab) and at the use of the agents in the health care setting. This is the first well-designed trial of such an intervention among laypersons. The results are pretty impressive.
Sure, a French elementary school ain't a trek in the wilderness. Yet, the impressive results in a very high-risk group with very large numbers is compelling. I think that we can rest assured that this approach in the back country is now evidence-based.
The exact citation for the study is: Pediatric Infectious Disease Journal 2010;29(11)994-998.
With the recognition that poor personal hygiene, not drinking water, is the real culprit leading to gastrointestinal distress among backpackers, more attention is being paid to hand sanitation. Although good ol' soap and water is the tried and true approach to this, it is not always practical in the backcountry. Lately, a lot of folks have been using alcohol-based hand sanitizers instead. Although I have admired their attention to hygiene, I have wondered if this approach was effective.
A group of French investigators have studied the hand sanitizer intervention in a group with a huge susceptability to hand-to-mouth transmission of gastroenteritis: 5 to 10 year old kids. Basically, the intervention was quite simple. In one school, all students underwent supervised use of hand sanitizers several times a day. In another school, they did not. The numbers of children developing diarrhea and/or vomiting during the study period were compared between the schools. The "intervention" school experienced about half of the number of GI infections as the control school. There were similar differences demonstrated between the schools in doctor visits, days lost from school, and working days lost by parents. There were no complications associated with the use of the gel.
Other studies have looked at the biology of this (effectiveness of gels in killing organisms in the lab) and at the use of the agents in the health care setting. This is the first well-designed trial of such an intervention among laypersons. The results are pretty impressive.
Sure, a French elementary school ain't a trek in the wilderness. Yet, the impressive results in a very high-risk group with very large numbers is compelling. I think that we can rest assured that this approach in the back country is now evidence-based.
The exact citation for the study is: Pediatric Infectious Disease Journal 2010;29(11)994-998.
Tuesday, March 29, 2011
What happens in the wilderness, redux
One concern I have long had about the wilderness first responder "movement" has been the disconnect between their content and the actual data speaking to the types of medical events encountered in typical backcountry expeditions. When I discuss this with folks (as at a recent AORE conference), a frequent refrain is that there are not enough good data about such events.
Bull %*#*.
In actuality, there are a number of registries and large series which have been the basis for numerous publications in the peer-reviewed medical literature over the past few decades. Indeed, the database from NOLS has produced three such publications. The fascinating thing about all of these reports is that they are strikingly consistent. In fact, it could be argued that we have had enough such studies.
Now along comes yet another such report, this time from the esteemed outdoor education program at Cornell University ("COE"). Although there is very little in the way of surprises here, this is a particularly well done study which did just about everything right. Ironically, the study is accompanied by an editorial which perfectly illustrates the fact that some folks just don't care about data.
First, the study itself. COE is a large program with an excellent ability to record, capture, and analyze data from its many treks. This report covered a six-year period, with 74,005 participant days. The activities included the usual suspects in such college programs, although there was an inordinate emphasis on climbing walls (nearly two thirds of the participant days). The remainder were more typical: backpacking, mountaineering, natural (rock and ice) surface climbing, various water sports, etc. Overall, the injury/illness rate in this large series was 1.5/1000 participant days. This is extremely close to the rate reported in previous studies from NOLS and Outward Bound. About one-third of these events necessitated evacuation, again a figure consistent with other reports. The distribution of these events was also very similar to a host of similar previous publications. Most (over half) were skin and soft-tissue injuries. There were no deaths, serious injuries, or (see one of my previous blog commentaries) anaphylaxis. There were ten fractures/dislocations, of which three were ankle and one was tib-fib. The other fractures were seemingly trivial: wrist, collarbone, nose and coccycx. The latter ("tailbone") is an injury many of us active folks have probably had without realizing it because of not taking an xray; I rarely if ever radiate someone's pelvis to document this fracture.
In a very thoughtful discussion, the authors of this report comment on the safety culture at COE, as well as their use of such data to inform programing. For example, the number of injuries associated with food preparation (lacerations and burns) has led to some changes in instruction. The authors assert, very correctly, that the pattern and severity of injuries in their outdoor recreation are dwarfed by those of other college sports. All in all, a very nice study. The publication information is: Wilderness and Environmental Medicine; 2010; 21:363-370. You can download a pdf from the journal's website.
The editors of the journal should have left well enough alone. They didn't. When the editors of a medical journal believe that there is something worthy of highlighting in an issue, they occasionally solicit an "editorial" to emphasize the study's importance. Inexplicably, the editors chose a WFR instructor with no apparent background or qualification in epidemiology to editorialize on the study. The editorial was generally lame and ill-informed. For example, the author considered it "surprising" to learn that outdoor recreation injury rates were lower than intercollegiate sports, although this observation has been widely known for decades, first publicized by Project Adventure in their safety studies. More troublesome, the editorialist violated a major rule of an editorial by using it to include unreviewed new data. He somehow turned the discussion around to femur fractures, using a alleged incident from one of his former students to "report" the successful construction of an ad hoc traction splint on a mountaineering trek. He went on to advocate for the teaching of and utilization of this technique.
This is a completely unsubstantiated case report, which has now made its way into the medical literature without peer review--a travesty for a medical journal. Femur traction splints constructed out of sticks, trekking poles, and similar items have been a staple of WFR courses for a long time. When I mention such constructions to trauma surgery colleagues, I generally get a "you've got to be kidding" response. My favorite description of the technique is from the Outward Bound First Aid Handbook: "Improvised traction splints employing ski poles, canoe paddles, and other pieces of equipment are more often architecturally interesting than medically useful." Amen. WFR course time spent on such nonsense teaches students techniques they will probably forget, will never need, and wouldn't work anyway.
Kudos to COE for a very helpful report. Darts to Wilderness and Environmental Medicine for spoiling it with a silly editorial.
Bull %*#*.
In actuality, there are a number of registries and large series which have been the basis for numerous publications in the peer-reviewed medical literature over the past few decades. Indeed, the database from NOLS has produced three such publications. The fascinating thing about all of these reports is that they are strikingly consistent. In fact, it could be argued that we have had enough such studies.
Now along comes yet another such report, this time from the esteemed outdoor education program at Cornell University ("COE"). Although there is very little in the way of surprises here, this is a particularly well done study which did just about everything right. Ironically, the study is accompanied by an editorial which perfectly illustrates the fact that some folks just don't care about data.
First, the study itself. COE is a large program with an excellent ability to record, capture, and analyze data from its many treks. This report covered a six-year period, with 74,005 participant days. The activities included the usual suspects in such college programs, although there was an inordinate emphasis on climbing walls (nearly two thirds of the participant days). The remainder were more typical: backpacking, mountaineering, natural (rock and ice) surface climbing, various water sports, etc. Overall, the injury/illness rate in this large series was 1.5/1000 participant days. This is extremely close to the rate reported in previous studies from NOLS and Outward Bound. About one-third of these events necessitated evacuation, again a figure consistent with other reports. The distribution of these events was also very similar to a host of similar previous publications. Most (over half) were skin and soft-tissue injuries. There were no deaths, serious injuries, or (see one of my previous blog commentaries) anaphylaxis. There were ten fractures/dislocations, of which three were ankle and one was tib-fib. The other fractures were seemingly trivial: wrist, collarbone, nose and coccycx. The latter ("tailbone") is an injury many of us active folks have probably had without realizing it because of not taking an xray; I rarely if ever radiate someone's pelvis to document this fracture.
In a very thoughtful discussion, the authors of this report comment on the safety culture at COE, as well as their use of such data to inform programing. For example, the number of injuries associated with food preparation (lacerations and burns) has led to some changes in instruction. The authors assert, very correctly, that the pattern and severity of injuries in their outdoor recreation are dwarfed by those of other college sports. All in all, a very nice study. The publication information is: Wilderness and Environmental Medicine; 2010; 21:363-370. You can download a pdf from the journal's website.
The editors of the journal should have left well enough alone. They didn't. When the editors of a medical journal believe that there is something worthy of highlighting in an issue, they occasionally solicit an "editorial" to emphasize the study's importance. Inexplicably, the editors chose a WFR instructor with no apparent background or qualification in epidemiology to editorialize on the study. The editorial was generally lame and ill-informed. For example, the author considered it "surprising" to learn that outdoor recreation injury rates were lower than intercollegiate sports, although this observation has been widely known for decades, first publicized by Project Adventure in their safety studies. More troublesome, the editorialist violated a major rule of an editorial by using it to include unreviewed new data. He somehow turned the discussion around to femur fractures, using a alleged incident from one of his former students to "report" the successful construction of an ad hoc traction splint on a mountaineering trek. He went on to advocate for the teaching of and utilization of this technique.
This is a completely unsubstantiated case report, which has now made its way into the medical literature without peer review--a travesty for a medical journal. Femur traction splints constructed out of sticks, trekking poles, and similar items have been a staple of WFR courses for a long time. When I mention such constructions to trauma surgery colleagues, I generally get a "you've got to be kidding" response. My favorite description of the technique is from the Outward Bound First Aid Handbook: "Improvised traction splints employing ski poles, canoe paddles, and other pieces of equipment are more often architecturally interesting than medically useful." Amen. WFR course time spent on such nonsense teaches students techniques they will probably forget, will never need, and wouldn't work anyway.
Kudos to COE for a very helpful report. Darts to Wilderness and Environmental Medicine for spoiling it with a silly editorial.
Saturday, February 26, 2011
Column Resumes
For several years, I wrote a regular column for the magazine of the Adirondack Mountain Club, Adirondac. They were having some financial challenges which caused their page allotment to shrink, so the column has been on hiatus.
The editor has asked me to resume the column in the summer, and I am doing so. As in the past, it will provide advice on the health and safety aspects of outdoor recreation, targeting a lay audience. The initial column will discuss some aspects of canoe safety. The Adirondack Mountain Club does not as yet have an online version of the magazine, but I will post the columns in the Publication area of my website.
The editor has asked me to resume the column in the summer, and I am doing so. As in the past, it will provide advice on the health and safety aspects of outdoor recreation, targeting a lay audience. The initial column will discuss some aspects of canoe safety. The Adirondack Mountain Club does not as yet have an online version of the magazine, but I will post the columns in the Publication area of my website.
Thursday, January 6, 2011
Best Giardia Story Ever
A buddy of mine who works as a college outdoor education instructor recently shared an experience with me. For reasons I will mention later, today is an amazingly appropriate day to bring this up.
My friend related a visit to one of the college's treks by a student instructor from the west. The visitor was appalled to learn that this particular program did not practice universal water treatment during their expeditions. When told that the local instructors had carefully considered things and no longer recommended routine treatment of most Adirondack waters, he commented that it must be because of something unique to New York, since tasting even a drop of untreated water in the American west was "guaranteed" to result in giardiasis. He went on with a litany of reasons why this was to be avoided at all costs, not the least being that giardiasis was essentially incurable, and that those unfortunate enough to acquire it would have it forever--often flaring up any time an offending food was consumed. He treated everything he drank on the trek. No one else did. Everyone was just fine.
Of course, everything about this would be simply silly if it were not for the fact that the person involved is en route to becoming a professional outdoor educator, presumably about to share such nonsense with unsuspecting students. This is hardly a "controversy" anymore; it is difficult to identify any true expert in this field who considers the "treat everything" approach to be necessary or appropriate. Which brings me to the reason why today is a very good time to tell this tale.
A report today (http://www.nytimes.com/aponline/2011/01/05/health/AP-EU-MED-Autism-Fraud.html?_r=2&ref=health) has confirmed once and for all that the original study linking vaccines to autism was not only incorrect, it was fraudulent. The 1998 study, by a British quack named Andrew Wakefield, reported 12 reportedly normal children in whom autism developed as a consequence of the MMR vaccine. The journal in which it was published retracted it long ago because of concerns about its validity, and all of Wakefield's coauthors disassociated themselves with its conclusions. Literally scores of well-designed studies involving thousands of children have been published subsequently, none of which have supported the Wakefield hypothesis. One would think that the concern would have gone away by now.
Sadly, things didn't work out that way. In the nearly 13 years since the Wakefield publication, concern about the MMR vaccine became rampant, leading many families to avoid it. This, in turn, has resulted in a resurgence of measles in the world, with countless preventable deaths. Nonetheless, uninformed "experts" have continued to trump this bogus association, believing a study of 12 patients over well-designed trials with thousands.
Believe it or not, this situation is nearly identical to the current infatuation of some wilderness folks with water-borne giardiasis.
There has been exactly one peer-reviewed scientific study suggesting a link between wilderness water consumption and giardiasis. This report, from 1976, reported that about 2/3 of participants in a camping trip in Utah's Uinta mountains acquired giardiasis. The authors ascribed the outbreak to consumption of surface water.
In subsequent years, it has become clear this this report was incorrect (although certainly not fraudulent--just wrong). Analyzing this incident in light of contemporary knowledge about giardiasis has made it clear that this was an epidemic of food- or hand-to-mouth borne infection. (This is discussed in more detail in a paper available on my website: http://adirondoc.com/publications/water_quality_2004.pdf).
Although no subsequent scientific studies have shown any association between North American wilderness water consumption and giardiasis (or, indeed, any infection), the damage was done with the single 1976 paper, just as it was with Wakefield's 1998 autism/vaccine study. "True believers" such as the student instructor continue to tout misinformation which has been long-since discredited--often embellishing it along the way.
While the damage done by this over 30 year old paper pales in comparison to that of the Wakefield study (I doubt that anyone has died because of it!), it certainly has had negative effects. Most strikingly, the incessant attention to water quality in the backcountry has eclipsed attention to a much more important strategy--hand washing---which probably would have prevented the Utah outbreak! It has created the market for a dizzying array of technologic fixes (filters, "steri-pens", etc) which exist to solve a problem which doesn't exist. It has perpetuated very bad science among folks who aspire to professional careers in outdoor education.
I'll conclude with a "stay tuned". With a couple of colleagues and a student, I am analyzing data from a series of studies we have done examining the colonization of backpackers' hands with (hope you're not eating lunch now) organisms found in FECES. Without giving away the results, let me just suggest that you avoid shaking hands with folks you meet in the wilderness...
My friend related a visit to one of the college's treks by a student instructor from the west. The visitor was appalled to learn that this particular program did not practice universal water treatment during their expeditions. When told that the local instructors had carefully considered things and no longer recommended routine treatment of most Adirondack waters, he commented that it must be because of something unique to New York, since tasting even a drop of untreated water in the American west was "guaranteed" to result in giardiasis. He went on with a litany of reasons why this was to be avoided at all costs, not the least being that giardiasis was essentially incurable, and that those unfortunate enough to acquire it would have it forever--often flaring up any time an offending food was consumed. He treated everything he drank on the trek. No one else did. Everyone was just fine.
Of course, everything about this would be simply silly if it were not for the fact that the person involved is en route to becoming a professional outdoor educator, presumably about to share such nonsense with unsuspecting students. This is hardly a "controversy" anymore; it is difficult to identify any true expert in this field who considers the "treat everything" approach to be necessary or appropriate. Which brings me to the reason why today is a very good time to tell this tale.
A report today (http://www.nytimes.com/aponline/2011/01/05/health/AP-EU-MED-Autism-Fraud.html?_r=2&ref=health) has confirmed once and for all that the original study linking vaccines to autism was not only incorrect, it was fraudulent. The 1998 study, by a British quack named Andrew Wakefield, reported 12 reportedly normal children in whom autism developed as a consequence of the MMR vaccine. The journal in which it was published retracted it long ago because of concerns about its validity, and all of Wakefield's coauthors disassociated themselves with its conclusions. Literally scores of well-designed studies involving thousands of children have been published subsequently, none of which have supported the Wakefield hypothesis. One would think that the concern would have gone away by now.
Sadly, things didn't work out that way. In the nearly 13 years since the Wakefield publication, concern about the MMR vaccine became rampant, leading many families to avoid it. This, in turn, has resulted in a resurgence of measles in the world, with countless preventable deaths. Nonetheless, uninformed "experts" have continued to trump this bogus association, believing a study of 12 patients over well-designed trials with thousands.
Believe it or not, this situation is nearly identical to the current infatuation of some wilderness folks with water-borne giardiasis.
There has been exactly one peer-reviewed scientific study suggesting a link between wilderness water consumption and giardiasis. This report, from 1976, reported that about 2/3 of participants in a camping trip in Utah's Uinta mountains acquired giardiasis. The authors ascribed the outbreak to consumption of surface water.
In subsequent years, it has become clear this this report was incorrect (although certainly not fraudulent--just wrong). Analyzing this incident in light of contemporary knowledge about giardiasis has made it clear that this was an epidemic of food- or hand-to-mouth borne infection. (This is discussed in more detail in a paper available on my website: http://adirondoc.com/publications/water_quality_2004.pdf).
Although no subsequent scientific studies have shown any association between North American wilderness water consumption and giardiasis (or, indeed, any infection), the damage was done with the single 1976 paper, just as it was with Wakefield's 1998 autism/vaccine study. "True believers" such as the student instructor continue to tout misinformation which has been long-since discredited--often embellishing it along the way.
While the damage done by this over 30 year old paper pales in comparison to that of the Wakefield study (I doubt that anyone has died because of it!), it certainly has had negative effects. Most strikingly, the incessant attention to water quality in the backcountry has eclipsed attention to a much more important strategy--hand washing---which probably would have prevented the Utah outbreak! It has created the market for a dizzying array of technologic fixes (filters, "steri-pens", etc) which exist to solve a problem which doesn't exist. It has perpetuated very bad science among folks who aspire to professional careers in outdoor education.
I'll conclude with a "stay tuned". With a couple of colleagues and a student, I am analyzing data from a series of studies we have done examining the colonization of backpackers' hands with (hope you're not eating lunch now) organisms found in FECES. Without giving away the results, let me just suggest that you avoid shaking hands with folks you meet in the wilderness...
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