Sunday, January 24, 2010

Abusing the placebo effect

Take two pills and drink plenty of liquids, or you can use the pills to sweeten your coffee. Homeopathy has been around since 1796, the result of a false syllogism by one Samuel Hannemann, and it is very big in my neighborhood. A local private school’s house physician is a homeopath. Fortunately, the year my daughter went to that school she did not get sick so I didn’t have to explain to anyone why he was getting nowhere near her.

Homeopahty is the notion that symptoms of a disease can be cured by administering extremely small amounts of a substance that will produce the same symptoms in a healthy person, the “law of similars.” Two centuries of scientific study have failed to show the slightest evidence it actually works.

The fine British science writer David Bradley found an interesting letter in a rather obscure British medical journal, Trends in Pharmacological Sciences, suggesting that homeopath even fails as a placebo instigator.

What’s wrong with giving a patient a placebo? The letter, written by Edzard Ernst at the Universities of Exeter and Plymouth, argues there are two kinds of professionals who prescribe homeopathic remedies. One, the people who actually believe it works. They give it to patients and patients get better. They get better, of course because in most cases, when you are sick your body just gets better if you leave it alone, and because of the placebo effect. Ernst argues those practitioners are simply unethical.

The other kind prescribes homeopathic remedies because of the placebo effect. What does it matter how the patient gets well as long as the patient gets well. I'll give you this pill, you think it will make you better, and often it will. The logic, Ernst writes, is “ethically flawed.”

It would, almost by definition, involve deceiving patients. If we tell our patients that a homeopathic remedy is devoid of specific therapeutic effects, we cannot expect them to respond with clinical improvement. To generate a positive response, we must maximise expectations — and this can only be achieved by using deception. Not telling the truth undermines trust and is unethical. What follows is simple: the prescription of homeopathic medicines is in conflict with fundamental principles of medical ethics.

More important, of course, is that the patient might use the homeopathic remedy instead of getting scientifically based treatment, something I see around here. In the case of a life-threatening disorder, that is serious stuff. For instance, the UK organization of homeopaths has been advertising they have been successfully treating flu for two centuries. They have not.

The main argument against homeopathic remedies as useful placebos is that a physician can make use of the placebo effect without actually administering a placebo. Just tell the patient this antibiotic is an absolute wonder drug, it always works,  and you have given the patient real medicine and added the benefit of a placebo. Giving homeopathic compounds may produce the placebo effect but does absolutely nothing else--except provide income for the practitioner.

By the way, Bradley has calculated that the effects of a homeopathic compound actually working--he uses a compound with less than one molecule of sulfur--is 600,000,000,000,000,000,000,000 to 1 against.

Tuesday, January 12, 2010

The Tides of Newtok

The post office at Newtok, AK. Mail comes by air several times a week. Zip code 99559.

If it costs $100 million to move 400 Eskimos, what will it cost to move Miami?--Joseph Patrick, 64, believes in retrospect, the villagers knew something was wrong back in the 1950s right after the Yup'ik moved into the new site, but it wasn’t until twenty years later they realized their world was turning upside down. Patrick is one of the Newtok elders, and if you travel to the village, the community insists you speak to them for they hold the wisdom of the place. They remember back in the day, before Newtok was doomed.

Until the 1950s, this community was located on higher ground, a place called Old Kealavic, about ten miles from the current location, where they lived in sod dwellings, half buried in the tundra. The students in the Old Kealavic community traveled to Bethel, St. Mary’s, Sitka or Anchorage for education, but in 1958, the Bureau of Indian Affairs decided that all Alaskan natives needed schools. Most of Alaska’s Eskimos and Indians found themselves settled into villages, usually beyond the state’s road system, villages built around their schools. These Yup’ik were moved from Old Kealavic to a new site. They called the new settlement Newtok. [The word Eskimo is not a pejorative in Alaska as it is in Canada and Greenland, where Inuit is preferred.]

The two men sat in a lounge in a newest Newtok school while the school’s young principle, Grant Kashatok, translated from the Yup’ik. The river then was frozen farther out, they said, and the mouth of the river, where it spilled into the sea, was colder then. Gradually it became shallower, the water became warmer and eventually the shoreline began moving further out. That means they soon found they had to travel farther to fish and hunt. Every year, it seemed, it got worse.

“We don’t have an ocean to go down to when we go hunting now,” Michael John, 71, said.
While the sea was retreating, the river was coming closer, and the permafrost beneath the town (permafrost that underlies most of Alaska) was melting right under them. They decided a decade ago, it was time to look for a place to move the settlement again.

A group of elders explored the area around the village to see if they could find a place. They preferred “old sites,” places where the Yup'ik had lived before to see if they could return, but the old sites were sinking too.

The elders had no trouble finding the sites. Because of erosion, the old bodies in the cemeteries were exposed on the surface.

Access to most of the villages of the Yukon-Kuskokwim delta in western Alaska is through Bethel, a frontier town of 7,000 on the Kuskokwim River. It is a bustling if cluttered port town, the economic base for the huge delta region. The area’s hospital is here, so is the administrative center for the native corporations. Hunters and fishers use it as a base--the delta is rich in wildlife, although part of it is a wildlife preserve. Mostly Bethel is a victim of its location.

Bethel has six miles of paved road that connect to nothing. The cars have no place to go once they get to Bethel by air or barge and never get to exceed fifty miles an hour.1 Like all Alaskan communities, including parts of Anchorage and Fairbanks, the custom of dumping your junk on the lawns or in the driveways prevails. I was told the reason Alaskans rarely throw anything out is that it is so expensive to bring in and because you never know when you need a spare part. Also, there is no real place to put it. Central dumps are not universally supported, in part because the ground is usually frozen. The result is an Arctic Appalachian culture, with old cars, couches, refrigerators, snowmobiles, animal skins and bones everywhere, particularly in front or back yards.

While Bethel is served by Alaska Airlines 737s from Anchorage, flights to the villages are organized by two competing bush airlines using single-engine planes. Airport security at Bethel is a throwback to the pre-9/11 days and even ticketing is informal. The pilot meets you at the doorway, collects your ticket, escorts you to the plane, helps load the baggage (you have to tell him your weight) and helps you into the aircraft. No one gets searched.

One day in May, one of my students, Amy Chaussé, and I flew across the tundra through snow squalls at between 400 and 700 feet, a thrilling, smooth and beautiful ride in a Cessna 208. Like most bush planes, the Cessna had half its sixteen seats removed for freight, the planes being the only way of getting mail and goods to the villages until the river ice melts, which doesn’t happen until late May, early June. I got to sit in the copilot’s seat. While some of the thousands of lakes and ponds were still frozen, the tundra grass was visible everywhere with only a hem of snow in pockets and in the shallow ridges. Now and again, the ground would be obscured by another squall, but the air stayed smooth. Occasionally an airstrip and a few houses would appear, another village, and ninety-four miles from Bethel, the village of Newtok. Flying in Alaska is statistically the most dangerous aviation in the world, but this flight was a joy.

Newtok sits on the north bank of the Ninglick River, one of the countless tributaries of the mighty Yukon, one of the world’s great rivers, which runs 2,000 miles from western Canada, up through interior Alaska, past the Arctic Circle and down toward the Bering Sea, eventually spreading like a coral fan across the vast tundra. There is no one mouth to the Yukon, but hundreds of outlets through the arteries and veins of the delta and the Ninglick is one. A second tributary, the Kealavik (also called the Newtok) once ran on the east side of the town, but years ago, it cut a new path, a shortcut to the Ninglick, bypassing the village.

The weather at Newtok is not awful by interior Alaskan standards, with maximum highs in the summer at fifty-six to sixty degrees Fahrenheit, and lows in the winter at eighteen to nineteen above zero. It has gotten as warm as eighty and as cold as negative thirty-five, but those are the extremes. Newtok gets better than two feet of snow every year. Freeze-up begins in early November on the rivers, late November on the Bering Sea, fifteen miles away. The ice on the river can be six to eight feet thick. Breakup is in May. The permafrost is not uniform, which accounts for the little puddles and ponds in the tundra, but at its thickest, it can go 600 feet down.

In Yup’ik tradition, houses should be round, but in Newtok the only thing round is the light blue tank holding the diesel fuel for the generators. The shacks sit on stilts to keep them off the permafrost. Electric cables run everywhere. Wooden planks serve as walkways. There being no vehicles except snow machines and ATVs, there is no need for streets.

The people of Newtok are members of the Central Alaskan Yup’ik group who populate the central coast of Western Alaska, across the sea from their cousins in Siberia. The Yup’ik have been there for about 2,000 years, and the Newtok Yup’ik share a heritage with Yup'ik on Nelson Island across the river. Collectively, they are known as Qaluyaarmiut, the dip net people, for the way they fish. Eskimos are generally collected as language groups, not tribes, and the Yup’ik are the largest, about 20,000 souls. Their first contact with Europeans was in the 1840s, when a Russian explorer, Lt. Lavrenty Zagoskin, of the Russian America Company, came through while surveying the delta. An occasional missionary visited and converted a few Yup’iks from their animist religion since, but they were something of a moving target, nomadic most of the year. The Eskimos spent spring and summer at hunting camps following the caribou and marine mammals, and then collected in settlements to pass the winter. As late as the 1960s, they would pack their belongings on dogsleds and gather at the banks of the Ninglick. They survived then--and to less extent now--harvesting fish and mammals from the sea, particularly seals and walruses. Like most natives, they gave up dogsleds decades ago in favor of gas-driven ATVs and snow machines.

Most Yup’ik in the community that became Newtok were almost completely isolated from the rest of the world until the 1920s, in part because the nearest road is eighty miles away. Then Alaska formed the Territorial Guard (now the Alaska National Guard) and men from the community began to see more of the outside world and the isolation ended.

The exact population depends on who you ask. Officially the census says are 353 people in Newtok, but the locals say there are about a hundred more. In the spring of 2008, the number was listed by authorities at 467. According to the 2000 census, there were eighty-seven housing units with four buildings empty. There are fewer buildings now. Except for young school teachers brought in from outside, the population is entirely Yup'ik. More than half the population was not in the workforce at the time of the census, and the median household income was $32,188. Things have not changed much since. There is a health clinic--sometimes staffed by a nurse--but for anything serious people are flown to Bethel or Anchorage. Drinking water comes from a nearby lake and goes into a water treatment plant. In the winter, melted ice provides the water. There is no sewage system; Newtok is a “honey bucket” community.

At least 180 Eskimo villages now are threatened by climate change and six of them--Shishmaref, Shaktoolik, Unalakleet, Koyukuk, Kivalina and Newtok--have only a few more years to live. In some cases, the Army Corps of Engineers has recommended Dutch-style sea walls to keep the villages from being washed away. In the case of three towns, Newtok, Kivalina and Shishmaref, the only salvation is to pick them up and move them. That is stunningly expensive and the political will to produce the money is not there. No one believes they will be the only towns that will confront this conundrum. Things are going to get much worse.

Alaska as more than 30,000 miles of coastline, and 80 percent of its population lives on the coast. The sea is rising, the storms are howling. Shishmaref and Kivalina, are getting blown away. Last year the 300 residents of Kivalina had to be evacuated because of an impending storm. Authorities were afraid the wind would knock over the diesel fuel tank and spread toxic liquid over the settlement. Newtok is victimized by both erosion and melting permafrost and living there has become untenable.

The troubles of Newtok can be seen on the wooden planking, which was fairly flat and straight when it was laid down but now dips and weaves between the buildings. By May, the predominant feature of the village is mud as the top level of soil, only inches thin above the permafrost and frozen through the winter, melts. One result of mud, the poverty and the culture, is filth. The sole exception is the new school, built in modular form ten years ago, the center of Newtok’s universe. It could be plopped in any upper-class suburban American community and be appreciated. Thanks to oil and gas royalties, many of the newer schools in Alaska are physically exceptional, often beautiful and usually well-equipped. Newtok's school is no exception, a haven in the mire. It also is jammed. In a town of around 400, there are 120 children in the school, from kindergarten to twelfth grade, all sharing the same facilities.

The school library (the only library in the village) is tiny, and the book selection odd: a great deal of fantasy and science fiction, sports books, a few classics, and several complete collections of Harry Potter. Even the shelving is idiosyncratic, with the Ultimate Baseball Book (a sport absolutely impossible to play on tundra) next to Using Maps and Globes and The Mystery of Stonehenge; a biography of every professional sports team sits next to books on teenage suicide (not irrelevant in village communities), and a history of the Crow Indians next to Robert Ballard’s book on the Titanic. Almost all the books are in English. The Yup'ik have a written language, designed for them by Moravian missionaries from Pennsylvania in the nineteenth century, but it is clumsy and archaic and in the 1960s, Irene Reed at the University of Alaska designed the newer, more modern one used now. Some of the books in the school library have the Moravian script on one side, the Reed script on the other because many of the older people predate Dr. Reed. As in most Alaskan villages, the children were forbidden to speak their native language in school but that changed years ago. The first two years of school are in Yup’ik (and the teachers Eskimo) and then they switch to English.

Like most Alaskan villages, Newtok and its school are well-connected by satellite to the rest of the world. Satellite dishes connect computers in the tribal office and the school to the Internet, and the village’s administrative offices are computerized. One schoolroom contains several dozen white Apple Macbooks.

In the schools, children are encouraged to learn a trade such as plumbing, carpentry or an electrical vocation in hopes of bringing the skill and knowledge back to the village. The school is likely the largest employer in Newtok.

Many of the people have phone service and many of the homes get a cable connection to the satellite feeds. If you ask the Newtok inhabitants what they do in their spare time, they will tell you they watch movies.

Heidi Post, a non-Eskimo school teacher from Michigan, in Newtok for the last two years, thought Newtok was “gross” and “disgusting” when she came for the first time, she told Amy Chaussé. But she stayed and is now part of the community, engaged to a young Yup’ik man. Her initial reaction is hardly unreasonable. Skinned fish hang from wooden posts on top of shack homes, floors are smeared with blood and guts from baby seals that are cut up in the middle of the small dwellings. She would try to teach her students about sanitation and cleanliness but was informed that they don’t get sick. She’s a kasaq (pronounced gussuk) which means white person, and only kasaqs get sick, she was told. That is patently untrue. Indeed, Alaska is the only state requiring children to get hepatitis B vaccine before they can enter school because of disease in honey bucket homes and towns. For all practical purposes, the Eskimo villages of America’s Alaska are the Third World. The villagers have high rates of lung and skin infections, largely because there are no sewage systems. While 99.4 percent of American homes have indoor plumbing, only two-thirds of the Alaskan villages do. It costs as much as $50,000 to add plumbing to a house because the pipes can’t be easily buried in the permafrost--yet--and even in oil-rich Alaska, that’s expensive. Moreover, the pipes are prone to freeze. According to the Centers for Disease Control and Prevention (CDC), children in these villages were hospitalized for pneumonia eleven times as often as the national average.

Children socialize in front of the school. The rate of gastrointestinal disease was not much higher, however, because there is access to clean drinking water; it was the water used to wash that carried pathogens. The school principal reminds the children to wipe their feet before they enter their own homes and urge their parents to occasionally mop the floor of their homes with bleach. Post says they don’t bother because the next day the women are preparing food again, which often involves dismembering a marine mammal.

Although there is no normal plumbing in Newtok, the faucets in the school produce water. You are told not to drink it because of E-coli, and there are water distilleries by every fountain and sink in the school. The toilets flush and the showers drain, with everything flowing to the main open sewer lagoon a few hundred feet from the school. The lagoon is largely contained by permafrost, which is, of course, melting. You can’t flush toilet paper because it will clog up the pipes. In many Eskimo communities, soiled toilet paper is put in plastic bags and thrown out with the rest of the garbage, a habit some of the people take with them if they move into the cities. The lagoon is where the village’s waste is dumped. Post says there is a huge dump for garbage that is burned a few times in the summer when it is dry but the villager’s do not go out there often, which is evident from trash from soda cans and diapers littered in the muck.
The sidewalks of NewtokThere is a central laundry facility.

The lights stay on in the school 24/7 so the pipes do not freeze and if the generator turns off it may not come on again. The school acts as hotel for visitors. For a small fee, you camp out on mattresses on the floor. Just call in advance. There is a full kitchen and food can be obtained from either of two small stores.

Post describes how the children love the school because it is so clean and she will sometimes “threaten” disobedient children with sending them home.

The school has a large budget to transport its sport teams to neighboring villages, usually by plane or by snow machines. Moving around is easier in the winter when everything is frozen solid and you can use ice roads. Traveling to other towns is how young people meet, date and get married. Post says relationships between young people within the town are discouraged. The elders will intervene if they witness a couple getting too close, she said. The elders will pull the young ones aside and tell them “No, you are brother and sister and must not date.” Post explains that “brother and sister” isn’t literal but in the Yup’ik sense, meaning the entire village is one big family (and they are most likely all blood related). Sociologists who have studied the Eskimo communities don’t believe a word of it. The winters are very long and very dark and there is not very much to do. The men of the village take turns being police, and occasionally, an Alaska State Trooper will fly in, but mostly it is a safe, peaceful town.

Post is fond of the children of Newtok and loves her job. Eskimo children, boys and girls, are irresistible, black eyes and hair and honey-colored skin, round faces that seem most natural when grinning. They are decidedly not shy around strangers. It was impossible for Chaussé or me to move anywhere in Newtok without a cloud of children surrounding us. Chaussé bought candy, which made us particularly welcome, but the children wouldn’t think of begging. They were simply enjoying having company.

The school season just ended when Chaussé and I visited, and Post was off for the summer, returning to her mother’s home with her Yup’ik fiance, George Charles. She wore an ivory carved ring on her finger. She will soon become part of the one big family in Newtok.

The river keeps eating away at the land, creeping closer and closer to the buildings. Newtok is below sea level. The ice that normally protected the village from storms is melting, and the storms have been far more savage than the village elders remember, with winds sometimes reaching hurricane velocity.

The community center is the one building in Newtok that most reflects the village’s plight. It’s popular with teenagers and older people who play bingo at night, but the floor is buckled and wavy as the permafrost beneath it melts. During spring, you will see the locals scooping out water while playing their game. There is no playground for young kids, only the school gym. There isn’t a safe place to put a playground because the equipment will just sink in the thawing permafrost, so the youngest kids play in the gym and out in front of the school, a few yards from the sewer lagoon. The wooden houses have to be lifted or adjusted regularly to compensate for the softening ground. The community center will not get fixed.

According to Orson Smith of the University of Alaska Anchorage, the erosion at Newtok is the result of storm surges, usually caused by the wind. The winds do not have to be particularly strong, just persistent and blowing over long lengths of ocean, something called “fetch.” That wind also blows waves against the shore, in Newtok’s case, from both rivers. The convergence of the Ninglick and the Kealavik made matters worse, changing the angle of the tides. The angle of the wind is important: obviously it has to be blowing toward the land, and of course, the closer to the perpendicular, the worst the effect on the coastline. Normally, sediment is carried away from the shoreline in the winter, and the shoreline gets to rebuild in the calmer summer when the process is reversed. Because of the climate changes, however, that rebuilding does not come close to replacing what the winter washes away in coastal Alaska, Smith says. In many areas, the storms clobber the edge of frozen ground, which resists the battering, and the waves undercut cliffs and bluffs. Buildings are toppling in Shishamef as the low cliffs collapse. When permafrost melts, the land subsides, making it an easier target for the waves.

Like for much of Alaska, good data are nonexistent or ambiguous so no one knows exactly how high the water gets when the area floods, only that it has gotten much worse in the last ten years. It now floods regularly twice a year. In 2005, Newtok was completely inundated. The more erosion, the easier it is for storm surges to hit the town.

The easiest way to avoid this tidal disaster is to get out of its way, which is what the people of Newtok would love to do.

The plight of the village reached a crisis stage when the barge landing on the Ninglick was declared unsafe and Newtok could no longer get summer supplies up the river from the Bering Sea--including diesel fuel to run the generators. Now everything must be flown in and that’s expensive.

“We got suspended from Northland Services [the barge company] because we lost our barge landing,” says Stanley Tom, who has risen to be the community organizer of Newtok. “No landing whatsoever…. It eroded away. It was a solid foundation and the barge companies cannot land. This is tundra, permafrost and it’s just going to sink down. If you leave material on the beach and if there is a south wind, it’s going to erode away and fall off.”

Fortunately for Newtok, they have Tom, forty-seven, father of nine (with a grandson and adopted niece living with him). He is a master at public relations and working the bureaucracy, and almost everyone in Alaska agrees that Newtok is likely to be one of the first town moved--if any town gets moved--and it will be Tom’s victory. “I have sleepless nights,” he says. “After the work, I’m like thinking. I really want my village to have a good clean village.”

Besides running his family’s small general store, Tom is the town’s administrator. He has acquired an astounding collection of documents in his battle, some outgoing to state and federal officials, and some incoming from the same. They cram filing cabinets and computer disks in his offices.

He is not a native to Newtok. He was born in the nearby village of Tununak, but his family traveled between the two villages, and he finally settled in Newtok as a teenager. He was named mayor at the age of twenty-four and has been reasonably in control of the village since then, even after the elders dissolved the village government and decided to govern by traditional rules.

Everyone agrees that Newtok is lost. Tom says that creates two issues. One, where the town should go, and two, and the more difficult question, is who is going to pay for the move. The first question has probably been answered; the second question isn’t close to an answer because no one wants to pay for it.

At first, the elders could not agree among six possible sites. That got whittled down to three by authorities but Tom and the villagers selected a fourth, nine miles away and across the river on Nelson Island. The site has the advantage of being on the south bank of the river, away from the thrust of the erosion. The new village will be called Mertarvik. Other Yup’ik who already live on the island don’t object to their neighbors moving closer.

The state Department of Transportation, is building a barge landing near Mertarvik, Tom says. All the other sites were too rocky and too high. The fact they can put the landing there is a de facto concession for the location, he says. The reconnaissance for the new runway has been completed and a well for water has been drilled.

“We are moving. There is no way of stopping us,” he says. “This winter they are going to bring in equipment to build roads near a quarry so they can test the rocks.”

© Text and photos [except for the Yup''ik girl] by Joel N. Shurkin, 2009. All rights reserved.
© Photo of Yup'ik girl by Amy Chassé, 2009. All rights reserved.