December 2010 | The Health Culture

Old age and the limitations of a healthy lifestyle

Posted by Jan on December 31, 2010 @ 10:41 pm

A nice op-ed in the NY Times touches on our belief that living a healthy lifestyle guarantees a long and able-bodied life. The author, Susan Jacoby, speaks specifically to the issue of dementia and Alzheimer’s.

Members of the “forever young” generation — who, unless a social catastrophe intervenes, will live even longer than their parents — prefer to think about aging as a controllable experience. …

Contrary to what the baby boom generation prefers to believe, there is almost no scientifically reliable evidence that “living right” — whether that means exercising, eating a nutritious diet or continuing to work hard — significantly delays or prevents Alzheimer’s. …

Good health habits and strenuous intellectual effort are beneficial in themselves, but they will not protect us from a silent, genetically influenced disaster that might already be unfolding in our brains.

Jacoby cites a review of knowledge about Alzheimer’s sponsored by the National Institute of Health. (emphasis added) Read more

Misc Links 12/31/10

Posted by Jan on December 31, 2010 @ 10:38 pm

Lessons Learned As ‘Doctors Behaving Badly’ Tour Ends (NPR)
States should not deal with doctors who molest patients by setting an age limit on who they can see. Nor should they require that problem doctors practice in prisons and poor neighborhoods.

Real Life Among the Old Old (NYT)
To believe 90 is the new 50 is a fantasy that fails to distinguish between hope and reasonable expectation

FoodPolitics catches up: USDA’s meat labeling (Food Politics)
Meat producers greatly prefer that you remain ignorant of the amount of fat and calories meat contains

Alcohol industry battles among itself over the issue of nutrition labels (Wash Post)
Alcoholic beverages are one of the few things we consume that don’t have a nutrition label. Manufacturers dispute average serving size Read more

Income inequality and American politics

Posted by Jan on December 30, 2010 @ 8:42 pm

I had looked forward to reading Winner-Take-All Politics: How Washington Made the Rich Richer–and Turned Its Back on the Middle Class. The authors are political scientists Paul Pierson and Jacob S. Hacker.

On the whole it was less trenchant than I had hoped it would be. It does, however, thoroughly document one very good point: US income inequality is not — or not simply – due to the economic consequences of globalization, like the shift from manufacturing jobs to service sector jobs, with the ensuing loss of pay and benefits. It’s also due to what’s happened in American politics. Business interests — represented by Republicans — have been much better at organizing themselves than have labor unions and interest groups that represent the middle class. And the cost of campaigning – which increased enormously once TV became the dominant campaign medium – has made Democrats willing to support legislation that favors the interests of those with money to spare. Read more

Misc Links 12/30/10

Posted by Jan on December 30, 2010 @ 4:01 pm

Canada to put bigger health warnings on cigarettes (Reuters)
Will cover three quarters of front and back of cigarette pack. “Unduly” delayed by tobacco lobbying

Judge Rejects City Law on Antismoking Posters (NYT)
Gruesome images won’t be required in convenience stores in NY. Judge: “Even merchants of morbidity are entitled to the full protection of the law, for our sake as well as theirs.”

Why the Rich Are Getting Richer (Foreign Affairs)
Nice book review of Winner-Take-All Politics: How Washington Made the Rich Richer–and Turned Its Back on the Middle Class. “The dramatic growth of inequality … is the result not of the ‘natural’ workings of the market but of four decades’ worth of deliberate political choices.”

Profiles in Cowardice (GoozNews)
White House end-of-life consultation directive not an example of open gov’t (kept quiet since early Nov). Political opportunists who stoke ignorance for votes are cruel and fiscally irresponsible.

Unearthing Prehistoric Tumors, and Debate (NYT)
Is cancer a disease of modern civilization? Interesting discussion of why it’s hard to say Read more

Misc Links 12/29/10

Posted by Jan on December 29, 2010 @ 2:15 pm

‘Death panels’ alive — and that’s good news for all of us (MSNBC)
“If Terri Schiavo taught us anything … “ By noted bioethicist Arthur Caplan (12/29)

Health care economics and the relationship between doctor and patient (KevinMD)
What’s wrong with the way medicine is practiced? By a pediatrician who decided to quit her practice (12/29)

Placebos Work Even if You Know They’re Fake: But How? (Time)
Placebos may activate parts of brain that produce dopamine, pain-killers. Found effective for pain, depression, Parkinsons (12/29)

Social whirl of a life? Thank your amygdala (Guardian)
Larger size of this clump of nerves in the brain correlated with being more gregarious (12/29) Read more

Misc Links 12/28/10

Posted by Jan on December 28, 2010 @ 8:11 pm

So Young and So Many Pills (WSJ)
More than 25% of U.S. children and teens take prescription drugs on a regular basis. Most have not been tested on children. (12/28)

Osama bin Laden is dead (Wash Times)
Medical history of bin Ladan. Conclusion: It’s unlikely he’s still alive (12/28)

Personal genomics tests prompt lifestyle changes (New Scientist)
Recipients of personal genetic information improved diet, exercised more, changed medications or dietary supplements (12/28)

Does health-care law need title reform? (Wash Post)
Awkward name symptom of broader problem: not enough branding (12/28)

A dose by any other name would not sell as sweet (BMJ)
Why do so many drugs begin with X or Z? Results in patients mistakenly being given Zyrtec instead of Zyprexa and vice versa (12/28) Read more

Misc Links 12/27/10

Posted by Jan on December 27, 2010 @ 3:30 pm

Obama Returns to End-of-Life Plan That Caused Stir (NYT)
Cautious progress on plans to reimburse physicians for end-of-life discussions, trying not to inflame death panel myth (which is bound to happen anyway)

Overhaul of food safety laws might not be to GOP’s taste (Wash Post)
Good summary of bill’s benefits. Republicans may deny funding, claiming: “We still have a food supply that’s 99.99 percent safe.”

A new wrinkle for job seekers (Chicago Tribune)
Older workers get cosmetic surgery to stay competitive

Drug overdoses on the rise in most age groups (MSNBC)
There are more deaths because there is more prescription drug use. Painkillers are main culprit

Bundle Up, It’s Global Warming (NYT)
Overall warming of the atmosphere is actually creating cold-weather extremes Read more

The problem is you

Posted by Jan on December 24, 2010 @ 12:27 pm

A post I wrote earlier this month — Character, personality, and cosmetic surgery — reminds me very much of something I wrote 30 years ago. It was a chapter called “The Problem Is You” in a book I published in 1981. Today I write about personal responsibility for health. In the 1980s my phrase to identify that emerging phenomenon was “the problem is you.”

The 1980s saw significant shifts in medicine and health care, among them a shift away from focused attention on disease and chronic illness to an emphasis on individual risk factors, the need for greater self-surveillance, and the promotion of personal responsibility for health.

Health includes psychological well being, and one of the areas where blaming yourself was most apparent was the self-help industry. What I wrote 30 years ago was prompted by Wayne Dyer’s book, Your Erroneous Zones, first published in 1976 and now available from Amazon in 17 different formats. Dyer’s message: responsibility for emotional dissatisfaction lies with the individual. The problem is you.

The dark side of positivity

The message from the self-help industry (you control your own destiny and have no one to blame but yourself) was also popular in the business community (successful positive thinking is essential if you want to impress employers, customers, and co-workers). It was eventually adopted by the health care industry (you are personally responsible for living a healthy lifestyle).

There is a dark side to positive thinking, however, as Barbara Ehrenreich describes in her recent book Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America. Read more

Misc Links 12/24/10

Posted by Jan on December 24, 2010 @ 12:05 pm

Most mass media news about health should be avoided. Its objective is to generate needless anxiety, in my opinion. An exception is the National Health Service’s Behind the Headlines. Here’s some health news I’ve collected recently.

Exercise ‘protects brain from ageing’ (NHS)
Not new or unsurprising, but it’s additional evidence that there’s a connection between even low levels of physical activity and the prevention of cognitive decline

Can dairy cut diabetes risk? (NHS)
The association was found only with whole-fat dairy, not low-fat. “The study is not robust evidence that dairy products can lower diabetes risk.”

Porridge suggested for heart health (NHS)
From a well-conducted randomized controlled trial: “A diet containing recommended amounts of wholegrains can have a positive effect on blood pressure, which is an important marker of cardiovascular health.”

Sun and vitamin D advice given (NHS)
How much sun? 10-15 minutes of midday summer sun with one third of skin exposed at the latitude of the UK. “The time required to make sufficient vitamin D varies according to a number of environmental, physical and personal factors and may vary between individuals.”

Five a day ‘saves lives’ (NHS)
A diet with plenty of fruit and vegetables, fibre, and low fat and salt levels can reduce the risk of chronic disease, in particular coronary heart disease. Read more

Doctor arrested for getting whistle-blowing nurses fired

Posted by Jan on December 23, 2010 @ 3:40 pm

No one should be allowed to intimidate nurses who report serious wrongdoings they observe. When a nurse goes public about improper medical treatment — a doctor who sewed “part of the rubber tip from suture kit scissors to a patient’s torn, broken thumb” and used olive oil on the abscess of a patient with MRSA — she shouldn’t be fired.

But that’s what happened to nurses Vickilyn Galle and Anne Mitchell earlier this year. Not only were they fired. They were prosecuted for making the accusations in the first place – an alarming development for advocates of whistle-blower protections.

Doctor charged with retaliation

Justice has been slow in coming, but has finally arrived. The doctor in question, Rolando G. Arafiles, has been arrested (and released on his own recognizance, sans passport). The punishment for his medical behavior will be up to the Texas Medical Board. Meanwhile, the Texas Attorney General’s office has charged him with two felonies in connection with his attempt to silence the nurses.

At the time of the original incident, Arafiles went to his friend – the county sheriff – and arranged to have the nurses’ computers searched. (The nurses had complained anonymously, and the complaint letter was indeed found on one of the seized computers). Mitchell and Galle were charged with misuse of official information and fired. Now it’s Dr. Arafiles who’s charged with misuse of official information and retaliation. (And the sheriff said he expects to be arrested next week.) Read more

Misc Links 12/23/10

Posted by Jan on December 23, 2010 @ 3:39 pm

Can Congress Make You Buy Broccoli? And Why That’s a Hard Question (NEJM)
Four reasons why it’s hard to answer this question. A legal opinion (12/23)

Doctor Arrested in Whistle-Blowing Case (NYT)
Doctor accused of practicing substandard medicine worked with his friend, the sheriff, to get nurses fired. Nurses vindicated. Doctor now out on bail. (12/23)

Medicine is not a Business (Drs for America)
Not all human endeavors should become the object of greed (12/23)

A Matter of Life or Death (NYT)
Editorial on the Catholic hospital that took the position: “Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save.” (12/23)

Left Out (American Interest)
“Why has a significant increase in income inequality in recent decades failed to generate political pressure from the left for redistributional redress, as similar trends did in earlier times?” Francis Fukuyama enumerates possible answers. (12/23) Read more

Misc Links 12/22/10

Posted by Jan on December 22, 2010 @ 5:01 pm

The Hazards of Nerd Supremacy: The Case of WikiLeaks (Atlantic)
Substantial, thought-provoking essay by philosopher of the information age, Jaron Lanier

Secrecy May Be Unnecessary for Placebo Effect (WebMD)
Ted Kaptchuk trial involved 80 IBS patients. “There may be significant benefit to the very performance of medical ritual.”

As China’s obsession with plastic surgery grows, so too do the pitfalls (Wash Post)
The first of a growing number of comments from the Western press on the popularity of cosmetic surgery in China, prompted by the death of Wang Bei

Obesity Increases Risk of Death in Severe Vehicle Crashes, Study Shows (Univ of Buffalo)
21% increased risk of death for moderately obese, 56% for morbidly obese. May need to rethink car design for the obese. The normal and underweight are at higher risk than the slightly overweight.

Increase in SIDS on New Year’s Day (Medscape Today)
33% increase in sudden infant death syndrome. Why? Probably the alcohol

The benefits of thinking about our ancestors (Research Digest Blog)
Thinking about our ancestors boosts performance on intelligence tests. We’re reminded that “humans who are genetically similar to us can successfully overcome a multitude of problems and adversities.” Read more

Why the US doesn’t have universal health care

Posted by Jan on December 21, 2010 @ 7:08 pm

Most high-income countries today have some form of national health insurance. Why is the US different? What stands in the way?

Economist Victor Fuchs addresses this question in a recent issue of The New England Journal of Medicine. The explanations he offers: Health care in the US is much more expensive than in other countries; the US lacks an egalitarian ethos; while the US government is a major consumer of health resources, it fails to use its bargaining power to obtain lower prices.

US health care is very expensive

Health care in the US is much more expensive than in other countries. Americans spend 50% more than the next-highest country. If you look at the average cost of health care in the 34 European countries that belong to the OECD, the US spends 200% more.

Fuchs asks: Could this be because the US government is held hostage by special interest groups? Why would this be true only in the US?

The answer probably lies in part in the structure of the U.S. political system, including the role of primary elections, long and expensive election campaigns, the separation of powers, the numerous congressional committees and subcommittees with overlapping authority, and the need for supermajorities in the Senate in order to pass meaningful legislation.

So yes, the way we conduct politics favors special interests, and the result is higher costs for health care. Read more

Misc Links 12/21/10

Posted by Jan on December 21, 2010 @ 7:08 pm

Transplants Cut, Arizona Is Challenged by Survivors (NYT)
Rationing in action (12/21)

Court Backs Patents for Diagnostic Tests (NYT)
A closely watched development in personalized medicine. Patents on tests raise costs and impede medical progress (12/21)

Drug Makers New Targets for U.S. Fraud Inquiries, Report Says (NYT)
Drug industry overtakes defense as main target of federal fraud investigations. Pharma makes so much money by bending or breaking the rules on off-label marketing that the fines are not a deterrent. (12/21)

Can Health Care Reform Survive Without The Mandate? (Gooznews)
Yes. Those who want insurance could buy it through exchanges during one annual open-enrollment period. Those without insurance won’t be treated in emergency room (amend Hill-Burton Act). Doable but unkind. (12/21)

Proposed Amendment Would Enable States to Repeal Federal Law (NYT)
Opponents of health care want constitutional amendment allowing states to overturn any act of Congress (12/21)

Why people blog about illness (Guardian)
Blogging “fosters senses of both control and social connection, each of which is crucial for psychological wellbeing.” (12/21) Read more

Why the increase in mental health problems for college students?

Posted by Jan on December 20, 2010 @ 8:19 pm

In a recent NY Times article on the rising number of college students with mental health problems, there’s an interesting comment on why the numbers are increasing.

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse.

The greater awareness of trauma doesn’t surprise me, but the first explanation hadn’t occurred to me. I’d like to see the evidence. My first take on psychotropic drugs for children is that they’re overdone, but I’m willing to be convinced otherwise. If this is true – that more students can attend college because of the drugs they take — then that’s good news.

This particular article has very little information on the students themselves. It’s mostly about how difficult it is for understaffed college counseling centers to cope with the increase. Read more

Carbs are the new no-no

Posted by Jan on December 20, 2010 @ 8:16 pm

What we’re hearing these days about carbohydrates – that we should blame them for the increase in obesity, diabetes, and heart disease – makes sense, but why did it take so long for this wisdom to prevail?

Part of the answer is political. The US Department of Agriculture has a big influence on what Americans eat. But where were the scientists? Unfortunately, much scientific research is funded by the government. If you want your grant renewed, you don’t threaten to bite the hand that feeds you.

So fat wasn’t the problem after all

The new wisdom about carbs is discussed in an LA Times story, “A reversal on carbs.” I was pleased to see clear acknowledgment that the advice to reduce fats in our diet resulted in increased carbohydrate consumption.

[T]he nation’s levels of obesity, Type 2 diabetes and heart disease have risen. “The country’s big low-fat message backfired,” says Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. “The overemphasis on reducing fat caused the consumption of carbohydrates and sugar in our diets to soar. That shift may be linked to the biggest health problems in America today.”

The chairman of Hu’s department says: “The good news … is that based on what we know, almost everyone can avoid Type 2 diabetes. Avoiding unhealthy carbohydrates is an important part of that solution.”

Unfortunately, while we were loading up on carbs, neuroscience discovered that they’re addictive. Avoiding them is not that easy, especially when they’re ubiquitous and cheap. Read more

Misc Links 12/20/10

Posted by Jan on December 20, 2010 @ 8:14 pm

A reversal on carbs (LA Times)
The country’s big low-fat message backfired. The overemphasis on reducing fat caused the consumption of carbohydrates and sugar in our diets to soar. That shift may be linked to the biggest health problems in America today.

Mental Health Needs Seen Growing at Colleges (NYT)
70s students saw college counselors for existential crisis: Who am I? “Now they’re bringing in life stories involving extensive trauma, a history of serious mental illness, eating disorders, self-injury, alcohol and other drug use.”

Real Cancer Drug Breakthrough Is Astronomical Prices (Forbes)
Cancer drugs are big business. The much-vaunted revolution in cancer therapy is driven by hype and high prices. Excellent piece,

New Puzzle: Why Fewer are Killed in Car Crashes (WSJ)
42% increase in fatal accidents caused by distracted driving, but total road fatalities down 22% in 2009 compared to 2005. Why? The economy (fewer rush hour accidents), technology (side airbags), more responsible teen driving.

The Bipartisanship Racket (NYT)
No Labels movement is “utterly clueless about why Americans of all labels are angry: the realization that both parties are bought off by special interests who game the system and stack it against the rest of us.”

Kate Middleton’s ‘commoner’ status stirs up Britons’ old class divide (Wash Post)
“I’m not against the middle class as such, but I do query whether she has the background and breeding to be queen one day.” Is this why we left England (or would leave now)? Read more

The day Neda Soltan died: Inside an Iranian hospital

Posted by Jan on December 19, 2010 @ 3:18 pm

A doctor in Iran relates what transpired when protest victims were brought to her hospital.

I was on duty as a surgical intern that night when a sudden rush of injured victims flooded the emergency room. I thought there must have been a big crash on the highway nearby, but there were all sorts of victims you don’t normally see together in a single crash. Some had been hit by sharp objects and some had fallen from a height; and then there was even a gunshot wound. When police officers followed the crowd I was sure this was no accident, at least not like any I had seen before. I ran to the officer who seemed to be in charge and asked what had happened.

The question was immediately stifled by an angry look and a wave of the hand “mind your own business”. I tried to explain that my colleagues and I needed to know the cause of the accidents and the nature of the trauma. Then a bearded tall man approached me “ask me!” he said. I immediately recognised the “plainclothes”. “I wanted to know”, I began. He locked his intense hatred into my eyes. “You have no right to ask any question. At least if you don’t want to join them.” And he pointed to the line of the victims lying on the beds and on the floor.

This beautifully written essay was submitted to The Lancet’s Wakley Prize Essay competition. Read more

Misc Links 12/19/10

Posted by Jan on December 19, 2010 @ 3:18 pm

Tests Detect Alzheimer’s Risks, but Should Patients Be Told? (NYT)
Does it help to know you are likely to get a disease if there is nothing you can do?

The Value of Self-Experimentation (Blog of Tim Farriss)
Fascinating description of how one man experimented on himself to find what worked for his acne, sleep, mood, weight control, brain function.

An essay on a topic of international health importance (Lancet)
What it was like to be a doctor in Iran the day Neda Soltan died

The Truth Wears Off: Is there something wrong with the scientific method? (New Yorker) (subscription req’ed for complete article)
Just because an idea is true doesn’t mean it can be proved. And just because an idea can be proved doesn’t mean it’s true. When the experiments are done, we still have to choose what to believe.

Are Most Published Studies Lies? (GeriPal)
Good explanation of regression to the mean: We get sick, then we recover. That doesn’t prove drugs made us get better.

Everything about medicine is now big business (KevinMD)
The medical industry stays in business by selling you things. Big problem. Health care providers used to have your best interests at heart. This is not how “business” works.

New obesity pill: new hopes, old fears (Lancet)
The use of Contrave– an anti-depressant/anti-addiction combo — to tackle a complex problem like obesity is worrying, especially when the benefits seem modest (5% weight loss)

An epidemic of loneliness (Lancet)
“Doctor”, she asks, “can you give me a cure for loneliness?” Patients whose only misunderstanding is to have lived to an age when they are no longer coveted by a society addicted to youth. Read more

Can Congress Force You to Be Healthy?

Posted by Jan on December 18, 2010 @ 9:28 pm

Law professor Jason Mazzone asks this question in a recent NY Times op-ed piece. His remarks were prompted by the recent Virginia ruling on the health care law’s individual mandate provision, the requirement that everyone must either be insured or pay a penalty.

To ask if health care legislation forces you to be healthy is misleading. Neither the government, the medical profession, or nor anyone else should force you to be healthy. A civilized nation, however, should make affordable health care available to all its citizens. These two are not the same thing.

Be personally responsible for your health or else

Governments want people to be healthy because this creates a productive workforce. Governments should support policies that create healthy environments in which its citizens can live and work. But no one wants Congress to force people to be healthy. What we want is not to go bankrupt when we get sick. We’re all going to die, and most of us will get sick or be in an accident before we die. We shouldn’t have to die prematurely simply because we can’t afford insurance. Read more

Misc Links 12/18/10

Posted by Jan on December 18, 2010 @ 5:40 pm

The U-bend of life: Why, beyond middle age, people get happier as they get older (Economist)
Life improves after the stressful middle years. Interesting comments

Can Congress Force You to Be Healthy? (NYT)
A good point or the wrong question? Virginia judge’s ruling could prove irresistible to the Supreme Court

You Gotta Believe: Birthers, truthers, and creationists threaten to take us back to the future (Utne)
One in 20 Americans believes NASA faked the Apollo moon landings. Half the population believes the world was made in six days. Americans take blind faith to disturbing new heights.

Tips on writing from Steven Johnson, ie., an actual successful writer (Oliver Burkeman)
Keep a “slow hunch” file, don’t over-research, cultivate serendipitous connections, set modest goals, and have a glass of wine

Some Measures Of Inequality Are More Equal Than Others (American Scene)
You can grow up in an American home today with a 40-inch flat-screen television and a daily caloric intake so high it’s detrimental to health, but lack access to basic medical and dental care … and leave school functionally illiterate.

Complete list of links

Image: The Economist

Character, personality, and cosmetic surgery

Posted by Jan on December 16, 2010 @ 9:53 pm

I am not a blogger. I know what Andrew Sullivan and the Huffington Post people say about how one should blog: Think of it as a conversation and just write what you would say to a friend. I can do that in a comment, but not in a post. It doesn’t suit my “personality” – and personality is a topic in this post.

But … I wrote a comment that got so long, it seemed like it should be a post. It’s a reply to something Roberta said in a comment on Wang Bei and cosmetic surgery.

[T]here is a personality or psychological need within some people that drives them to have plastic surgery to fill a hole inside them. I think people who seek fame and want to go into the entertainment industry, like Wang Bei, by and large have a certain personality type. And it is largely based on a need for constantly being in the spotlight, and a need for constant applause or approval. The roots of these needs would be many and complex, but could include genetics and parenting style.

Here’s my reply. Read more

The death of Wang Bei: Cosmetic surgery as a moral choice

Posted by Jan on December 5, 2010 @ 10:16 pm

In my customized Google news, I have a category for cosmetic surgery. Most items that turn up are self-serving PR announcements, but recently there was lengthy coverage of the death during cosmetic surgery of aspiring Chinese pop star Wang Bei.

The details are tragic: She was only 24. Ironic: She was already beautiful. And dramatic: Her mother was having the same procedure at the exact same time. So her mother woke up to discover her daughter was dead. Or perhaps not. According to conflicting reports, her mother was told nothing until the next day. The news reports out of China do not strike me as especially reliable.

For example, Wang Bei’s death was first reported as an anaesthetic accident, but the majority of stories describe the cause of death as bleeding from the jaw. Wang was having facial bone-grinding surgery “to make her jaw line fashionably narrow and her face smaller.” (Chinese women are said to prefer an oval face shaped like a ”goose egg.”)

The blood from Wang’s jaw drained into her windpipe, and she suffocated. Is that an “anaesthetic accident?” Wang’s surgeon claims the operation was a success and that Wang died of an unexpected heart problem several hours after the procedure. Read more

Monthly Archives: December 2010

The dark side of positivity

Doctor charged with retaliation

US health care is very expensive

So fat wasn’t the problem after all

Be personally responsible for your health or else