When it’s too late for a doctor’s help

I’m a fan of Caitlin Doughty. She’s a mortician, based in L.A. and author of Smoke Gets in Your Eyes (about working in a crematorium) and From Here to Eternity (about how other nations and cultures deal with death). She’s a funny lady and good writer and an advocate for funeral industry reform. Here are a few things I’ve learned from her.

In America, death has been a big business since the turn of the twentieth century. America’s funeral industry has become more expensive, more corporate, and more bureaucratic than any other funeral industry on Earth. (American funerals cost $8,000 to $10,000 not including the burial plot and cemetery costs.) What’s more, our funeral system is notorious for passing laws and regulations to interfere with diverse death practices and enforcing assimilation toward Americanized norms. After Hurricane Katrina, a group of Benedictine monks in southern Louisiana began selling low-cost, handmade cypress caskets. The state’s Board of Embalmers and Funeral Directors drummed up a cease-and-desist order, claiming that only funeral homes licensed by their board could sell “funeral merchandise.” (Eventually, a federal judge sided with the monks.)

Many Muslims would like to be able to open funeral homes in the U.S. Islamic custom is to wash and purify the body immediately after death before burying it as quickly as possible, ideally before nightfall. They reject embalming, recoiling at the idea of cutting into the body and injecting it with chemicals and preservatives. Yet many states have draconian regulations requiring funeral homes to offer embalming and for all funeral directors to be trained as embalmers, even though the embalming process itself is never required.

An executive of Service Corporation International, the country’s largest funeral and cemetery company, admitted that “the industry was really built around selling a casket.” As more of us are choosing cremations, the industry must find a new way to survive financially by selling not a “funeral service” but a gathering in a “multisensory experience room.”

The problem with cremation is that the process uses the same amount of energy required for a 500-mile car trip; roughly the same amount of energy as a single person uses in an entire month. What’s more, it releases 400 Kgs of carbon dioxide into the atmosphere plus a host of other pollutants and carcinogens, the worst of which is mercury from dental fillings.

Alternatives to cremation are available in a few places (very few). Here are three I know about:

Composting: The Urban Death Project, available in Seattle.

Burial directly into the ground: Joshua Tree Memorial Park, California.

Open air pyre: Crestone End of Life Project, Colorado.

My husband and I are opting for composting, but it’s not yet legal in California. Maybe if we live long enough….

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Fascia: attention must be paid

Fascia is the tough, flexible tissue that surrounds and connects muscles, bones, and organs. (Picture raw chicken.) Your body has two kinds: dense and loose. Dense fascia holds muscles, organs, blood vessels, and nerve fibers in place. It also helps your muscles contract and stretch and stabilizes your joints. Loose fascia is more slippery. It allows your muscles, joints and organs to slide and glide against one another.

Problems with fascia can range from annoying to serious. One in ten people have experienced plantar fasciitis in their feet (count me in). It’s an inflammation of the fascia that connects your heels to your toes. The most serious fascia problem is necrotizing fasciitis, an infection that spreads along the fascial plane and can cause deep tissue destruction, sometimes requiring limb amputation.

In the past, doctors thought fascia was just packaging for more important body parts. Now we know that fascia is key to flexibility and range of motion. Because fascia is alive with nerve endings, it can also be a source of pain. The longer it is damaged or inflamed, the more sensitive it becomes.

If you’re sedentary for a long time, fascia can shorten, become overly rigid and congeal into place, forming adhesions that limit mobility. In fact, inactivity can cause fascia to reshape itself. Fascia that is too short, stiff, or sticky in one part of the body can lead to pain and dysfunction elsewhere. And, as you might imagine, it stiffens with age.

If you’ve got pain, it can be tricky to determine whether it’s coming from your fascia or from muscles and joints. As a rule, muscle and joint problems tend to feel worse the more you move, while fascia pain lessens with movement.

Like everything else, it seems, the most effective way to keep your fascia sturdy and elastic is to stay active. Experts say that the best activities are those that involve bouncing, such as dancing, jumping jacks, tennis, skipping. (I know—there’s no way ….) They also suggest dynamic stretching, such as twists, squats, or lunges. Happily, swimming is also good. Some lay people swear by other techniques, such as Rolfing, yin yoga, and myofascial release. While experts question the long-term effectiveness of such treatments, at least they don’t require jumping.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Screening for prostate cancer

Prostate cancer is currently the most diagnosed cancer (excluding non-melanoma skin cancer) among U.S. men. Most cancers are localized, meaning that they don’t metastasize and most grow slowly or not at all. No worries about those. Only about seven percent of patients have a disease that does spread—the cancer to worry about.

Screening for prostate cancer was approved by the FDA in 1986 and became widespread in the late 1980s and in the 1990s.Yet the approval occurred in the absence of evidence that early detection of prostate cancer leads to improved patient outcomes. Studies have shown a modest reduction in prostate cancer mortality with PSA (prostate-specific antigen) testing: Screening 1000 men may prevent deaths from prostate cancer in 1.3 men in the 13 years after initial screening.  The problem with screening is that it finds prostate cancer in some men who would never have had symptoms from their cancer in their lifetime. Treatment can cause complications without yielding benefit.

The point of screening is to find cancers that may be at high risk for spreading if not treated. The thing is, about three out of four men with a raised PSA level will not have cancer. A high reading can be caused by medications, urine infections, certain sports, and ejaculation. False positive readings, which are common in older men, can lead to unnecessary tests, such as biopsy of the prostate, and can cause men to worry about their health. Biopsies can be painful and result in infection and blood in the semen. (Men who are 70 or older should not be routinely screened. Men between 55 and 69 should make their own decisions about screening.)

Patients whose tests reveal localized cancer have two options: 1) Treat the cancer with radiation therapy or radical prostatectomy, or 2) “active surveillance,” which may include periodic biopsies, MRIs, and PSA tests. Research has shown that prostate cancer mortality is low, regardless of the treatment. Nevertheless, the patient and his doctor must weigh the trade-offs between the benefits and harms of treatments. Harms include urinary incontinence, erectile dysfunction, and bowel dysfunction. Considerations about what to do include the patient’s wishes, remaining life expectancy, and the risk of progression to metastasis and death.

I’m glad I’ll never have to think about this—for myself, anyway.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

A personal story about a medication

In May and June of 2022, I had both knees replaced. I was given a prescription for diclofenac, a non-steroidal-anti-inflammatory (NSAID) and instructed to take one each morning and evening. I took only two or three, so had a lot left over. Lately, I’ve discovered that they are a great pain reliever for my sciatica, so I started taking them several times a week.

When researching the side effects of that drug, I came across research conducted by Washington State University College of Pharmaceutical Sciences that investigated the fact that, for some people, diclofenac causes heart damage. In the U.S., diclofenac could be purchased over the counter until 2013, at which time the FDA restricted it to prescription-only because of the heart damage reports. Nevertheless, more than 10 million prescriptions for diclofenac are written every year in the U.S., and it is one of the most widely used NSAID drugs worldwide, including countries in Asia, Africa, and the Middle East where it can be purchased without prescription.

I wrote to Bhagwat Prasad, one of the lead researchers. He wrote back. Here are excerpts from our several email exchanges. I began by introducing myself and explaining my history of taking diclofenac, after which I add the following sentences:

Me: Is there a way I can find out if I am one of those for whom diclofenac can cause heart problems? Diclofenac is the only medication I take.

Bhagwat: Our study suggests that individuals who don’t carry UGT2B17 gene are prone to higher levels of diclofenac in blood and risk to greater toxicity after oral administration. However, there are many factors that affect safety of diclofenac in different people.

Me: Since last writing to you, I had an MRI and learned that I have “severe spinal stenosis” (L4-L5). Painful sometimes. I do lots of stretching and exercising. Diclofenac is a big help.

I signed up with 23 and Me when the company first got started. I’ve contacted them and was able to search my raw data. I got the following response: “No genes or markers found matching UGT2B17.” I guess that’s bad news, but good to know. I’ll keep taking diclofenac on golf days anyway. It works.

Bhagwat: Thank you so much for these updates. First, I should thank you for taking care of yourself and prioritizing your health. You have become my role model! This is all very impressive that you have 23andMe data available for you to consider when taking medicine. [He goes on to recommend sharing this information with my physician and reducing the dose, etc.]

Me: I want to share a bit of alarming information from a book I read recently, called From Here to Eternity, by Caitlin Doughty. The book describes various ways in which different peoples from around the world deal with death. In Mumbai, the Parsis build platforms on which they place their dead bodies for vultures to devour. Doughty writes, “The vulture population has dropped 99 percent. In the early 1990s, India allowed the use of diclofenac (a mild painkiller similar to ibuprofen) for ailing cattle. Hoof and udder pain were eased, but when the animal perished and the faithful vultures soared down for the meal, the diclofenac caused their kidneys to fail.”

Are you familiar with this? As you can imagine, that paragraph caught my attention!

Bhagwat: Yes, I am aware of the vulture being vulnerable to extinction with diclofenac use. It’s a huge man-made disaster as we are killing the scavengers. The problem has recently been noticed in Spain and UK as well. Diclofenac causes vasoconstriction and damages kidneys of vultures. There are multiple reports of kidney related problems of diclofenac in humans with chronic use. [So far, email exchanges end here.]

Maybe I shouldn't even take diclofenac on golf days.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.