Archive for January, 2010

Hell’s-a-poppin’ anti-homeopathy campaign stages multiple mass overdoses at pharmacy doorsteps

Johnny Carson once said that if you want to clear your system out, sit on a piece of cheese and swallow a mouse. Many would claim that a homeopath’s prescription for colonic purging would be about as helpful. In the UK activists have devised a colourful way to make their point. The Guardian reports on a series of unusual protests outside pharmacies in the UK. On Saturday, January 30, hundreds of self-proclaimed skeptics gathered to denounce the Boots chain’s hawking of homeopathic remedies, treatments that are unregulated and have little or no scientific basis. At precisely 10:23am local time protesters staged a series of mass overdoses in several cities, downing entire bottles of pills and potions to emphasize their worthlessness as medicine.

A promised sympathy demo was to have taken place in Canada, but at least according to CanadaPharmacyNews, no one seems to have braved the cold to have at it with Canuck homeopathy.

Skeptics argue that theories behind homeopathy – which relies on the extreme dilution of animal, plant, mineral as well as synthetic substances so that remedies do not contain a molecule of the original substance – are utter nonsense. Most scientists agree that the only possible impact of such remedies is as a placebo. The 10:23 Campaign, which organized the demonstrations in Britain, has created an interesting website, with a provocative collection of videos. Richard Dawkins is entertaining as he demolishes homeopathic theory in less than ten minutes.

As predicted, no ill effects were reported from consuming massive amounts of homeopathic remedies. Anti-homeopathy groups have targeted Boots because they believe its nationwide status as a long-established pharmacy retailer gives the public false confidence in such products. The sale of homeopathic pills and potions in drugstores – along with potato chips, candy and soft drinks – sends a mixed message.

The anti-homeopathy lobby believes that by diverting people with genuine complaints away from conventional medicine homeopaths can put lives at risk. They cite cases of patients who have been been warned away from vaccinations, given homeopathic preparations for serious diseases like malaria, or advised to stop taking medication for cardiac disease.

The Canadian Pharmacists Association (CPhA) has not changed its position on homeopathy since 1998, when it issued a brief on herbal and homeopathic products, making several recommendations that generally revolved around ensuring that such preparations are regulated, that their claims of efficacy are substantiated by available clinical data, and that the safety of the Canadian public is protected.

The Natural Health Products Regulations require all homeopathic medicines to have a licence before being sold in Canada. Licence holders are issued a product number which must appear on the label of their product. The Natural Health Products Directorate (NHPD), which is responsible for issuing product licences for all natural health products, uses evidence submitted by applicants to critically assess the safety, efficacy and quality of NHPs before approving them for sale in Canada.

In addition to a product licence, all businesses in Canada which manufacture, package, label and/or import homeopathic medicines for sale must also have a site licence as of January 1, 2006. For more information on Canadian regulation of natural and homeopathic products, see the Health Canada website. Despite these detailed rules, Canada’s pharmacies are full of products of questionable pedigree. Caveat emptor.

People from protest group 10.23 take a mass 'overdose' of homeopathic remedies in central London

Photo credits:

flickr photo by TW Collins
flickr photo by ten23campaign

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Addiction programs in Manitoba: support is flat in the great flatlands

As a have-less province with a significant fraction of the population that is poorly educated and un- or underemployed, Manitoba has its share of drug-related problems. Manitobans with addictions (many of whom have mental health issues) do not have ready access to treatment. Resources are inadequate and there are long waits. Take the case of methadone intervention programs.

Manitoba has only one-quarter of the methadone spaces per capita as compared to neighbouring Saskatchewan, and it is a sad fact that some programs currently operating in Winnipeg are feeling oxygen-deprived. Two Ten on Maryland, in Winnipeg’s inner city, is a non-profit post-treatment program for recovering addicts run by a former meth addict, Ian Rabb. He has been requesting more support from the provincial government for years, claiming that additional funding is required to provide round-the-clock supervision of clients and improve safety.

Manitoba spends $22 million a year on addiction services. Not surprisingly, belt-tightening is going on throughout government – the province faces a projected $592-million deficit this year – but officials claim this hasn’t prevented the funding of vital programs.

In a recent Winnipeg Free Press article [1] Rabb accuses the government of foot-dragging and insincerity when it claims that money is tight. In his view the programs offered at the facilities save the government money. Clients stay out of hospital and jail, and most of them eventually get off welfare.

By coincidence, in a letter to the editor on the same day a local representative of the Canadian Mental Health Association, Nicole Chammartin, pleads for improved harm-reduction programs for those with addictions, specifically mentioning methadone treatment. “We require a comprehensive and responsive addictions system that serves everyone,” concludes Chammartin.

Existing research provides some evidence for the value of harm-reduction programs for addicts. A Lancet study published last October found that psychosocial interventions used in England are associated with reduced use of heroin and crack cocaine [2]. Outreach programs can lead to high levels of compliance, general improvement, and treatment satisfaction [3]. Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement [4].

However, it is difficult to demonstrate conclusively the effectiveness of programs and successful treatment outcomes. A recent Cochrane Review went so far as to say that “there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification” [5].

Although Manitoba’s left-of-centre NDP government makes the appropriate clucking noises when it comes to addiction problems, its record is not looking good. The Addiction Foundation of Manitoba’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [6] has shown itself to be effective, but insufficient funds are being directed at this serious problem. People with intractable addictions are waiting for help and inner-city programs are stalled, while money earned from government-run casinos is lavished on developing yet more affluent suburbs and on purchasing law-and-order fetishes like police helicopters to make suburbanites feel safer.

References

1. Owen B. Cuts at addictions centres? Director may trim services without new provincial funding. Winnipeg Free Press. 2010 Jan 23;Sect. A:8 (col. 3).

2. Marsden J, Eastwood B, Bradbury C, Dale-Perera A, Farrell M, Hammond P, Knight J, Randhawa K, Wright C; National Drug Treatment Monitoring System Outcomes Study Group. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009 Oct 10;374(9697):1262-70. PubMed PMID: 19800681.

3. Henskens R, Garretsen H, Bongers I, Van Dijk A, Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction. Subst Use Misuse. 2008;43(10):1464-75. PubMed PMID: 18615321.

4. Morris ZS, Gannon M. Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care. 2008 Aug;20(4):271-6. PubMed PMID: 18492708.

5. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004580. PubMed PMID: 15846721.

6. Bodnarchuk J, Patton D, Broszeit B. Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [Internet]. Winnipeg: Addiction Foundation of Manitoba; 2005 July [cited 24 Jan 2010]. Available from: http://www.afm.mb.ca/pdf/MINE_report_final.pdf

Photo credit: cc licensed flickr photo by wysiwtf

Bring on the mind control, please

You don’t expect to find anything funny in a book with a title like this: Breeding Bio Insecurity: How US Biodefense is Exporting Fear, Globalizing Risk and Making Us All Less Secure (Chicago, 2009). In the London Review of Books Thomas Jones writes that “Lynn Klotz and Edward Sylvester make a compelling case for a radical and immediate change in America”s biosecurity policy.”  Foreign Affairs says “the authors make a plausible and disturbing case.” Other reviewers have called it “forceful and provocative,” even “indispensable.”

The book argues that the conditions of research in bioweapons and biosecurity pose a greater risk to the health and security of Americans than do bioterrorist attacks, but that this risk can be countered and defeated with greater efforts against infectious diseases and greater international oversight and transparency. It also raises the question about the moral and legal issues around the billions spent since 9/11 on R&D into bioweapons counter-measures like antibiotics, antivirals, antidotes and vaccines. Testing them clearly requires ready availability of the bioweapons agents themselves, something that contravenes the Biological Weapons Convention, which bans the development, production, and stockpiling of microbial or other biological agents or toxins.

Ever since Hannibal’s forces threw clay pots full of snakes onto the decks of enemy ships in an ancient naval battle against the Pergamenes, nations have turned to biological warfare when it has suited them – especially when it can be claimed that massive reserves of anthrax, smallpox, plague, ricin, botulinum and ebola serve to defend the homeland. Despite the extreme unlikeliness of a large-scale biological terrorist attack, the United States, for example, has 219 labs studying anthrax alone. The number of people working in biodefence has increased twentyfold in the past decade.

A review in Science claims that the authors’ argument deserves serious attention:

Klotz and Sylvester spotlight the huge sums of money invested by the U.S. government in biodefense research. Here, they claim, secrecy is having corrosive effects. They also argue that the money pouring into biodefense research is out of proportion to the level of threat. In addition, they contend, this massive investment has backfired to create more risk because now more scientists are working with dangerous pathogens, thus increasing the chances of accident, theft, and deliberate misuse.

All weighty stuff. But, as Thomas Jones in LRB notes, Klotz and Sylvester also get carried away by what sounds like Cold War paranoia. At one point they bring up the subject of “the scariest weapons of all: mind-control agents.” These are largely the realm of science fiction, but apparently white-ruled South Africa carried out research into the use of MDMA for crowd control. Given the apartheid regime’s usual methods – attack dogs, tear gas, beatings, and shootings – a plan to use Ecstasy to suppress a revolt sounds positively benign.

“Ecstasy or smallpox: I know which I’d rather be attacked with. Bring on the ‘mind-control’, please.”

Photo credit: Flickr creative commons licence, uploaded by ClevelandSGS


A victory for common sense around harm reduction: Vancouver’s injection site wins a court battle

Insite supporters can breathe a sigh of relief. On January 15, 2010, the B.C. appeal court upheld a 2008 ruling by the province’s Supreme Court that allows the supervised injection site in Vancouver’s Downtown Eastside to stay open.

Liz Evans, the executive director of the Portland Hotel Society, which runs Insite, told The Globe and Mail: “Let’s hope [Prime Minister] Stephen Harper doesn’t waste any more taxpayers’ money by taking this to the Supreme Court.”

The debate over the future of Insite has been passionate in the two years since the Canadian government, in the face of convincing research, began questioning the validity of a harm reduction approach to injection drug use.

Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accused the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite’s work with drug users. “This government may already have garnered a reputation for being the most antiscience government in Canadian history,” they wrote in a sharply worded article published online in April 2008.

Doing exactly what it was set up to do

Kerr and Wood charge the government with attempting to “cloud science” and “manufacture uncertainty.” In the Tories’ get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including more than 20 studies by the authors which have appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

  • contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
  • helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
  • achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
  • not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to “deviant behaviour” is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite’s articulate defenders — not even the largely positive conclusions of the government’s own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

Ideological warfare

Given the significant disagreement on this issue, perhaps the very term “harm reduction” is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have “sufficiently inflamed … drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented.” Leshner advocates the avoidance of ideological intensity. “Let’s get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense.” This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one’s-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

Scientific arguments are insufficient in themselves

In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as “legalizers” in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction’s muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, “Without commitment to ‘strong rights’ and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really ‘legalizers’ harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention.”

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. The decision of the BC Appeal Court in favour of Insite is a victory in what has become a culture war waged on the backs of people who have the least power in this country.

References

1. Leshner AI. By now, “harm reduction” harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

Photo credit: cc licensed flickr photo by audreyjm529


Will Smitherman clean up Toronto’s soggy bottom? The man with the incontinence product runs for mayor

The Globe and Mail reported today on the official entry of George Smitherman into the race for mayor of Toronto.

A former health minister and deputy premier, Smitherman is renowned for much more than merely having been Ontario’s first openly gay MPP. Over the years the aggressive politician dubbed “Furious George” left a trail of arched eyebrows and stares of incredulity as he blundered into modest notoriety.

Two years ago, in what will surely be remembered as the nadir of his public career, Smitherman demonstrated appalling, cringe-making insensitivity as he made a bad mess worse in responding to criticism of the treatment of the elderly in the province’s largely private nursing homes. He told the media that he was prepared to don an adult diaper — and use it — to justify his government’s policies. Not surprisingly, this deranged outburst did not sit well with an outraged public.

The criticisms Smitherman’s health ministry received were justified. The Ontario Association of Non-Profit Homes and Services for Seniors claimed that seniors in nursing homes should be getting at least three hours of personal care; it said the average in the province is about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, called for a standard of 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, 2008, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn’t only critics of the Liberal government who were angry. There were loud calls for the minister’s resignation, even within his own caucus.

Wags and cynics sharpened their quills. In March the National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so … freeing. I had three large coffees … and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won’t make that mistake again! I think this will really help in my discussion with the nurses’ union. Five hours seems to be the limit before things get a little soggy. I think I’ll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. “I wasn’t trivializing the matter,” Smitherman said. “I take it really, really seriously.” The minister could not be reached for comment for a long time after that; but his “diary” entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper “stunt.” I explained that I only thought it would gain a better understanding of the issue, but he wouldn’t listen. “Also, George,” he said, “please tell me you weren’t wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift.” I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, addsed that this wasn’t the first time that “Furious George” has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as “Taj Ma-hospitals.”Another classic outburst was featured on Stephen Colbert’s American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists “a bunch of terrorists, and I don’t negotiate with terrorists.” “Bravo, sir,” Mr Colbert said. “Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs.”


During the “incontinence product” controversy in 2008 Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE’s Ontario chapter, who said the minister completely missed the point. The problem wasn’t the products, but the cruel reality that residents in long-term care facilities were forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario’s health minister possibly be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should have tried absorbing some of those important statistics and the advice of experts. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

From Eyeweekly.com here is a a taste of what to expect when Smitherman hits the Toronto campaign trail – a few Diaper George gems:

On announcing his candidacy intent: “A native son is coming home to serve.”

On wearing adult diapers to ensure nursing home residents are getting adequate care: “I’ve got one of these incontinence products … on my desk and I’m really giving this matter very serious contemplation.”

On controversial energy audits for homebuyers: “They taught me in some Grade 10 course — which was almost at the end of my stream of education — the notion of caveat emptor, buyer beware.”

On music: “I’ve been working out to the new Whitney Houston. I’m a gay man, so I love Whitney.”

On working with others: “Nobody should associate me with the status quo.”


References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.


Cancer with no smiley faces. Barbara Ehrenreich frowns at the cost of sugar-coating illness

The Guardian has an interesting piece on Barbara Ehrenreich’s reaction to her own cancer as described in her new book, Smile Or Die: How Positive Thinking Fooled America And The World. She was immediately struck by what she calls “pink ribbon culture” and the insistence on “positive thinking,” an intrusive ideology that has a strong hold on the American imagination. For Ehrenreich cancer was not a rite of passage or a “gift.”

But rather than providing emotional sustenance, the sugar-coating of cancer can exact a dreadful cost. First, it requires the denial of understandable feelings of anger and fear, all of which must be buried under a cosmetic layer of cheer. This is a great convenience for health workers and even friends of the afflicted, who might prefer fake cheer to complaining, but it is not so easy on the afflicted. One 2004 study even found, in complete contradiction to the tenets of positive thinking, that women who perceive more benefits from their cancer “tend to face a poorer quality of life – including worse mental functioning – compared with women who do not perceive benefits from their diagnoses.”

I am reminded of Zizek’s analysis of our society’s generalized injunction “Enjoy!” We are all under the spell of this injunction, what Zizek calls the superego aspect of today’s “non-repressive” hedonism – the constant provocation we are exposed to, enjoining us to explore all modes of jouissance – with the result that our enjoyment is more hampered than ever. Recall the classic yuppie type who combines narcissistic self-fulfillment with the utterly ascetic discipline of rigorous workouts and obsessions around health food. This injunction to smile through thick and thin, through disease and world calamities, can have profound consequences. In a pseudo-permissive society in which the more we are encouraged to care for ourselves the more we lack a fixed identity, ideology directly mobilizes that lack to sustain the endless process of consumerist “self-re-creation.” We no longer have any choice but to pursue happiness forever.

The very injustice of our economic and political system is what allows us to perceive failure (or success) as undeserved or contingent. It is much easier to accept inequalities or misfortunes if one can claim that they result from an impersonal blind force such as the “free market.” This ideology is also at work in the cheerful acceptance of disease that Ehrenreich finds so intolerable.

Breast cancer … did not make me prettier or stronger, more feminine or spiritual. What it gave me, if you want to call this a “gift”, was a very personal, agonizing encounter with an ideological force in American culture that I had not been aware of before – one that encourages us to deny reality, submit cheerfully to misfortune and blame only ourselves for our fate.

Smile or Die will be released in Canada in August 2010. An excellent essay by Ehrenreich on this topic, originally published in Harper’s Magazine, can be found at the Breast Cancer Action website: Welcome to Cancerland: A Mammogram Leads to a Cult of Pink Kitsch.

Here is how it ends:

For me at least, breast cancer will never be a source of identity or pride. As my dying correspondent Geni wrote: “IT IS NOT O.K.!” What it is, along with cancer generally or any slow and painful way of dying, is an abomination, and, to the extent that it’s manmade, also a crime. This is the one great truth that I bring out of the breast-cancer experience, which did not, I can now report, make me prettier or stronger, more feminine or spiritual-only more deeply angry. What sustained me through the “treatments” is a purifying rage, a resolve, framed in the sleepless nights of chemotherapy, to see the last polluter, along with, say, the last smug health insurance operative, strangled with the last pink ribbon. Cancer or no cancer, I will not live that long of course. But I know this much right now for sure: I will not go into that last good night with a teddy bear tucked under my arm.



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