It is troubling that his closest allies dismissed this as just a “bad night.” This situation is reminiscent of Monty Python’s Black Knight, who, after losing all his limbs after a duel with King Arthur, insists it is “only a flesh wound.” Such deflection ignores the serious implications of what we witnessed.

While I am not a neurologist, but just a humble retired GI doc, I have observed patients and family with neurologic symptoms and signs, taught mental status exams  for 5 years to  medical students and watched 10 seasons of ER. While watching the debate, terms like “abnormal prosody” and “paraphrasing errors” came to mind.. Coupled with a noticeably slowed, narrow gait, vascular Parkinson’s disease may be the disease process we are witnessing. This can mimic neurodegenerative disorders and  often follows a progressive course.

The stakes are too high to ignore these signs. Ensuring that the most powerful position in the world is held by someone who is neurologically and psychologically sound is not just a matter of political strategy—it is a matter of national and global security. If we are to avoid potential tragedy, we must confront these issues with the seriousness they deserve.

The recent debate should prompt a thorough and transparent evaluation of President Biden’s capacity to fulfill the demands of his office. Anything less risks dooming not just our nation, but the world, to the consequences of impaired leadership. The time for empathy and decisive action is now, for the sake of all our futures.

Prepare yourself for a mind-boggling journey into the world of science, where living with a fluffy animal is the secret to warding off inflammatory bowel disease, autoimmune issues, allergies, and even mental health problems. Get ready for a glimpse into what a health care encounter in the 21st century might just look like. Trust me, it’s going to be a wild ride!

Scene 1: Dr. Barkster’s Office

Dr. Barkster (raising an eyebrow): “Mrs. Paw-some, forget about your traditional prescriptions, because I have a prescription that will blow your mind! Say hello to the furriest remedy out there – a dog!”

Mrs. Paw-some (taken aback): “A dog? But Doctor, won’t our house turn into a hairy chaos zone?”

Dr. Barkster (grinning): “Oh, Mrs. Paw-some, let me tell you, the wonders of fur-therapy are worth every lint roller in existence! Brace yourself for the fur-filled adventure I’m about to unfold.”

Scene 2: The Immune System Superhero

Dr. Barkster (striking a superhero pose): “Imagine a furry dog as your child’s immune system superhero, ready to tackle autoimmune diseases like a true champion! Recent studies show that early exposure to furry dogs can boost the immune system’s resilience, reducing the risk of developing autoimmune issues.”

Mrs. Paw-some (excited): “So, you’re saying a furry dog can be our child’s very own shield?”

Dr. Barkster (nodding): “Exactly! By bringing a dog into your family, we’re empowering your child’s immune system, one wag at a time!”

Scene 3: The Mental Health Marvel

Dr. Barkster (putting on a detective hat): “Hold on tight, because the mental health benefits of furry dogs will blow your mind! They’re like cuddly therapists with wagging tails. They offer unconditional love, endless belly rubs, and they’re the perfect built-in antidepressants!”

Mrs. Paw-some (laughing): “So, our dog will be our very own four-legged therapist?”

Dr. Barkster (smiling): “You got it! Dogs have this incredible ability to reduce stress, anxiety, and even improve social interactions. Plus, they’ll help your child develop empathy and a sense of responsibility.”

Scene 4: Finding the Paw-fect Match

Mrs. Paw-some (curious): “But Doctor, how do we find the right furry companion for our child’s optimal health?”

Dr. Barkster (serious yet humorous): “Ah, the quest for the paw-fect match! It begins with considering your child’s personality, activity level, and your family’s lifestyle. Is your child an energetic explorer or a snuggly bookworm? Are you a family of adventure seekers or more of a cozy homebody bunch?”

Mrs. Paw-some (enthusiastically): “We’re definitely a lively bunch!”

Dr. Barkster (chuckling): “Well then, a playful and energetic breed might be just the ticket! But don’t forget, shelter dogs are often paw-some choices too, so give them a chance to wiggle their way into your hearts!”

Scene 5: The Apocryphal Algorithm for Choosing the Perfect Breed

Dr. Barkster (with a mischievous smile): “Ah, Mrs. Paw-some, I have a little secret algorithm up my sleeve that can help you choose the perfect breed based on your child’s medical needs!”

Mrs. Paw-some (intrigued): “An algorithm? How pawsitively intriguing, Doctor! Do tell!”

Dr. Barkster (clearing his throat dramatically): “Behold, the Apocryphal Algorithm for Choosing the Perfect Breed!”

Allergy Avengers: If allergies are an issue, fear not! Look for hypoallergenic breeds like Poodles, Bichon Frises, or Portuguese Water Dogs. They’ll keep the sniffles at bay while providing endless cuddles.

Anxiety Alleviators: For anxiety relief, consider breeds like Cavalier King Charles Spaniels or Golden Retrievers. Their calm and gentle nature will soothe those frazzled nerves.

ADHD Energizers: If your child has energy to spare, go for breeds like Border Collies or Australian Shepherds. These energetic bundles of fur will keep up with all the endless activities and games.

Depression Defeaters: To combat the blues, breeds like Labradors or Beagles are perfect. Their playful antics and unwavering loyalty will bring smiles and joy to even the gloomiest of days.

Dr. Barkster (waving his hands like a magician): “And voila! The Apocryphal Algorithm presents you with a list of potential breeds to consider, tailored to your child’s medical needs. But remember, this algorithm is purely apocryphal, so be sure to consult with a professional before making any decisions!”

Mrs. Paw-some (laughing): “Doctor, you truly have a flair for the theatrical! Thank you for guiding us through this fur-filled journey.”

Scene 6: The Microbiome Marvels: Dogs, Soil Bacteria, and Healthier Homes

Dr. Barkster (raising an eyebrow): “Mrs. Paw-some, brace yourself for another mind-blowing discovery! Did you know that dogs can actually change the microbiome of humans to a healthier mix?”

Mrs. Paw-some (intrigued): “Dogs and microbiomes? That’s fascinating, Doctor! How does it work?”

Dr. Barkster (excitedly): “Hold on tight! When dogs dig in the soil, they unwittingly bring soil bacteria into our homes. And here’s the kicker: when they give their human housemates a loving lick, they introduce those beneficial bacteria into our bodies!”

Scene 7: The Soil Spectrum in the Apocryphal Algorithm

Dr. Barkster (adjusting his spectacles): “Now, let’s incorporate the magnificent world of soil into our Apocryphal Algorithm! Different soil types that dogs interact with can bring diverse bacteria, offering unique health benefits.”

Rich Loamy Licks: If your dog enjoys digging in nutrient-rich, loamy soil, they might introduce beneficial bacteria associated with improved digestion and nutrient absorption. Consider breeds like Labrador Retrievers or German Shepherds, known for their earthy explorations.

Sandy Salutations: Sandy soils bring their own set of health benefits. Breeds like Dalmatians or Greyhounds, who enjoy frolicking on sandy beaches or in sandboxes, may introduce bacteria associated with skin health and reduced allergies.

Clay Kisses: If your furry friend loves digging in clay-rich soil, they might bring in bacteria associated with a stronger immune system. Breeds like Airedale Terriers or Staffordshire Bull Terriers, known for their enthusiastic digging skills, might be just the companions for a clay-inspired microbiome boost.

Peaty Pooch Pals: Dogs fond of exploring areas with peat soil can introduce bacteria associated with improved mental health and reduced inflammation. Breeds like Border Terriers or Irish Setters, who enjoy hikes in boggy areas, might be the perfect peaty pooch pals.

Dr. Barkster (with a grin): “Remember, this soil-inspired algorithm is purely fictional but showcases the fascinating connection between dogs, soil bacteria, and our health.”

Mrs. Paw-some (laughing): “Doctor, you never cease to amaze! Our furry friends truly bring the magic of nature into our homes.”

Epilogue:

Dear readers, while the soil-inspired microbiome marvels may be an intriguing concept, the love, companionship, and joy a furry dog brings into our lives are undeniable. So, embrace the pawsitivity, let your child’s health thrive, and embark on an adventure with a four-legged friend who will not only leave paw prints on your hearts but potentially beneficial soil bacteria too! And remember, if you decide to welcome a furry companion into your home, make sure to consult with a healthcare professional to find the best fit for your family and always keep those lint rollers handy!

Morning arrived quickly and surgical rounds began as a retinue of visiting professors, fellows, residents, interns, social workers, case workers, physical and occupational therapists and finally third year medical students filed in behind Dr. G. In my sleep deprived mind, I saw his surgical cap as a tri-cornered hat, his pocketed stethoscope as a sword and his entry through the door of the large L.A. County Hospital ward as passing under a faux Arc de Triomphe after his conquests at Austerlitz. Moments later, he transmogrified into a fusion Perry Mason and Clarence Darrow, as he interrogated a profusely sweating surgical resident who had the misfortune of a post cholecystectomy wound infection.

Many decades later, playing “where are they now?,” I did the perspicacious detective work of finding out what accolades Dr. G. had received in the 21st century.  In other words, I had googled his name. Up came the answer: He had retired to a South Pacific Island to manage a greenhouse and take care of plants and trees on the island. He had become a plant and tree doctor! The head of Los Angeles County Trauma Response who had mended miles of injured intestines, cauterized thousands of bleeding blood vessels, and drained an ocean of abscesses had become a tree and plant caretaker. I was gobsmacked to say the least.

 Trees were meant to be cut down to make way for McDonalds’ parking lots, inspire insipid poems that 4th graders needed to memorize, and knock down errant golf balls.  (Dwight Eisenhower, the Supreme Commander of D- Day and former  U. S. President, urged Augusta National Golf Club to cut down a tree on the 17th hole that consistently stymied his tee shot).

As the years peeled away and I grew more gray, I learned respect for green. Peripatetic journeys with my botany-wise spouse and selected artificial intelligence plant apps opened up the world of beauty and ecological necessities of our flora. The mountain ash leaves feeding an army of tadpoles, our Red Osier Dogwood stabilizing our topsoil and preventing erosion, sunflowers blooming in summer and providing sustenance for bees, the Oregon Crabapple providing shelter and food for the Bluebird and Cardinal, and the joyful human stroll under the elevated tunnel of American Elms lining the Literary Walk at Central Park, are fine examples of the edification and beauty I had discovered in my new-found hobby of tree identification and exploration. 

Dr. G had seen decades of turmoil and tragedy mending the human body in East LA. He found tranquility and peace tending the South Pacific flora thousands of miles from the mainland. His time spent caring for trees, I would like to think, was like a healing tonic for a soul undoubtedly troubled and fractured from the many toils and challenges of practicing medicine and surgery for decades.  In a sense, he was finding his humanity and giving back to the planet what we have taken for granted for so long: the life-giving beauty of the Kingdom Plantae.  I have to admit, I completely understood.

While learning about truth, honesty, civility and camaraderie in school, the real world of hidden agendas creeped in. New and improved Fruit Loops tasted  exactly the same as the old Fruit Loops. Two box tops and $2.00 did not get you “life sized action figures” but ant sized plastic toy soldiers. Reality only accelerated with age. “This VCR  is state of the art and will remain a standard for years,” the Circuit City salesman told me with a straight face in 1982 as I drained my bank account of $1,200.  Obviously, the advertising on cereal boxes and a stereo salesman suffered from hidden agendas or conflicts of interest.

The world of medicine brought its own litany of hidden agendas. Pharmaceutical representatives extolling the virtue of their brand name products when a generic and a lower cost substitute achieved the same goals. I entered the profession during the era of drug sponsored free Caribbean vacations, five star restaurant outings,  and “free” basketball playoff tickets. Was there a potential for bias in prescribing habits when you’re cutting into a filet mignon paid for by an acid reducer you haven’t used before? One would have to think so.

Transparency in medicine became clearer when government edicts regulated Pharma’s gifts to the medical profession. The trips, five star restaurants, and  sporting event tickets disappeared.  Finally, even complementary pens and trackpads were forbidden. Quite rightly, transparency in prescribing was demanded by consumers. Today, the consumer can check on their provider’s lunch reimbursements, Medicare payments, and Big Pharma consultant fees. A simple internet search will quickly reveal the truth regarding your doctors financial ties—if any— to pharmaceutical companies and the like.

Regretfully, most of the world operates with hidden agendas and conflicts of interest unbeknownst to the consumer or general public. However, to the world of medicine’s credit, regulatory agents have collectively required physicians to publicly reveal conflicts of interest.  For example, if you are a physician presenting a paper at a meeting regarding your research on a drug, you must disclose any conflict you have with the company making or marketing said drug.  Furthermore, your research paper must cite any conflict you have as well.

Certain areas of the field of medicine have escaped transparency and issues of reporting conflicts of interest.  Lobbying has produced the DSHEA Act of 1994 which stripped regulation and FDA oversight from over-the-counter pharmaceuticals. Many over-the-counter medicines have not been subjected to vigorous oversight or proof of efficacy.  Billions of dollars of products are bought that may have little or no assurance that they help or improve what it professes to do on the package information. Fortunes have been made from this lack of transparency to the patient slash consumer.  It would seem, in the public’s interest, that a warning indicating that a product that has not been rigorously tested and proven in its stated efficacy, should be placed on the product packaging.

It seems that physicians and some areas of medicine are leaders in self-reporting conflicts of interest and public available transparency of these conflicts should be the standard applied to all businesses that interface with the public at large.  For example, politics operates in the world of dark money facilitated by Citizen’s United and the death of campaign reform.  So when a politician publicly espouses a certain political opinion, why do they not have to disclose any influence or conflicts of interest they might have that would benefit from their political stance on an issue?  Doesn’t the American citizen need this transparency to be an educated voter?

Furthering this argument, Journalists in a variety of communication forums report information in the public’s best interest.  Under their by-line in a newspaper or in a chyron on the bottom your television screen there should be a clear statement of any conflict of interest the journalist might have.  If you own stock in a company that spilled oil into the ocean, I’d like to know that when you present information on the oil-spill.  

A rational world should apply the rules that govern conflicts of interest or hidden agendas in a schoolyard playground the same as they should in the world of medicine, politics and journalism to name a few.  Self-reporting, fairness, and truthfulness should be a minimal requirement for all who interface with the public who are purportedly looking out for your best interest.  

Let’s level the playing field. 

The fates of Dr. Li Wenliang and Dr. Anthony Fauci will be irrevocably linked in our current times. Both physicians were muted by their respective political overlords:  Dr Wenliang sacrificed his life in the pursuit of warning the world of a deadly airborne virus originating in Wuhan, China and Dr Fauci, by the Trump Administration in thwarting his public health efforts in limiting morbidity and mortality. In these unsettling times, the assault on medicine and public health is not only lethal, but tolerated by industry, public opinion and political factions. 

When capitalism and profit intersect with human health, the American experience has often been in the favor of the former. American medicine in the 19th century was profit driven, fueled by several hundred medical schools that had no legitimate science curricula, no formal training programs and no criteria for competent professors. US medical students, desiring a top flight education, would journey to Paris to get state of the art instruction. Snake oil salesmen who peddled dangerous potions for multiple ailments thrived in the 19th century. 

The 20th Century provided some sanity and sanctity in the pursuit of science and healthcare. Abraham Flexner, an American educator, at the request of the Carnegie Foundation, reported in 1910 on quack medical training that resulted in the closure of multiple schools and began the scientific basis of medical education in the U.S. The Food and Drug Administration, established in 1906,  provided an oversight of drug therapy and provided a safety net to the general public.

Greed and the pursuit of profit in healthcare today still cannot be denied.  Popular entertainment reinforces the profit motive. Mr. Wonderful, on Shark Tank, when reviewing a vitamin and herbal supplement, gleefully queried the proprietor, “I don’t care if it works, what are your yearly sales?” Gordon Gecko, in the 1980’s movie “Wall Street”, uttered “Greed is good.”  Even in the 1950’s, Jim Anderson,  the iconic principled father in “Father Knows Best” sitcom during  the Eisenhower era, readily endorsed the Springfield snake oil salesman’s request for a business license because he was good to his dog and family. 

Congress got into the act of greed and greenbacks in response to a potential flood of pharmaceutical lobbyist money, further sacrificing the principles of science and public safety. Utah Senator Orin Hatch orchestrated potential legislative medical malpractice with The Dietary Supplement and Health Education Act of 1994 (DSHEA) which decreed that over the counter supplements and herbal products did not need to prove safety data prior to their release to the public and any complications would only need to be voluntarily reported. The supplement companies could not claim to treat a “disease” but misleading euphemistic claims such as “supporting health, “wellness,” or supporting a biologic system could be used in advertising without any scientific data to confirm the claim. What was the result? The OTC industry money profits increased from $9 billion to $50 billion,  Salt Lake City, Utah became a destination for the supplement companies. Hatch’s family became lobbyists for the industry and he and other members of Congress had a reliable flow of campaign donations.  What did the consumer get? The answer is clear: A flood of products that resulted in liver injury, life threatening drug interactions and occasional cardiovascular deaths. Product labeling was often misleading or wrong. Probiotics, living bacteria that can contribute to health, were often non viable or absent when analyzed by microbiologist/scientist scrutiny (R. Knight, UC San Diego). Families put themselves into financial jeopardy by spending hundreds of dollars per month on bogus supplements hawked by salesmen and health providers. This was a legislative fiat that legally supported medical quackery.

Now the technology industry is attempting to expand their profits by tapping into our health obsession and circumventing health law. Products that evaluate sleep hygiene, pulse and heart rhythm and oxygenation are entering watches, phones and bracelets. When developing a new technology, the rational response is to compare your experimental device to a gold standard that accurately measures the outcome you are looking at. For sleep analysis this is polysomnography, a medical test that looks at EEG, respiratory rates, eye movements among other data; oxygenation gold standard is the transmission pulse oximeter. Tech companies, such as Fit Bit and Apple, for instance, bypass the gold standard test and support their device results with an opaque “secret artificial algorithm.”  In the few studies that compare products to their gold standard, they are often shown to be inaccurate. The companies, unable to get FDA approval, then take guidance from the supplement industry by using “wellness” as the reason for the biometric. With no reproducibility and no public direction on the meaning and actionable explanation for the results, we are left with tech company advertising babble to encourage their purchase. 

It has been the pandemic of 2020 that has shown the stark reality of science deniers. Trump’s effort to undermine science and mask wearing and the infiltration and destruction of our beloved NIH, CDC and FDA autonomy has been an armageddon moment in healthcare. Pushing hydroxychlorquine, megavitamins and experimental medications that have not been fully vetted in randomized controlled studies as effective cures is unacceptable to the medical community and cannot be recommended as treatments to the public at large. Furthermore,  anti-vaxers, and proponents of the deadly “Herd Immunity” strategy are further evidence of our dilemma.

I am reminded of Dr. John Snow, a British obstetrician in the mid 19th century, who observed his London patient washing her infant’s diapers in a common water pump in town that spread cholera throughout the community. Snow’s work established the water-borne source of cholera and his urging of removing water pump handles. His pleas went unheeded by the public and scientists of his time leading to the death of thousands of additional victims in the cities around the globe. Accepting well designed investigations and their conclusions are our only way to avoid a “Dark Ages” outcome of health goals.

Our hope for the future lies in the investment of science teachers, high quality training of physicians and allied health providers, debunking and removing dangerous healthcare products on our social networks and providing the public with political leaders who want to move away from the past and into the evidenced based medical world of the present. 

Humans have constructed great civilizations in only 10,000 years, surmounting  challenges and establishing the supply chains that provide food, clothing and shelter for the billions that inhabit this planet.  Yet we are impeded by one major human foible: selective long term memory loss in order to cope with the next medical task at hand. What do I mean?  Take human memory and the history of contagious disease in society. We learn, at an early age, that American and international history were shaped by infectious disease. Early settlements in Virginia in the 16th century failed due to malaria outbreaks. In 18th century Philadelphia, an outbreak of yellow fever forced our founding fathers to flee the city.  Bubonic plague outbreaks in Europe in the 6th and 14th centuries killed 50% of the inhabitants and changed Roman and Medieval society. The medieval citizens fled the crowded cities for pastoral domiciles sensing that social distancing would prevent the deadly illness. Great armies were felled by typhus and cholera during the Napoleonic Wars and World War II.  We don’t have to go back very far to see a world where our parents and grandparents had a stark recollection of epidemic infectious disease. Diphtheria, polio and measles, to name a few childhood illnesses were part of their daily reality. Parents banned their children from community swimming pools, recognizing that distancing them from the source was paramount.  I, born in 1953, recall fellow students in my class with leg braces from polio following summers spent hospitalized. As I entered medicine in the 1970’s, there were reminders of past epidemics on the wards. I rounded in iron lung wards in Rancho Los Amigos Hospital in Downey, California. I ambulated the pediatric wards at L.A. County-USC Medical Center, puzzled by the prominent parapets outside the patient rooms. “They were there so that physicians could round and quarantine themselves during polio outbreaks,” my attending noted.  Again, in the early 1980s a mystery illness with a severely immunocompromised picture in the patient appeared in daunting numbers. The AIDS epidemic was upon us as we scrambled for its cause and cure. As time passed, the memories of these debilitating epidemics receded whereupon complacency and the rise of the anti-vaccination movement became the cause celebré of the 1980’s and beyond. The resurgence of the measles due to lack of sufficient vaccination in the 1980’s did little to discourage the anti-science crowd. Perhaps a lack of firsthand experience with the measles contributed in part to their anti-vaccine stance.  As I gazed into the mouth of a patient during the measles outbreak and saw a Koplik spot, a physical finding that indicates measles, I realized that the outdated knowledge of this physical finding I learned 10 years prior was not so archaic. Actually, I had simply forgotten about this pathognomonic signal of impending rubeola. “Out of sight,out of mind,” I said to myself.

Now, the COVID-19 pandemic has arrived and upended our lives as did the many infectious diseases of bygone years.  Initial roll-out efforts for mass testing, tracking and isolating has been less than adequate. We have finally resorted to social distancing, an ancient form of infection avoidance.  Clearly, the same weapons seen in the great mortality known as the Bubonic Plague during the 14th century. Ultimately, a vaccine will rescue us along with medical mitigation via drugs and antibody rich plasma from those who have recovered. Let us take the lessons of this catastrophic time and the stories from our heroes: the first responders, the healthcare team and informed public servants with us for centuries to come.  Otherwise, we sentence ourselves to repeat the same mistakes.