“Welcome to Holland”

In the book entitled “Maybe you should talk to someone” by Lori Gottlieb, chapter 12 is most memorable because it hits home. The title is based on the essay “Welcome to Holland” by Emily Perl Kingsley, a mom who has a child with Down’s Syndrome. It talks about having your life’s expectations turned upside down.

When you’re going to have a baby, it’s like planning a fabulous vacation trip – to Italy. You buy a bunch of guide books and make your wonderful plans. The Coliseum. The Michelangelo David. The gondolas in Venice. You may learn some handy phrases in Italian. It’s all very exciting.

After months of eager anticipation, the day finally arrives. You pack your bags and off you go. Several hours later, the plane lands. The flight attendant comes in and says, “Welcome to Holland.”

“Holland?!?” you say. “What do you mean Holland?? I signed up for Italy! I’m supposed to be in Italy. All my life I’ve dreamed of going to Italy.”

But there’s been a change in the flight plan. They’ve landed in Holland and there you must stay.

The important thing is that they haven’t taken you to a horrible, disgusting, filthy place, full of pestilence, famine and disease. It’s just a different place.

So you must go out and buy new guide books. And you must learn a whole new language. And you will meet a whole new group of people you would never have met.

It’s just a different place. It’s slower-paced than Italy, less flashy than Italy. But after you’ve been there for a while and you catch your breath, you look around…and you begin to notice that Holland has windmills…and Holland has tulips. Holland even has Rembrandt.

But everyone you know is busy coming and going from Italy…and they’re all bragging about what a wonderful time they had there. And for the rest of your life, you will say “Yes, that’s where I was supposed to go. That’s what I had planned.”

And the pain of that will never, ever, ever, ever go away…because the loss of that dream is a very, very significant loss.

But…if you spend your life mourning the fact that you didn’t get to Italy, you may never be free to enjoy the very special, the very lovely things…about Holland.

Welcome to Holland, by Emily Kingsley

The story here my friends is simple. There are times that we will never get what we work for. What we wish for. Life is never made to be fair. As one friend of my mom (who has Lymphoma) would say, there are good days and there are bad ones. We smile at the good days, punch away with the bad ones and when we’re still alive tomorrow, we thank the almighty for another sunrise.

When Emily had a child with Down’s, she landed in Holland. Not a bad place to be. But like most mom’s, she wanted to be in Italy. Those of us who have had bad days never expected our flight plans to be redirected. It is infuriating. After all, we chartered that destination for the longest time. We rationalise that pent up anger because Holland isn’t the place we wanted to be.

If we huffed and puffed at every misdirection in our lives, we’d end up miserably angry at ourselves and at the world. But the story of Emily provides us a lesson in hope and reality.

The other day was a bad day for my mom. Whenever she hears people moving on to the after life, she gets more depressed. I can’t blame her. I’d feel the same way if I were in her shoes. If I made you complete the sentence Before I die _________________________, how would this sentence look? Get married. Go skydiving. Say sorry to my wife.

And so many, if not most of us, make a bucket list. Gottlieb tells us like it is:

We think we make bucket lists to ward off regret but really they help us to ward off death. After all, the longer our bucket lists are, the more time we imagine we have left to accomplish everything on them. Cutting the list down, however, makes a tiny dent in our denial systems, forcing us to acknowledge a sobering truth: Life has a 100 percent mortality rate. Every single one of us will die, and most of us have no idea how or when that will happen. In fact, as each second passes, we’re all in the process of coming closer to our eventual deaths. As the saying goes, NONE OF US WILL GET OUT OF HERE ALIVE.

Lori Gottlieb, “Maybe you should talk to someone”

The lesson from Emily’s essay on “Welcome to Holland” is straightforward. We make plans, but sometimes those plans don’t come to fruition. For most of us, the alternative route isn’t as devastating as it seems. You see, wherever life takes us, we need to roll with the punches. It’s the only way we will survive a world that’s never fair.

And if you liked this post, get the time to download the book from Kindle or purchase the book. Because who knows, Holland might just be a good place to be, after all.

Of drugs and Dengvaxia

I will make this introduction brief. Many have inquired on my take on Dengvaxia. I will dot the “i”s and cross the “t”s. I will not delve in politics but on science. After all, we all know where politics has led us. Hopefully, this article will educate everyone, using layman’s terms on the good and bad of Dengvaxia.

Does the vaccine work? (Efficacy)

Like all medicines and drugs (and supplements), there is no 100% guarantee on anything. More so for biologicals that require appropriate cold chain handling from the get go up to the time before it is administered to the patient! Because of the many unknowns in between, an investigational drug in clinical trial settings are sadly, handled much better, than when it is already in the market.

There is no perfect vaccine (or medicine to treat an illness). But to answer the question, yes it works to a certain extent. Efficacy endpoints vary from patient to patient. Their immune status, genetic markers, allergy history, age, risk factors and overall disease are but a few considerations on why patients respond to or fail to respond to or develop adverse effects to medicines.

How a vaccine is handled should be exhaustively evaluated as well. Some vaccines are easily destroyed when they are left to stand at poor temperature controls. In the private clinics, vaccines are given to patients directly from the refrigerator (or other appropriate cold chain source). Public health programs must assure that this cold chain is addressed properly – from the warehouse to the program site to the time of administration of multi-dose preparations. Vaccines inappropriately stored properly are like blank bullets. It gives you a false sense that you’re protected when in reality you’re not.

The take home message here is that the drug itself cannot be solely the problem if it doesn’t always work the way it’s expected to. It’s like giving license to a bullet and expecting it to do wonders at protecting you from harm. Without the gun and without appropriate knowledge on how to use the gun, the bullet can either be useless or deadly.

Is it safe? (Safety)

Like all medicines fresh out of clinical trials, there is much information that still needs to be gathered. Yet.

With all the essential clinical trial phases already concluded, relevant findings on the safety (and efficacy) of a medicine at the time it is released for commercial purposes is most likely ready.

Everyone needs to remember that there is NO SUCH THING AS A DRUG WITH NO SIDE EFFECTS. When someone tells you that, the person is lying. No one can assure anyone with absolute certainty that adverse reactions will not occur. However, adverse reactions need to be monitored and managed appropriately.

After all, even medicines which have been in the market for the longest time have side effects. Through the science of pharmacovigilance, we are able to pick up other side effects that once were not seen when these medicines were initially marketed. That’s because when more people are using a medicine, we get to have more information regarding how the drug is to be used and not used. For example, paracetamol is available as an over-the-counter medicine used to treat anything from pain to fever. Making it available as an OTC medicine is based on data continuously being gathered even if it has been in the market for half a century. Yet it is one of the most common cause of drug-induced hepatitis worldwide when used improperly.

Approval from regulatory agencies, anywhere in the world, are based on documentary evidence submitted at the time of application. For example, cancer medicines are approved based on a limited number of patients because the overall population afflicted with the disease may actually be small from the onset. Regulatory authorities may, in certain instances allow drugs for special diseases or compassionate purposes, to submit parts of the application while they are completing the whole clinical trial. In regulatory science, this is called a “rolling submission”.

The appropriateness of this type of submission practice is dependent on how stringent the review is in each regulatory agency for every country.

As the drugs roll out of the pharmaceutical market, there needs to be continuous monitoring of the claims, indications, special precautions, contraindications, drug interactions and adverse events. Only then can we know which medicine is good for both the goose and the gander. As I mentioned, the more patients using a particular medicine, the higher the probability we will find out more about what a drug can, or cannot do.

Is Dengvaxia useful during an outbreak?

Sadly not.

The fact that the certificate of product registration of this vaccine has been revoked, will take it awhile to make it available again in the local market. Let’s make it clear. There is NO BAN. The FDA cannot “ban” products at their whim. What revocation means is that the applicant will need to start the whole application process from square one.

But more than the so-called “ban” as a reason for its usefulness (or not) during an ongoing outbreak is the immunization schedule for Dengvaxia. Based on the manufacturer’s data, it is given 6 months apart for 3 doses – 0-6-12 months – in order to achieve the optimum immune response for the vaccine.

Finally, the approved age for vaccine use is 9 years and up. Even on the presumption that, say, more than 80% of Filipinos in certain areas of the country may have had one episode of dengue by the time they are 9 years old, majority of the patients with severe dengue are children 4-7 years old. Which makes this vaccine useless for the people who need it most.

The final say

Unfortunately, nothing in this world is risk free. In the world of medicine, the astute physician weighs benefits over risks when deciding what is best for the patient. Patients must be made to fully understand that thin line of risk over benefit. And consent to agreeing with their healthcare provider on how to prevent, cure or provide comfort against any illness. After all, it is our Hippocratic oath – to first do no harm – that makes us decide, in our best judgement, to err on the side of the best interest of the sick.

Trolls vs. Trolls

On a lazy summer beautiful weekend, the mass shooting in Texas and 13 hours later in Ohio, left an ugly carnage reflecting hate and prejudice. But that’s not the story of this writing.

The World Wide Web reeled its ugly head when the dark side showed how the internet and social media has become an indirect yet lethal instrument of sowing discontent.

This snapshot investigative writing published in the Philippine Daily Inquirer last August 6, 2019 gives us a peek into the dangerous world of trolling:

From a pig farm in an undisclosed location in the Philippines to popular coffee shops in the country’s urban business districts, the dark side of the Web is churning out material ranging from seemingly harmless but eyebrow-raising claims of popularity by Philippine politicians to lethal creeds of racism posted by the gunman in the El Paso, Texas mass killing on a supposedly free speech online forum called 8chan which is being run by an American expat in the Philippines.

While the Philippines is becoming an international hub for internet trolling that caters mainly to political clients, according to a Washington Post investigative report, other reports painted a blacker, deadlier picture of some web site operations originating from the country.

The mass shooting was followed almost half-a-day later by another that claimed nine lives in Dayton, Ohio but the El Paso carnage offered clues to how the Philippines is becoming like a war room for internet operators that provide services akin to call centers but work in hard-to-detect anonymity which allows them to flaunt laws and shields them from accountability.

Read more:

We live in very dangerous times. The battle ground has shifted to social media. With so much disinformation being sowed by keyboard warriors, the gullible are led to believe what friends and foes post online. Trolling engages people who are easily suggestible into believing lies and disinformation and make them seem real and making a parallel universe come to life.

And that’s the problem. Oftentimes without reading the article, someone presses the SHARE button too quickly. A haphazardly placed article by some random opinionated lowlife who makes a living trolling online is being shared multiple times. The following has begun. And the consequences are magnanimous.

Accountability is low. Consequences are high. Truths are buried and muddled by half wits who use technology as a tool for financial remuneration – no matter what the repercussions are.

We live in different times my friends. A time where war is born from keyboards and dark secluded places we used to call homes. A time where influencers quickly transform opinions into social media yet refuse to take full responsibility of their actions. Where followers are easily duped into believing lies from pretenders and peddlers or information.

Trolls are critics with no credentials. And the fight on social media between trolls vs. trolls puts every ignorant fool in between that chains of war. We need to fight that war by not feeding it with our attention. Only then, will the trolls die.