Day 5 of the Australian Journey 2012

Today is our second day in Warburton with Auntie Jennie and the Karith House of Prayer.   Every morning on the Australian Tour, I get up before the sun and run.   Yesterday I ran along the Upper Yarra River to Martyr Hill (a 27% grade) where I painstakingly ascended to the top, then entered the Donna Buang Trail, a 70 kilometer hike, of which I sampled just the first bit. The songs of the birds spectacularly surrounded me, resembling what I would expect from a rain forest, though in my naivete, I expected monkeys to be part of the auditory scenery.   I had the privilege to see a beautiful red fox, which surprised me since I didn't think foxes lived in Australia.   Later when I asked about the fox, I learned that they had been brought to Australia by the British rulers for their classic fox hunt.   The foxes quickly overran the local wildlife since they had no natural predators and became pests.   (Just like the English, someone at the breakfast table quipped.)   I pointed out that it wasn't actually the fault of the foxes, since they weren't the ones to buy the tickets to Australia and probably didn't enjoy the journey either.   You can get $10 for killing a fox and presenting its pelt.   It's equally not the personal fault of those who have English ancestry for bringing the foxes since they weren't alive when the fox idea was conceived and executed.   I don't think we have to hold guilt for the deeds of our ancestors.   There's enough in the world to make everyone dysfunctional without needing more.   I agree with don Miguel Ruiz and Olivier Clerc that we need to forgive and be forgiven more than we need to blame and be blamed.

This part of Australia superficially resembles Vermont, where I live.   The mountains are a bit higher in Vermont, but that's where the resemblance ends.   There's no rocks here.   The forest floor is thickly filled with ferns and exotic looking plants that resemble large pineapple plants without   the fruit.   The major tree is the eucalyptus or gum.   As one ascends to the higher altitudes, pines appear, but not like any Vermont pine.   Last year we were running when it was still dark and saw a wombat.   I only saw scat this year.   Surprisingly given daylight savings time, the sun rises late in Southeastern Australia.

This morning I took a different route.   I ran up a new road on the same steep hill to get to the O'Shaunessy Aqueduct Trail.   I ran along an old aqueduct for a ways before turning up the hill on the Mt. Victoria Trail.   I wondered how one keeps the water out of the aqueduct even as streams tumbled down the hill beneath it.   Nature was breaking up the concrete and taking back the land.   A short ways up the last trail, I had to turn around and ran back to Karith.   I can vouch that it's quicker to run downhill than uphill but it's harder on the thighs.

Warburton is a small town, barely one row of buildings on either side of the road.   The architecture is one I have only encountered in Australia, a kind of combination between English country homes and Indonesian style.   The closest I have seen elsewhere is the French Quarter in New Orleans.   The Upper Yarra River runs behind one of those rows, flowing all the way to Melbourne and into the ocean there.   I met a woman named Maya who wrote a marvelous book on her hiking journey along the Upper Yarra River from its source to the sea.   I asked her if she was going to honor any other rivers, but she said, "No, this is my homeland.   That is my River.   I wouldn't have authority or permission to write about anyone else's river.   She was obviously aboriginal in her thinking about land and territory.

When we arrived at the Village Hall where we were doing the workshop, the door was locked.   We milled around in front of the movie posters including George Clooney's latest film for the Town Hall doubled as the Village Cinema.   Since "the show must go on", we had to improvise.   Our hosts were frantically trying to track down one of the City employees to open the building.   I suggested we go sit beside the river and at least get started.   We meandered down our side of the river to the Brisbane Bridge and crossed over to the other side where I had spotted a nice grassy area suitable for our group.   Rocky and I proceeded to do the opening song to honor the Four Directions after we had acknowledged the land, the aboriginal people who were attached to this land along with their ancestors, and the spirits who walked upon the land.   Then we did a spirit calling song to make sure that proper notice had been given to the spirits that we were planning to do a ceremony.   Auntie Jennie then spoke some about the importance of men coming into the medicine.   In her family as in mine, there were at least two, if not three, generations which were entirely lacking in men.   All the men were dead or in jail or lost.   My grandfather was the only exception as was Aunt Jennie's.   She continued to talk about the men in her family and her ancestors which inspired me to propose that we do a tobacco ceremony in which we smoke for the spirits and anyone who receives a message from them stands up and delivers it.   This turned out to be a powerful ceremony.   I offered the tobacco and a number of people stood and spoke in Quaker meeting fashion.   In my mind's eye I saw my ancestors crossing the great divide (the Pacific Ocean) and embracing Auntie Jennie's ancestors and all sitting down in a circle and smoking together to signify unity and peacefulness.   One said that war actually hadn't been on the planet all that long and could still be eradicated.   I saw ancestors standing behind each person present.   Several others spoke of similar sightings.   We passed tobacco around the circle for everyone to smoke just as I had seen.   Then one of our hosts appeared and announced that the employee who was supposed to open the hall had finally arrived and we could return.   Many of us did not want to leave the river and its soothing sounds as it moved past the first rocks I had seen in this countryside.

After we settled back into the building, Rocky spoke about the untold and silent stories that become physical illnesses.   These stories need to be elicited.   The organs and the tissues who manifest the diseases need to be engaged in conversation to tell their stories.   The lessons we were learning were not just pertinent to mental health.   He gave an example of working with a woman who was having severe right hip pain.   He used acupuncture and some osteopathy while he encouraged her to let her hip tell its story.   As a surprising but highly relevant story emerged, the pain moved to the left hip, then the left knee, and then left her body.   It had been stuck in her hip.   I suggested Brian Broom's marvelous book, Meaning-full Illness.   Auntie Jennie confirmed that this view was also consistent with what aboriginal people believe and how they heal in her area of Australia.

After lunch we wanted people to experience how ceremony builds community, so we chose a ceremony that I created based upon my readings from ethnographies written before 1900 of a "Welcome to Camp" ceremony.   It hasn't been done since 1880, as far as I can determine.   I can imagine someone getting ready to bristle, so I'll quickly say that I believe it's acceptable to create ceremony for specific purposes as the need arises.   It's not a Native American ceremony because it's not currently done and there's no model to follow or elder to teach it.   It may have some Native American flavor (we can't help infusing our spirituality into the ceremonies we create), but it's really an ecumenical attempt at experiencing some degree of transcendence toward the spiritual, which is exactly what I would call it.   Or, since I'm also a member of the Unitarian-Universalist Church, perhaps I should call it a "U-U greeting ceremony".

   The inspiration for this ceremony comes from Plains peoples of North America, before they were penned into reservations.   In those days, camps frequently moved.   During certain times of the year camps would join each other for celebrations and larger rituals.   A ceremony was done to oversee this process.   In one that I read, seven tipis were set in each of the seven directions so that the person walked a spiral toward the center.   This was done outside and to the East of the main camp.   Those people wanting admission to camp participated in the ceremony along with those who controlled the admissions process.   The supplicant who wished to enter the camp started in the West and passed to each of the directions.   In the original ceremony, the intent was that each person proved that he possessed the virtue of that direction.   In my readings, only men participated, but that may have been a side effect of the gender-nearsightedness of many of the ethnographers writing before 1880 who were often sexist and might not have noticed women even if they outnumbered men.   At each direction, the applicant to the camp tells a story about a deed that exemplifies the virtues of that direction.   In my ceremony, I used courage for the west, strength and endurance for the north, receiving and following a vision for the east, compassion for the south, protecting someone for the sky, and nurturing someone for the earth.   Then he is welcomed in the center and led into camp.   I'm going to guess no one was ever turned away because the incoming group were known and had been previously vetted.   This was just a formal way to say hello.

I use my ceremony with Native American people though, as I said, it is not a traditional Native American ceremony.   I use it especially with people who have drug and alcohol problems because they are not used to saying anything positive about themselves.   The beauty of this ceremony is that it emphasizes one's good traits and deeds.   So many people are quick to tell stories about their faults and misdeeds, but isn't it much harder to tell stories about what we have done well, or times when we have been courageous, or strong, or compassionate, or protected someone or something else?   This ceremony forces people to reflect upon what is good about them and to share it with another person who only listens, standing in the position that symbolically represents one of the Directions.   Participants feel how it changes them to tell good stories instead of bad stories and they feel the camaraderie that comes from being heard without commentary or personal response and being accepted.   Those who have completed the process are led to a nearby part of the room where they can sing, dance, or help each other in some way.   We keep a continual steam of singing and dancing going, because, as a Sari elder told us in Mexico, you can never sing or dance enough for the spirits.   When we did ceremony with her, she would exhort us with "mas bailando; mas cantando".

We did this ceremony with the group and Auntie Jennie agreed that it did succeed in giving them some flavor of the transcendence and sense of group membership that participation in tradition ceremony in community provides.   People also spoke about how difficult it was at first to be positive about oneself and how embarrassed they were.   Isn't it interesting that we are more embarrassed to tell positive stories about ourselves than negative ones?!   They also spoke about how transformative it felt to actually get out the positive story and for it to be accepted. They described the joy of completing the process and being welcomed to the community.   For some that community will continue, since talking circles are held weekly for those who live in the area and efforts are being made to find constructive ways for people to spend time with each other.

Later that evening after the workshop, we talked with our hosts about the problem in aboriginal communities for some people that family gathering was centered around drinking or doing drugs. The physician in our party who worked in the aboriginal community reported that she wasn't permitted by some families to make home visits on Thursday, Friday, or Saturday because of the partying that they didn't want her to see.     In relation to this we talked about the power of ceremony, even the ceremony of drinking together, for it is, after all, a kind of eucharist or communion.   It's no accident that alcohol is called "spirits".   We talked about the necessity of engaging the elders to put healthier ceremonies back into place in communities in such a way that people can notice and can attend.

In Warburton, we finished the day by offering traditional pipe ceremonies for those present.   We left to return to Melbourne to prepare to travel into the East Gippsland countryside early the next morning for Culture Camp 2012.

Drug Abuse Prevention; Why do the American media avoid discussing research findings?

This week on American television, as part of its coverage of the 2010 Vancouver Winter Olympic Games, particularly on the CNN Network each morning at the gym were I exercise, the morning news was astir with discussions of Insite, a Vancouver-based project that provides addicts with a safe site to inject, including clean needles. The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.

Why do the American media avoid discussing these research findings? Why are the opinions of uninformed people in towns like Decatur, Georgia, and Cumberland, Maryland, more meaningful than the results of carefully conducted scientific research? Why is evidence-based medicine abandoned when it comes to drugs? Why is the existence of credible research not even mentioned? The best that was done was to mention that the director of the Insite Program believed that lives were being saved. Not mentioned was the hard scientific evidence amassed to back his position. Why does science not matter when it comes to drug policies?

CNN implied that Insite was operating under the legal radar and that the Vancouver Police Department were pretending not to notice its existence. In fact, in 2003, the regional health authority in Vancouver successfully applied to the federal government for a legal operating exemption to pilot Insite.3 This exemption was granted following the release of feasibility data which suggested that Insite had the potential to reduce public drug use and overdose deaths.4,5 Insite was established following prior experience of similar facilities in European and Australian settings. Corresponding research suggested that these facilities had unique potentials to reduce public illicit drug use while promoting the use of sterile syringes and providing emergency care in the event of overdose.6-9 Since opening in 2003, Insite has been a place where people could inject drugs and connect to health care services from primary care to treating disease and infection, to addiction counseling and treatment. Few areas suffer more from the lack of response to research than illicit drug use.1,2

Dr. Evan Wood, Director of the University of British Columbia's Center for Excellence in HIV/AIDS research reported in The Calgary Herald on January 31, 2010, that despite criticisms levied by Conservatives (and the American media), the benefits that Insite provides are real and verified.

Dr. Wood pointed out that drug prohibition has created a massive global revenue stream for organized crime, worth an estimated $320 billion US annually. These enormous proceeds threaten the political stability of entire regions, including Mexico and Afghanistan. In the U.S., where the war on drugs has been fought most vigorously, the incarceration of drug offenders has placed a huge burden on the taxpayer and contributed to the world's highest incarceration rate. Primarily as a result of drug-law enforcement and mandatory minimum sentences, one-in-eight African-American males in the age group 25 to 29 is incarcerated on any given day, despite the fact that ethnic minorities consume illicit drugs at the same rate as white and other sub-populations. Paradoxically, ever-increasing drug enforcement expenditures and incarceration levels have not prevented the drug market from becoming more efficient.

The association between drug prohibition and increased inner-city violence is consistent. A recent international example is the upsurge in severe drug-related violence in Mexico subsequent to Mexican President Felipe Calderon's escalation in the fight against Mexican drug traffickers. Increasing gun violence in Canadian cities has been directly linked to clashes between organized crime groups over the enormous drug market profits.

HIV and overdose death rates are highest in areas where law enforcement is prioritized over evidence-based public health strategies. These harms are significant given HIVs spread beyond its traditional risk groups and its burden on the health system. Each and every case of HIV is estimated to cost $250,000 in medical expenses. For the above reasons, conservative economists like Nobel Prize winner Milton Friedman have long argued that the "war on drugs" does much more harm than good.

Due to their effectiveness, harm reduction policies are now endorsed by all evidence-based scientific consensus bodies, including the U.S. Institutes of Medicine and the World Health Organization. This consensus is based on rigorous reviews of the large volume of international scientific evidence indicating that harm-reduction programs save tax dollars and improve public health by reducing HIV rates while increasing uptake of addiction treatment. To read more from Dr. Evan, see click here

In Europe, more than 65 programs like Insite bring street-based drug addicts indoors where they can be prevented from sharing needles and overdosing while increasing enrollment into addiction treatment. Insite has replicated the European experience, and is undoubtedly the most highly studied health clinic in Canadian history. More than 30 peer-reviewed studies show that Insite reduces public injecting, reduces HIV risk behaviors (e.g., needle sharing), and increases rates of addiction treatment. Studies seeking to identify potential harms of the facility found no evidence of negative impacts. Studies were independently peer-reviewed and published in top scientific periodicals, including the New England Journal of Medicine, The Lancet and the British Medical Journal.

During the period from March 10, 2004 to April 30, 2005, 4,764 individuals registered to use Insite. Heroin was used in nearly half of all injections, and cocaine was injected 37% of the time. There were 273 witnessed overdoses, none of which resulted in a fatality. There were also 2,171 referrals to addiction counseling and other support services. These early results indicated that Insite was being successfully integrated into the community. The facility was attracting a wide cross-section of injection drug users, and staff were successfully intervening in overdose events on site and actively referring drug users to addiction treatment and other services.10

A 2006 study showed that Insite was attracting a large number of hard-to-reach intravenous drug users and that the existence of the facility presented an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject. Finally, the facility was also an important point of contact for HIV-positive individuals who were not yet participating in HIV care and treatment.11

One concern prior to the opening of Insite was whether the facility would encourage injection drug use by making drug injection easier and more comfortable for intravenous drug users. Therefore a study was made to determine whether or not the opening of the facility would be accompanied by a worsening of community drug use patterns. The drug use behaviors of 871 intravenous drug users were observed in the one year period before the opening of Insite and in the one-year period after. The drug use behaviors studied included the rates of relapse into injection drug use among former users and the cessation of injection drug use among current users. The study found that after Insite opened there was no substantial increase in the rate of relapse into injection drug use among former users (the rate of relapse was 17% prior to the opening and 20% after). There was also no substantial decrease in the rate of injection drug use cessation among current users (the rate was 17% prior to Insite's opening and 15% after). This research showed that the benefits of Insite on reducing the high-risk behaviors of intravenous drug users and on increasing public order were not offset by negative effects on drug use patterns among Vancouver's intravenous drug using population.12

Critics suggested that the availability of a supervised injection facility might discourage drug users from seeking treatment for their addiction. A study was conducted to examine the effect of Insite on the use of detoxification services, which is the entry point into the addiction treatment continuum in Vancouver. The study followed more than 1,000 Insite users between December 1, 2003 and March 1, 2005. Of this group, 185 (18%) began a detoxification program at some point during the study period. Individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently. The study also found that contact with Insite's addictions counselor significantly increased a person's chances of enrolling in detox. Contrary to fears that Insite might be deterring drug users from seeking treatment, these findings strongly suggested that Insite was facilitating entry into detoxification services among its clients.13

In another study, researchers measured the effect of Insite on the use of detoxification services by comparing rates of detox service use among injection drug users in Vancouver in the year before Insite opened and in the year after it opened. The researchers also investigated whether those individuals who attended Insite and enrolled in detox were subsequently more likely to enroll in methadone maintenance or other drug treatment programs. They learned that, in the year after Insite opened, there was a 33% increase in detoxification service use, compared to the year prior to the opening of the facility. The study also showed that Insite clients who entered detox were 1.6 times more likely to enroll in methadone treatment and 3.7 times more likely to enroll in other forms of addiction treatment. As well, individuals who entered detox visited Insite less frequently in the month after enrolling in detox services than in the month prior to enrollment. This research indicated that Insite encouraged intravenous drug users to enter detox. It also suggested that drug users who enrolled in detox were more likely to remain in subsequent treatment programs and reduce their use of Insite.14

I don't have an answer for why ideology trumps scientific evidence in the United States and its media. Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?

Treatment Programs -" Do they work?

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"Live" from the Creativity and Madness conference in Santa Fe, New Mexico, February 14, 2010, Valentine's Day, we consider the question of treatment does it work? Treatment is a billion dollar industry in America. We have treatment programs for everything from alcohol users to drug users to people who have too much sex, to people who have too little sex, to people who eat too much, to people who eat too little, to people who eat and then purge, to people who cut themselves, to people who are too sad, to people who are too happy. So many people go for treatment and so many experts purport to tell people how to reform. The question does it work? Does treatment actually help anyone?

When I worked in Saskatchewan, we attempted to address the simple question of whether "28 day alcohol treatment programs" worked. In general, they didn't. People came home and quickly resumed drinking. At the time I was working with Native people in Northern Saskatchewan. The irony was that we had unlimited funds to send people south to 28 day treatment programs and no funds to organize local support for people coming back from treatment programs.

Previoiusly, when I consulted to an Eating Disorders Treatment Program, I was asked to do a follow-up study of their clients. I discovered that the most successful patients were the "bad patients", those identified by the staff as unlikely ever to succeed. The least successful patients were the "good patients", those who complied, who did everything they were told, who were pleasant and easy. Ironically, the relapse rate of this $1,000 per day, 28 day treatment program was greater than spontaneous recovery rates reported in the literature. Five years after people were diagnosed with eating disorders, 65% had recovered with no treatment. In the treatment program I studied, after 5 years, fewer than 30% recovered with treatment. Apparently treatment did no good.

At this conference, I spoke to a friend about this. He had worked in an adolescent treatment program. He had the same insight. The teenagers who were labelled as bad patients appeared to do the best. These individuals appeared to have "self-agency". They had enough sense of personal power that they could fight the authorities of the treatment program. They could rebel against the treatment staff. In his experience, these patients had the highest likelihood of responding, of recovering. What they had, which apparently we all need, is self-agency, a sense that our efforts can and will make a difference. The compliant patients, the good patients, lacked self-agency. They did what they were told and played the role of good patients, and, once discharged, had no role to play, no direction, and promptly relpased.

Treatment programs of all sorts consume a large amount of the health care budget. Let's examine the assumptions upon which these programs are based. Almost uniformly, they are based upon the assumption that a class of experts exist, who know more about other people than the people themselves know. These experts tell an inferior class of patients how to reform themselves and how to behave to live "the good life". The problem with this is that it doesn't work. Rational expositions of how to live rarely change people's behavior. Largely this is a waste of breath. Why? Because we do not behave as we do out of ignorance. We behave as we do because of our beliefs. They tell us how to behave. Cognitive-behavioral therapists figured this out. But from where do beliefs come? They come from our interpretations of our experience which exist in the form of stories. If you want to know how I cam to believe, ask me to tell a story about an experience which led me to form the conclusion that I have formed. Ask me to tell several stories. I will do so and, whether or not you agree with my interpretations of these experiences, you grasp that I believe my interpretations, and that these stories I tell have come together to generate my conclusions which I now believe wholeheartedly. If you want to change my beliefs (which is necessary to change my behavior), then you need to find stories that contradict the stories I tell to support my belief(s). They need to be compelling, believable stories. They need to convince me. Telling me to think differently or arguing with my beliefs doesn't work.

My friend had an excellent example. He told me a story of a patient who came to him to tell him that the treatment program was a crutch for the girls who were attending it. She described how they preferred to "freak out" and scream and come to treatment than to deal with their problems. He arranged for her to give a lecture to staff about her stories and conclusions and beliefs. She did, but mostly staff ignored her insights, since they definitely knew what was true and this teenager who had no training couldn't possibly know anything.

He told me another story about a girl who was assigned to him because no one else had been able to help her stop cutting. He asked her to talk to "cutting". What did it want? How did it help? She responded with the story of Austin Powers. She said, she had been frozen like him and awakened. When she awakened, she was full of pain. She needed to shut down the pain and cutting did that. It refroze her. My friend proposed a metaphor to her. He asked her to imagine herself as a greenhouse. Each time she tried love, someone broke a window and it got replaced with a wooden board. Eventually, he said, "your greenhouse is mostly covered with plywood and inside has become dark. You need to pick one board at a time to replace with glass, he said. This metaphor worked for her and her cutting reduced.

What was different? He listened to her story. He found a metaphor that resounded to her. He found a metaphor that she could use for change. He didn't tell her what to do. He didn't lecture her. He didn't pretend to know more about her than she knew. He listened to her and then responded to what she said in a way that indicated that he had understood her and then offered her a new twist on her story which could be even more useful. This is the essence of what we call narrative therapy.

My point is that we need to be suspicious of experts. We need to question those who purport to know how to treat others. We need to suspect those who claim to know our minds better than ourselves. We need to question those who would control us and tell us how to make our lives better. We need to suspect those who would do other than empower us.

From a public policy point of view, from a health care reform point of view, from a health care finance point of view, we need to question expensive 28 day treatment programs and focus on more local programs, respectful and empowering, respecting of each person's story, and capable of helping people to transform their story into a better one.

Waste in our system

Here's a dogbite story.  Every blog about health care reform needs a dogbite story.  My friend who lives outside of Los Angeles has a very large dog.  One day her dog got into a fight with another very large dog and she made the mistake of getting in the middle. He bit her. Bad doggie.  Don't bite the hand that feeds you!  But dogs will be dogs.  She wasn't going to do anything about it but her family and friends convinced her to go to Urgent Care.  There, a nurse practitioner (who didn't identify herself as a nurse practitioner) sewed it up. Unfortunately, even a third year medical student probably knows not to suture a dog bite tightly closed.  That visit cost $1600.00.  The time involved was less than one half hour.  Then she had to go to the emergeny room when the inevitable infection began in her arm.  The sutures had to be removed. The wound had to be thoroughly irrigated.  She needed three days of intravenous antibiotics and then continued on oral antibiotics. That process cost $20,000.00.  If she had stayed home and cleaned the wound with soap and water, probably she would have been fine, and that would have cost $0.  Think about this.  Probably the nurse practitioner is making $40 per hour and the ER doctor is making $80 per hour.  Where did all the money go?

Eliminate Home Health Care?!?

Today's San Francisco Chronicle headlines announce that Congress has figured out how to insure 30 million people -- eliminate Medicare home health care and reduce Medicare payments to physicians.  Brilliant!  Imagine what a cost savings that will be.  Then even fewer physicians will accept the pitiful payments that Medicare offers and all the seniors who are maintaining in their homes with the help of home health nurses can go to the hospital or to a nursing home. That should save lots of money.  The physicians who will be hurt the most by this policy, of course, are the geriatricians.  What apparently no one wants to address are the enormous wastes of dollars spent on lab tests and on end-of-life care that is relatively futile.  Today, I heard about a 105 year old man who was taken to the coronary cath lab.  Does that make sense?  Or my friend, whose orthopedic surgeon orders an MRI every three months just in case he finds something that he can surgically treat.  I have story after story of people who had hundreds of thousands of dollars of laboratory tests, but no one had ever taken a careful history.  I had a patient who received 2 MRIs, one CT, two ultrasounds, one HIDA scan, colonoscopy, and duodenoscopy, only to be put on narcotics, when the history revealed in 20 minutes that her symptoms worsened on birthdays and when she ate whole wheat bread.  The diagnosis was celiac disease and she was normal after three weeks of gluten.  Probably didn't need all those tests -- just a careful history.  Until we wake up and look at the state of medicine today, health care reform will not work.