What do ticks, heart attacks, and protozoa have in common?

October 5, 2011

I recently did a column in my wilderness health series in Adirondac¬†magazine on the topic of ticks – Ticked Off). I warned the editor that as soon as the column came out, he would be receiving irate letters. He didn’t believe me.

The ink on the magazine was hardly dry when the first complaint came across his desk.

I was taken severely to task for minimizing the problem of Lyme disease among users of the outdoors.

Read the piece and judge for yourself. Lyme disease is a nasty affliction, but virtually always treatable with a short course of a common antibiotic; deaths from Lyme in the US are virtually unheard of. “Chronic” Lyme disease exists mainly in the minds of a group of unfortunate folks with some sort of chronic pain syndrome and a group of “specialists” who make a living from them. Hikers in tick-infested areas should take some simple precautions, but not consume much mental energy worrying about them.

The whole thing got me thinking about the irrational way in which those of us in the outdoor education industry decide what to worry about. It isn’t just ticks.

I spend a lot of time working with challenge course programs, especially around issues of “medical screening”. There have been a few (actually very few) cases of sudden cardiac death involving users of these courses, although on a per-participant-hour basis the actual risk is statistically at baseline. See article : Sudden Unexpected Death on Challenge Courses. (Remember, over 300,000 people experience sudden cardiac death annually, and every one of them was doing something at the time!) This has not stopped some in the industry from arguing for exhaustive (and completely unvalidated) screening methods to select out those at risk. This has reached the ludicrous point of some arguing that failure to implement such screening is “unethical”! Of course, experienced cardiologists will tell you that they cannot predict the risk of sudden death in any specific individual, but this has not stopped facilitators from implementing simplistic checklists–preventing nothing but also potentially depriving folks who could benefit from such a program from participating.

I have commented previously on the silliness which has inflicted many outdoor instructors regarding the risk of water-borne giardiasis. Although the scientific data on this problem are abundantly clear, there continue to be programs which enforce water treatment strategies which are entirely unsupported by data. Some of these are so bizarre (keeping utensils which are “dipped” in suspect water separate from “clean” ones; flushing out the microliters of water caught in screw-top water bottle grooves) they seem more suited for the Book of Leviticus than outdoor education materials.

The problem with this sort of thing is that there actually are some very good data which should inform our decision making in these areas. Sadly, most outdoor education programs do not seem to integrate such epidemiologic data into their policy development.

We worry needlessly about water quality, while rarely enforcing hand sanitation–a far better way to address the spread of intestinal infection on the trail. We push for wide availability of “Epi Pens” without prescription to trek leaders, with virtually no data pointing to anaphylaxis as an actual problem in outdoor education courses. Of course, those who push for Epi Pens are not the ones advocating flu shots and immunization updates–a vastly more important intervention for a group about to set out on a lengthy expedition. Many programs insist on lengthy “woofer” courses and refreshers for their leaders, in the face of absolutely no evidence that such programs meaningfully impact safety, even if a fraction of their skills could be retained. Epidemiologic data clearly point to automobile accidents and drowning as the major causes of death on treks–have you ever heard of a program with a mandatory driver education or water safety recertification requirement?

In my “day job” as an academic physician, I am constantly surrounded by the drumbeats of those insisting that everything we do be firmly grounded in evidence. When I step into the outdoor education arena, however, it appears that unsubstantiated opinion, anecdote, and dogma regularly trump evidence.

We must do better.