A Dugyot in the U.S.A.: How is the Fellowship Going?: Going into fellowship has been one of the most humbling things i've experienced in my life. It stripped all the facades i had built up ...
Friday, December 5, 2014
Solving Ebola
The press have been discussing the current outbreak of Ebola in West
Africa. They stress that it is an awful way to die, that there is no
cure, and that health workers are dying despite apparently taking all
necessary precautions. More learned writers have been explaining that
Ebola is quite hard to catch unless you come into direct contact with
contaminated bodily fluids, and that simple precautions should be enough
to contain it. Yet other commentators are pointing out that the death
rate is very low compared to other well known diseases, and that we need
to keep the threat in perspective. So, we have an intelligence test
item to solve.
The World Health Organization, in partnership with
the Ministries of Health in Guinea, Sierra Leone, Liberia, and Nigeria
announced a cumulative total of 1440 suspect and confirmed cases of
Ebola virus disease (EVD) and 826 deaths, as of July 30, 2014. Of the
1440 clinical cases, 953 cases have been laboratory confirmed for Ebola
virus infection. Previous outbreaks have been more often in the Congo,
Gabon and Uganda.
Infectious disease dynamics can be modelled,
and controlling this outbreak should be pretty easy, at least from a
conceptual point of view. This disease is a short-incubation period
(about three weeks), relatively low transmissibility, high lethality
infection. Whereas a sneeze can transmit pathogens with great
efficiency, hence the easy airborne spread of influenza, avoiding fluids
is easier. Soap, water, disinfectants, protective clothing for nurses,
body bags for victims, quick burial in chlorine covered graves or better
still cremation, quarantine for all contacts, and the same procedures
for those quarantined victims if they die: all of these should be
sufficient. In terms of disease control it should be noted that men who
have recovered from the disease can still transmit the virus through
their semen for up to 7 weeks after recovery from illness. Severely ill
patients require intensive supportive care. Patients are frequently
dehydrated and require oral rehydration with solutions containing
electrolytes or intravenous fluids. No specific treatment is available.
New drug therapies are being evaluated. Barrier nursing is required to
protect health staff, but the standards of protection required are very
high, and hard to observe when health workers are subject to high
ambient temperatures. If treatment is really unlikely to help victims,
then in a big outbreak it might best to avoid attempts at close contact
nursing, and rely on quarantine and subsequent disinfection as the best
way to save more lives. Perhaps hydration packs distributed to homes
under quarantine would be best, but that is for public health
specialists to judge.
Why isn’t all this happening? Many of the
locals either do not understand the transmission method (from forest
animals like bats), or chose to disbelieve it, and are not changing
their behaviours regarding funereal procedures, which involve bathing
and kissing the corpse, all of which are part of altruistic respect for
the dead person. The locals are also prey to false correlation: they see
people who are mildly ill going into hospital, and then taken out dead
soon afterward by space-suited Western health workers. In terms of
Kahneman’s Type 1 fast and sloppy thinking, this is understandable.
Ebola hospitals are dangerous places. Westerners in space suits are
unusual and disturbing, and in fact even the notion of a hospital may be
the wrong strategy in these outbreaks. However, if a populace suspect
that health workers spraying disinfectant may be malevolently spreading
bottled Ebola, then there is a massive health education challenge to be
faced.
Western doctors very much want to help, but getting to the
outbreak locations they quickly find that local facilities are
inadequate, that barrier nursing is very difficult to achieve to a high
standard and, although this is less often conceded, that nursing might
be of little real help. However, early treatment improves outcomes, and
about 40% are pulling through at the moment. Hence the wish to provide
treatment, and some groups like Medecins sans Frontieres have not lost
doctors to Ebola. Wanting to help others is humanity at its best. These
missionary doctors write heart-wrenching diaries about families being
wiped out, and about their lack of resources, about the stigma with
which the afflicted are treated and about their guilt at seeing ill
patients dying without comforters next to them. They don’t publically
question why the countries in which they operate are in such a mess. The
conventional answer is that they are poor and wracked by conflict.
Guinea,
Sierra Leone, Liberia, and Nigeria, the countries in the front line of
this particular outbreak, share West African environments. Sierra Leone
and Liberia have a particular history, in that they were formed and
settled to take repatriated American slaves. From some points of view,
they should be models of governance. That has not been the case. If all
these countries had been governed well even remote country hospitals
would have had basic resources, and there would have been widespread
knowledge of basic hygiene and disease control. Quarantine would have
been explained, established and monitored.
Can we deduce
anything from the failure to deal with the epidemic? The governments of
these countries may have regarded their poorer citizens as being of
little interest to them, living as they do in poverty in remote villages
near tropical forests. Government officials tend to be snooty, and
African governments have often disregarded the needs of their citizens.
They say that they have given plenty of public health warnings, but the
disease keeps spreading. Disasters test the morality of the organising
structure, and those structures have often been found wanting.
Could
it be that these countries simply don’t understand the threat and don’t
understand how to deal with it, or that they don’t do so in sufficient
numbers to provide an effective response?
Little is known with
certainty about intelligence levels in these countries. Those
governments do not measure cognitive ability, nor do they participate in
the PISA and other international scholastic studies. If one gathers
together various published papers on intelligence test results, then the
IQ figures for the Congo are in the 64 to 73 range; for Guinea 70; for
Ghana 60-80; for Nigeria 64-70; and Sierra Leone 64. Some of the samples
are of reasonable size, one and a half thousand, so it is not all a
patchwork of tiny studies, though there is plenty of room for
improvement. The figures are so low by Western standards that they are
hard to believe, but when educational elites in South Africa are tested
they are often in the IQ 100 range, consistent with being the top 2% of a
population which has an actual mean of IQ 70.
Botswana is an
exceptional African country in many ways, has put a lot of money into
education, and has participated in Trends in International Mathematics
and Science 2011, and Progress in International Reading Literacy Study
2o11. Botswana is a test case, an exemplar of the current achievement of
an African country which takes education seriously. If you look at
their scholastic achievement and compare it with the achievements of
countries with well established IQ measures, then Botswana comes out at
an estimated IQ of 70. Sub-Sarahan African intelligence test results
have been much debated by intelligence researchers, and the estimates
range from about IQ 70 from Richard Lynn to IQ 80 from Jelte Wicherts.
The key argument is about the representativeness of samples. The tests
seem to be OK, much to popular surprise. Humans in all continents appear
to solve basic problems in the same way. Africans have the same
cognitive operating system as other continental groups. There are power
differences, but not operating system incompatibilities.
Are the
behaviours of the average citizens in these countries consistent with
these estimates? Western critics of international intelligence testing
regard these estimates with considerable scepticism, particularly
considering that IQ 70 is seen as too low to lead an independent life
and earn a living in Western economies. However, that is the way the
results come out, and the match with achievements is reasonably close,
certainly when scholastic achievements are measured. Although all
countries have the equivalent of witchdoctors, in the West these are
usually a homeopathic side-line and less dominant in public health, but
in African countries they still sway many people on important health
matters. Seen from afar, the response to Ebola has not been intelligent.
Equally, the response to HIV has often been weak and contradictory.
Finally,
should we be less alarmed about Ebola, and be more scared of measles,
malaria and car accidents? Those who would ask us to bear in mind these
comparative statistics misunderstand human nature. New threats demand
great fear, which is the prudent reaction till the true nature of the
predator is known. We humans are also concerned about how we die.
Bleeding to death from a galloping haemorrhagic fever is far more scary
than our favoured exit, to breathe our last as peacefully as possible,
expiring gently, entirely unblemished, while lying in clean sheets in
our own house with our loving family in attendance. Furthermore, as even
the dullest actuary must know, the statistics on Ebola are comforting
only at the moment. If this outbreak continues to be mismanaged, the
numbers could look very different in a few year’s time. Then we would
have to say that we had failed a simple test in public health.
Hope not.
Africa. They stress that it is an awful way to die, that there is no
cure, and that health workers are dying despite apparently taking all
necessary precautions. More learned writers have been explaining that
Ebola is quite hard to catch unless you come into direct contact with
contaminated bodily fluids, and that simple precautions should be enough
to contain it. Yet other commentators are pointing out that the death
rate is very low compared to other well known diseases, and that we need
to keep the threat in perspective. So, we have an intelligence test
item to solve.
The World Health Organization, in partnership with
the Ministries of Health in Guinea, Sierra Leone, Liberia, and Nigeria
announced a cumulative total of 1440 suspect and confirmed cases of
Ebola virus disease (EVD) and 826 deaths, as of July 30, 2014. Of the
1440 clinical cases, 953 cases have been laboratory confirmed for Ebola
virus infection. Previous outbreaks have been more often in the Congo,
Gabon and Uganda.
Infectious disease dynamics can be modelled,
and controlling this outbreak should be pretty easy, at least from a
conceptual point of view. This disease is a short-incubation period
(about three weeks), relatively low transmissibility, high lethality
infection. Whereas a sneeze can transmit pathogens with great
efficiency, hence the easy airborne spread of influenza, avoiding fluids
is easier. Soap, water, disinfectants, protective clothing for nurses,
body bags for victims, quick burial in chlorine covered graves or better
still cremation, quarantine for all contacts, and the same procedures
for those quarantined victims if they die: all of these should be
sufficient. In terms of disease control it should be noted that men who
have recovered from the disease can still transmit the virus through
their semen for up to 7 weeks after recovery from illness. Severely ill
patients require intensive supportive care. Patients are frequently
dehydrated and require oral rehydration with solutions containing
electrolytes or intravenous fluids. No specific treatment is available.
New drug therapies are being evaluated. Barrier nursing is required to
protect health staff, but the standards of protection required are very
high, and hard to observe when health workers are subject to high
ambient temperatures. If treatment is really unlikely to help victims,
then in a big outbreak it might best to avoid attempts at close contact
nursing, and rely on quarantine and subsequent disinfection as the best
way to save more lives. Perhaps hydration packs distributed to homes
under quarantine would be best, but that is for public health
specialists to judge.
Why isn’t all this happening? Many of the
locals either do not understand the transmission method (from forest
animals like bats), or chose to disbelieve it, and are not changing
their behaviours regarding funereal procedures, which involve bathing
and kissing the corpse, all of which are part of altruistic respect for
the dead person. The locals are also prey to false correlation: they see
people who are mildly ill going into hospital, and then taken out dead
soon afterward by space-suited Western health workers. In terms of
Kahneman’s Type 1 fast and sloppy thinking, this is understandable.
Ebola hospitals are dangerous places. Westerners in space suits are
unusual and disturbing, and in fact even the notion of a hospital may be
the wrong strategy in these outbreaks. However, if a populace suspect
that health workers spraying disinfectant may be malevolently spreading
bottled Ebola, then there is a massive health education challenge to be
faced.
Western doctors very much want to help, but getting to the
outbreak locations they quickly find that local facilities are
inadequate, that barrier nursing is very difficult to achieve to a high
standard and, although this is less often conceded, that nursing might
be of little real help. However, early treatment improves outcomes, and
about 40% are pulling through at the moment. Hence the wish to provide
treatment, and some groups like Medecins sans Frontieres have not lost
doctors to Ebola. Wanting to help others is humanity at its best. These
missionary doctors write heart-wrenching diaries about families being
wiped out, and about their lack of resources, about the stigma with
which the afflicted are treated and about their guilt at seeing ill
patients dying without comforters next to them. They don’t publically
question why the countries in which they operate are in such a mess. The
conventional answer is that they are poor and wracked by conflict.
Guinea,
Sierra Leone, Liberia, and Nigeria, the countries in the front line of
this particular outbreak, share West African environments. Sierra Leone
and Liberia have a particular history, in that they were formed and
settled to take repatriated American slaves. From some points of view,
they should be models of governance. That has not been the case. If all
these countries had been governed well even remote country hospitals
would have had basic resources, and there would have been widespread
knowledge of basic hygiene and disease control. Quarantine would have
been explained, established and monitored.
Can we deduce
anything from the failure to deal with the epidemic? The governments of
these countries may have regarded their poorer citizens as being of
little interest to them, living as they do in poverty in remote villages
near tropical forests. Government officials tend to be snooty, and
African governments have often disregarded the needs of their citizens.
They say that they have given plenty of public health warnings, but the
disease keeps spreading. Disasters test the morality of the organising
structure, and those structures have often been found wanting.
Could
it be that these countries simply don’t understand the threat and don’t
understand how to deal with it, or that they don’t do so in sufficient
numbers to provide an effective response?
Little is known with
certainty about intelligence levels in these countries. Those
governments do not measure cognitive ability, nor do they participate in
the PISA and other international scholastic studies. If one gathers
together various published papers on intelligence test results, then the
IQ figures for the Congo are in the 64 to 73 range; for Guinea 70; for
Ghana 60-80; for Nigeria 64-70; and Sierra Leone 64. Some of the samples
are of reasonable size, one and a half thousand, so it is not all a
patchwork of tiny studies, though there is plenty of room for
improvement. The figures are so low by Western standards that they are
hard to believe, but when educational elites in South Africa are tested
they are often in the IQ 100 range, consistent with being the top 2% of a
population which has an actual mean of IQ 70.
Botswana is an
exceptional African country in many ways, has put a lot of money into
education, and has participated in Trends in International Mathematics
and Science 2011, and Progress in International Reading Literacy Study
2o11. Botswana is a test case, an exemplar of the current achievement of
an African country which takes education seriously. If you look at
their scholastic achievement and compare it with the achievements of
countries with well established IQ measures, then Botswana comes out at
an estimated IQ of 70. Sub-Sarahan African intelligence test results
have been much debated by intelligence researchers, and the estimates
range from about IQ 70 from Richard Lynn to IQ 80 from Jelte Wicherts.
The key argument is about the representativeness of samples. The tests
seem to be OK, much to popular surprise. Humans in all continents appear
to solve basic problems in the same way. Africans have the same
cognitive operating system as other continental groups. There are power
differences, but not operating system incompatibilities.
Are the
behaviours of the average citizens in these countries consistent with
these estimates? Western critics of international intelligence testing
regard these estimates with considerable scepticism, particularly
considering that IQ 70 is seen as too low to lead an independent life
and earn a living in Western economies. However, that is the way the
results come out, and the match with achievements is reasonably close,
certainly when scholastic achievements are measured. Although all
countries have the equivalent of witchdoctors, in the West these are
usually a homeopathic side-line and less dominant in public health, but
in African countries they still sway many people on important health
matters. Seen from afar, the response to Ebola has not been intelligent.
Equally, the response to HIV has often been weak and contradictory.
Finally,
should we be less alarmed about Ebola, and be more scared of measles,
malaria and car accidents? Those who would ask us to bear in mind these
comparative statistics misunderstand human nature. New threats demand
great fear, which is the prudent reaction till the true nature of the
predator is known. We humans are also concerned about how we die.
Bleeding to death from a galloping haemorrhagic fever is far more scary
than our favoured exit, to breathe our last as peacefully as possible,
expiring gently, entirely unblemished, while lying in clean sheets in
our own house with our loving family in attendance. Furthermore, as even
the dullest actuary must know, the statistics on Ebola are comforting
only at the moment. If this outbreak continues to be mismanaged, the
numbers could look very different in a few year’s time. Then we would
have to say that we had failed a simple test in public health.
Hope not.
Ebola in 2040: will stigma save us?
One of the few perks of being a psychologist in a medical school
(apart from occasionally running to a colleague to check a personal
health matter) was talking to researchers about the real state of
knowledge in any particular field.
The Middlesex Hospital Medical
School, which started in 1746 and was subsumed into UCL in 1987, had a
great talent for developing new services. In a very minor way I added to
that trend by setting up, with two other colleagues, a national
referral centre for post-traumatic stress disorder, which is still in
operation as an NHS clinic.
However, of much greater importance
was the clap clinic. At a time when the usual appellation was Venereal
Disease, two clinicians got together and decided, over a glass of
champagne, to move it from the dark basement to the full daylight. In
1964 Duncan Catterall established the first Chair of Genito-urinary
Medicine at the Middlesex Hospital Medical School, and so when the first
symptoms of a strange sexually transmitted disease showed up in the
very early 80s, James Pringle House started seeing the first cases and
was at the forefront of European research. I went to seminars, talked to
colleagues, and sometimes met the guest speakers for a canteen lunch.
The greater the expert, the quicker they were to admit that no-one knew
what the hell was going on.
To my dismay, the public management
of the disease quickly veered away from traditional public health
concerns, and became a political battlefield. At the WHO headquarters in
Geneva senior colleagues muttered that they had been criticised for
saying the virus came from Africa: a colonialist perspective, they were
told. Even years later, those who worked in the field in London talked
sadly, and privately, of the difficulties they encountered with giving
straightforward health warnings. I wanted to design a simple poster to
illustrate the relative risks, but it got no further than a large page
in my filing cabinet. Such, dear readers, were the difficulties of
quickly disseminating an opinion before blogging became available.
It
was clear to researchers that blood was the key vector of transmission
(contaminated blood transfusions had a 90% chance of resulting in the
recipient getting HIV), so that shared needle drug injecting and to a
lesser extent anal intercourse without condoms were high risk
activities, but public broadcasts talked vaguely about icebergs, and
suggested everyone was at risk. I did some research on public
perceptions of risk at that time, and AIDS figured high in the public
mind. The common folk knew that it was a “gay plague” but the expert
emphasis seemed to be on getting heterosexuals to use condoms. The great
and the good were interviewed and asked to say the word “condom” on
camera which they valiantly did. The correct way of putting on a condom
was demonstrated on television, using a cucumber. This led to some
worried calls about whether one could catch AIDS from a cucumber.
However,
it was generally agreed that the UK government had done “rather well”
and had got on top of the crisis. Now, with Ebola in the news, I thought
it worthwhile looking at the current situation for the HIV virus in the
UK, 30 years on from the first outbreak. This might give us a possible
scenario for imagining what Ebola might look like in terms of
prevalence.
In fact, the UK response to HIV seems to have been at
the European average. Statistics vary in different parts of the world,
but I imagine that European statistics have a modicum of accuracy.
Finland, Germany, Malta, Norway (and Cuba, see below) did very well (0.1
%); Denmark, Greece, Netherlands and Sweden and Israel pretty well
(0.2%) and Belgium, Iceland, Ireland, Luxemburg and the United Kingdom
were average (0.3%). Austria, France, Italy, Spain, Switzerland were a
bit worse (0.4 %) and Portugal very much worse (0.7%). Of course, these
are not sub-Saharan African levels (as high as 25% in Swaziland and
Botswana) but given that the governments knew what was coming, and had
resources available, they are not stellar achievements.
Greg
Cochran mentioned the case of Cuba, which had forewarning of the virus
in the US and two years to prepare for their first case.
http://westhunt.wordpress.com/2014/09/28/forty-days/
They
quarantined patients for 8 weeks of health education, tracked contacts
in a very determined way, and used their relative isolation to put
public health before private liberty, an approach which comes naturally
to the regime. Their resultant prevalence of roughly 0.1% is one-sixth
the rate of the United States, one-twentieth of nearby Haiti.
http://news.bbc.co.uk/1/hi/in_depth/sci_tech/2003/denver_2003/2770631.stm
http://www.nytimes.com/2012/05/08/health/a-regimes-tight-grip-lessons-from-cuba-in-aids-control.html?pagewanted=all&_r=0
HIV
probably moved from monkeys to humans before the 1950s, although the
first cases were recognised in 1981 in the US. About 100,000 people in
the UK are infected, mostly homosexuals, and heterosexuals from
sub-Saharan Africa. More than 20 per cent of them do not know it, and
are several times more likely to transmit the virus to their partners
than those who have a diagnosis. Half of the newly diagnosed cases in
the UK seek medical help when they are in the late stages of disease. In
2012, there were 6,360 new diagnoses of HIV, which is 17 a day in case
you find that more dramatic. In England the local authorities with the
highest prevalence of diagnosed infections are London, Brighton and
Hove, Salford, Manchester, Blackpool and Luton, and in Scotland,
Edinburgh. Treatment with antiretroviral drugs reduces the risk of
transmission by more than 90 per cent. The cost of these drugs is said
to be £20,000 a year and given the current almost normal life spans of
HIV patients, 20 years of medication seems a prudent minimum for
budgeting purposes. The money spent per capita on NHS services in
England was £1,979 in 2011, so each patient with HIV consumed at least
10 times the resources of an average patient every single year.
http://www.avert.org/uk-hiv-aids-statistics.htm
A
possible explanation for the apparently lacklustre performance of the
UK may be that many of the cases are imported: that is, brought in by
Black Africans infected in Africa. Looking at the demographics of the UK
in 2011 that shows that 55,730,000 persons are classified as White and
1,905,000 are classified as Black or Black British. Looking at the HIV
figures (this is broad brush, because I have omitted the “mixed” groups)
the HIV rates per 100,000 are as follows:
Whites: 93 per 100,000
Blacks: 2015 per 100,000
So,
the rate seems to be 21 times higher among Africans. The fact that so
many Africans have come to the UK cannot be blamed on the quality of UK
public health warnings aimed at changing the behaviour of the local
population. The White rate is exactly comparable with the best European
nations at 0.1%
Nonetheless, considering that about 36 million
people in the world are infected by HIV and that 30 million have died,
the management of HIV is hardly a global success story. Does this give
us any help in looking ahead to the prevalence of the Ebola virus in 30
years’ time? Prediction will depend on whether treatments or
vaccinations become available, but my impression, no more than that, is
that the spread of the virus should be much slower, very much slower.
HIV can be passed on whilst the carrier still looks good for sex, and
sex is fun, so HIV gets an easy ride. Ebola can only be passed on (if
the experts are right) when the carrier is looking pretty ill and
unattractive, and dealing with ill people is a duty, and not much fun.
Furthermore, Ebola is so virulent at the moment that immediate death
rates are high. With simple precautions it should be contained. Even
when “protocols” fail, the reproduction rate of the virus in human
carriers should be low. Despite all the worrying news, it should be a
simple matter to avoid the spread of the disease.
On a more
speculative note, perhaps we shall be saved by stigma. By fearing all
people who look as if they are ill with Ebola, stigmatising them and
avoiding all contact with them, definitely not putting ourselves at risk
by helping them, particularly not touching them when they are dying or
dead, the virus will die out. So, in one corner we have the virus, in
the other corner the uncertain public, caught in an awkward tussle
between altruism and abject fear. Ebola has its best chance of spreading
in societies which don’t believe it exists (like in parts of Africa),
and to a lesser extent in those which don’t believe that, given the
virus does exist, the absolute priority is to change our behaviour
quickly (parts of the wealthy West). Informed opinion ought to be right,
but with every failure of both treatment and containment in Western
hospitals public belief is eroded.
Although it goes against altruistic instincts, futile attempts at interventionist treatments may be making matters worse.
(apart from occasionally running to a colleague to check a personal
health matter) was talking to researchers about the real state of
knowledge in any particular field.
The Middlesex Hospital Medical
School, which started in 1746 and was subsumed into UCL in 1987, had a
great talent for developing new services. In a very minor way I added to
that trend by setting up, with two other colleagues, a national
referral centre for post-traumatic stress disorder, which is still in
operation as an NHS clinic.
However, of much greater importance
was the clap clinic. At a time when the usual appellation was Venereal
Disease, two clinicians got together and decided, over a glass of
champagne, to move it from the dark basement to the full daylight. In
1964 Duncan Catterall established the first Chair of Genito-urinary
Medicine at the Middlesex Hospital Medical School, and so when the first
symptoms of a strange sexually transmitted disease showed up in the
very early 80s, James Pringle House started seeing the first cases and
was at the forefront of European research. I went to seminars, talked to
colleagues, and sometimes met the guest speakers for a canteen lunch.
The greater the expert, the quicker they were to admit that no-one knew
what the hell was going on.
To my dismay, the public management
of the disease quickly veered away from traditional public health
concerns, and became a political battlefield. At the WHO headquarters in
Geneva senior colleagues muttered that they had been criticised for
saying the virus came from Africa: a colonialist perspective, they were
told. Even years later, those who worked in the field in London talked
sadly, and privately, of the difficulties they encountered with giving
straightforward health warnings. I wanted to design a simple poster to
illustrate the relative risks, but it got no further than a large page
in my filing cabinet. Such, dear readers, were the difficulties of
quickly disseminating an opinion before blogging became available.
It
was clear to researchers that blood was the key vector of transmission
(contaminated blood transfusions had a 90% chance of resulting in the
recipient getting HIV), so that shared needle drug injecting and to a
lesser extent anal intercourse without condoms were high risk
activities, but public broadcasts talked vaguely about icebergs, and
suggested everyone was at risk. I did some research on public
perceptions of risk at that time, and AIDS figured high in the public
mind. The common folk knew that it was a “gay plague” but the expert
emphasis seemed to be on getting heterosexuals to use condoms. The great
and the good were interviewed and asked to say the word “condom” on
camera which they valiantly did. The correct way of putting on a condom
was demonstrated on television, using a cucumber. This led to some
worried calls about whether one could catch AIDS from a cucumber.
However,
it was generally agreed that the UK government had done “rather well”
and had got on top of the crisis. Now, with Ebola in the news, I thought
it worthwhile looking at the current situation for the HIV virus in the
UK, 30 years on from the first outbreak. This might give us a possible
scenario for imagining what Ebola might look like in terms of
prevalence.
In fact, the UK response to HIV seems to have been at
the European average. Statistics vary in different parts of the world,
but I imagine that European statistics have a modicum of accuracy.
Finland, Germany, Malta, Norway (and Cuba, see below) did very well (0.1
%); Denmark, Greece, Netherlands and Sweden and Israel pretty well
(0.2%) and Belgium, Iceland, Ireland, Luxemburg and the United Kingdom
were average (0.3%). Austria, France, Italy, Spain, Switzerland were a
bit worse (0.4 %) and Portugal very much worse (0.7%). Of course, these
are not sub-Saharan African levels (as high as 25% in Swaziland and
Botswana) but given that the governments knew what was coming, and had
resources available, they are not stellar achievements.
Greg
Cochran mentioned the case of Cuba, which had forewarning of the virus
in the US and two years to prepare for their first case.
http://westhunt.wordpress.com/2014/09/28/forty-days/
They
quarantined patients for 8 weeks of health education, tracked contacts
in a very determined way, and used their relative isolation to put
public health before private liberty, an approach which comes naturally
to the regime. Their resultant prevalence of roughly 0.1% is one-sixth
the rate of the United States, one-twentieth of nearby Haiti.
http://news.bbc.co.uk/1/hi/in_depth/sci_tech/2003/denver_2003/2770631.stm
http://www.nytimes.com/2012/05/08/health/a-regimes-tight-grip-lessons-from-cuba-in-aids-control.html?pagewanted=all&_r=0
HIV
probably moved from monkeys to humans before the 1950s, although the
first cases were recognised in 1981 in the US. About 100,000 people in
the UK are infected, mostly homosexuals, and heterosexuals from
sub-Saharan Africa. More than 20 per cent of them do not know it, and
are several times more likely to transmit the virus to their partners
than those who have a diagnosis. Half of the newly diagnosed cases in
the UK seek medical help when they are in the late stages of disease. In
2012, there were 6,360 new diagnoses of HIV, which is 17 a day in case
you find that more dramatic. In England the local authorities with the
highest prevalence of diagnosed infections are London, Brighton and
Hove, Salford, Manchester, Blackpool and Luton, and in Scotland,
Edinburgh. Treatment with antiretroviral drugs reduces the risk of
transmission by more than 90 per cent. The cost of these drugs is said
to be £20,000 a year and given the current almost normal life spans of
HIV patients, 20 years of medication seems a prudent minimum for
budgeting purposes. The money spent per capita on NHS services in
England was £1,979 in 2011, so each patient with HIV consumed at least
10 times the resources of an average patient every single year.
http://www.avert.org/uk-hiv-aids-statistics.htm
A
possible explanation for the apparently lacklustre performance of the
UK may be that many of the cases are imported: that is, brought in by
Black Africans infected in Africa. Looking at the demographics of the UK
in 2011 that shows that 55,730,000 persons are classified as White and
1,905,000 are classified as Black or Black British. Looking at the HIV
figures (this is broad brush, because I have omitted the “mixed” groups)
the HIV rates per 100,000 are as follows:
Whites: 93 per 100,000
Blacks: 2015 per 100,000
So,
the rate seems to be 21 times higher among Africans. The fact that so
many Africans have come to the UK cannot be blamed on the quality of UK
public health warnings aimed at changing the behaviour of the local
population. The White rate is exactly comparable with the best European
nations at 0.1%
Nonetheless, considering that about 36 million
people in the world are infected by HIV and that 30 million have died,
the management of HIV is hardly a global success story. Does this give
us any help in looking ahead to the prevalence of the Ebola virus in 30
years’ time? Prediction will depend on whether treatments or
vaccinations become available, but my impression, no more than that, is
that the spread of the virus should be much slower, very much slower.
HIV can be passed on whilst the carrier still looks good for sex, and
sex is fun, so HIV gets an easy ride. Ebola can only be passed on (if
the experts are right) when the carrier is looking pretty ill and
unattractive, and dealing with ill people is a duty, and not much fun.
Furthermore, Ebola is so virulent at the moment that immediate death
rates are high. With simple precautions it should be contained. Even
when “protocols” fail, the reproduction rate of the virus in human
carriers should be low. Despite all the worrying news, it should be a
simple matter to avoid the spread of the disease.
On a more
speculative note, perhaps we shall be saved by stigma. By fearing all
people who look as if they are ill with Ebola, stigmatising them and
avoiding all contact with them, definitely not putting ourselves at risk
by helping them, particularly not touching them when they are dying or
dead, the virus will die out. So, in one corner we have the virus, in
the other corner the uncertain public, caught in an awkward tussle
between altruism and abject fear. Ebola has its best chance of spreading
in societies which don’t believe it exists (like in parts of Africa),
and to a lesser extent in those which don’t believe that, given the
virus does exist, the absolute priority is to change our behaviour
quickly (parts of the wealthy West). Informed opinion ought to be right,
but with every failure of both treatment and containment in Western
hospitals public belief is eroded.
Although it goes against altruistic instincts, futile attempts at interventionist treatments may be making matters worse.
The flu is a virus!
It is winter and a lot of people are sick. Around here, and around the
country, there are two big kinds of sick – one is mainly gastrointestinal
disease with vomiting and diarrhea as the main symptoms, and the other upper
respiratory infections with congestion, cough, and sometimes shortness of
breath as the main symptoms. The first (GI) are mostly caused by norovirus in adults and adolescents and
rotavirus in small children (and, recent reported, the elderly). The
respiratory version is frequently influenza, or other viruses. Viruses. Not bacteria, which can be treated
with antibiotics. Viruses do not respond to antibiotics.
country, there are two big kinds of sick – one is mainly gastrointestinal
disease with vomiting and diarrhea as the main symptoms, and the other upper
respiratory infections with congestion, cough, and sometimes shortness of
breath as the main symptoms. The first (GI) are mostly caused by norovirus in adults and adolescents and
rotavirus in small children (and, recent reported, the elderly). The
respiratory version is frequently influenza, or other viruses. Viruses. Not bacteria, which can be treated
with antibiotics. Viruses do not respond to antibiotics.
This is not to say that they cannot make you very sick. They can, and do.
Especially in the old and very young and immunocompromised, influenza virus can
lead to major bacterial complications and death; the swine flu outbreak of 1918
killed more people than WW I. When there are major influenza epidemics, there
is a big excess of deaths. This is a really good reason to get the flu shot.
Everyone who does not have a firm contraindication (e.g., allergy to eggs, a
previous episode of Guillain-Barre syndrome) should receive the vaccine. People
should expect that their health care providers have received the vaccine. It is
not 100% effective, but it is very effective, and helps make the disease milder
even if you contract it, and it decreases transmission.
Especially in the old and very young and immunocompromised, influenza virus can
lead to major bacterial complications and death; the swine flu outbreak of 1918
killed more people than WW I. When there are major influenza epidemics, there
is a big excess of deaths. This is a really good reason to get the flu shot.
Everyone who does not have a firm contraindication (e.g., allergy to eggs, a
previous episode of Guillain-Barre syndrome) should receive the vaccine. People
should expect that their health care providers have received the vaccine. It is
not 100% effective, but it is very effective, and helps make the disease milder
even if you contract it, and it decreases transmission.
It is not a reason to get antibiotics for a viral upper respiratory
infection or bronchitis. Pneumonia, yes (even though a fairly large percent of
pneumonias are viral, it is hard to tell); pneumonia as a complication of
influenza, particularly in elderly or immunocompromised people with other
chronic diseases (heart, lung, kidney, diabetes, cancer) is very serious. But these people, who
have or are likely to have bacterial pneumonia and need antibiotics, represent
a tiny fraction of the people treated with antibiotics for viral bronchitis
(not to mention even less severe viral upper respiratory infections such as
sinusitis, non-strep pharyngitis, and otitis). Bronchitis is no fun. It can
make you feel miserable, create chest pain when you cough, and generally make
you really sick. It can also last a really long time – 4-6 weeks of coughing is
typical. But viruses don’t respond to antibiotics, even if you’ve been sick for
a week or a month.
infection or bronchitis. Pneumonia, yes (even though a fairly large percent of
pneumonias are viral, it is hard to tell); pneumonia as a complication of
influenza, particularly in elderly or immunocompromised people with other
chronic diseases (heart, lung, kidney, diabetes, cancer) is very serious. But these people, who
have or are likely to have bacterial pneumonia and need antibiotics, represent
a tiny fraction of the people treated with antibiotics for viral bronchitis
(not to mention even less severe viral upper respiratory infections such as
sinusitis, non-strep pharyngitis, and otitis). Bronchitis is no fun. It can
make you feel miserable, create chest pain when you cough, and generally make
you really sick. It can also last a really long time – 4-6 weeks of coughing is
typical. But viruses don’t respond to antibiotics, even if you’ve been sick for
a week or a month.
A recent study published
on-line-before-print in JAMA-Internal
Medicine by Gonzales and colleagues[1] looked at the
use of decision support by either paper algorithms or computer systems in
reducing the use of antibiotics for acute bronchitis in a very large
multi-practice group in rural Pennsylvania (Geisinger Health System). They
found basically two things: both the paper and computer assisted decision
support tools reduced the rate of antibiotic prescribing about equally and both
did so significantly more than in “control” practices that got neither.
Unfortunately, the rate dropped from about 80% of to about 68%; that is, a
large majority of those presenting with acute bronchitis received antibiotic
prescriptions even after the intervention.
on-line-before-print in JAMA-Internal
Medicine by Gonzales and colleagues[1] looked at the
use of decision support by either paper algorithms or computer systems in
reducing the use of antibiotics for acute bronchitis in a very large
multi-practice group in rural Pennsylvania (Geisinger Health System). They
found basically two things: both the paper and computer assisted decision
support tools reduced the rate of antibiotic prescribing about equally and both
did so significantly more than in “control” practices that got neither.
Unfortunately, the rate dropped from about 80% of to about 68%; that is, a
large majority of those presenting with acute bronchitis received antibiotic
prescriptions even after the intervention.
In a “Commentary” in the same issue, “Antibiotic Prescribing for Acute Respiratory Infections—Success
That’s Way Off the Mark”[2] , Jeffrey Linder
notes that the problem with the study is that the “success” was very limited;
that is, it moved the inappropriate use of antibiotics down, but it was still
many times too high. His comparison is to the use of aspirin after heart attack,
and how improving the rate from 30% to 40% would have been inadequate; luckily
we are now at 94-99%. Another metaphor, more graphic, would be if we were happy
that, over 10 years, the number of people killed by the average mass murderer
dropped from 15 to 12!
“Since 2005," Linder notes,"a Healthcare Effectiveness Data
and Information Set measure for patients aged 18 to 64 years states that the
antibiotic prescribing rate for acute bronchitis should be zero. Despite the
evidence, meta-analyses, and performance measures, antibiotic prescribing for
acute bronchitis in the United States remains at more than 70%.” He is
critical of the Gonzales study because, even after its “statistically
significant” intervention, “The
antibiotic prescribing rate—an event that should never happen for these
patients—in ‘successful’ intervention practices was still more than 60%. For
individual clinicians…we need to redefine success. Success is not reducing the
antibiotic prescribing rate by 10%;
success is reducing the antibiotic prescribing rate to 10%.”
That’s Way Off the Mark”[2] , Jeffrey Linder
notes that the problem with the study is that the “success” was very limited;
that is, it moved the inappropriate use of antibiotics down, but it was still
many times too high. His comparison is to the use of aspirin after heart attack,
and how improving the rate from 30% to 40% would have been inadequate; luckily
we are now at 94-99%. Another metaphor, more graphic, would be if we were happy
that, over 10 years, the number of people killed by the average mass murderer
dropped from 15 to 12!
“Since 2005," Linder notes,"a Healthcare Effectiveness Data
and Information Set measure for patients aged 18 to 64 years states that the
antibiotic prescribing rate for acute bronchitis should be zero. Despite the
evidence, meta-analyses, and performance measures, antibiotic prescribing for
acute bronchitis in the United States remains at more than 70%.” He is
critical of the Gonzales study because, even after its “statistically
significant” intervention, “The
antibiotic prescribing rate—an event that should never happen for these
patients—in ‘successful’ intervention practices was still more than 60%. For
individual clinicians…we need to redefine success. Success is not reducing the
antibiotic prescribing rate by 10%;
success is reducing the antibiotic prescribing rate to 10%.”
Or less. Many people will say “I got antibiotics and I felt better in a
couple of days”. Almost all of these
people would have gotten better anyway. There are some studies that show, in
large populations, taking antibiotics can shorten symptoms by about a half-day.
(This is probably because of some minor bacterial co-infection in some folks,
especially those with chronic lung disease). But not by a week, or 2 or 3.
Length of time of symptoms is not an indication for antibiotics for a viral
illness. And that half day? Linder points out that “5% to 25% of patients who will have an adverse reaction. Worse, at
least 1 in 1000 patients who take an antibiotic will wind up in the emergency
department with a serious adverse drug event.” This is, to put it mildly, not good.
Doctors and other health professionals should know this, and most of them
do. Sadly, however, they not only frequently prescribe antibiotics for viral
illnesses because their patients “want them”, but also take them themselves for
the same non-indications. Doctors, nurses, and others are among the greatest
“abusers” of antibiotics (by which I mean taking them when they are not
needed). Amazingly, many of these same health care providers are those who do
not get the influenza vaccine, which they should be getting! The justification
of “I need to stay healthy, and can’t miss work, because I need to care for my
patients and don’t want to transmit illness to them” is wrong on 3 counts: 1)
Taking antibiotics for a virus won’t make you less sick or shorten the course
of your illness, 2) Taking antibiotics won’t prevent you from transmitting a
viral illness, and 3) Taking antibiotics for a viral illness increases the risk
of superinfections (e.g., yeast vaginitis), drug reactions, and the development
bacteria that are resistant to common antibiotics, which you can spread to your
patients. By the way, you also don’t need antibiotics for norovirus or other
viral (or, indeed many forms of bacterial) gastroenteritis.
couple of days”. Almost all of these
people would have gotten better anyway. There are some studies that show, in
large populations, taking antibiotics can shorten symptoms by about a half-day.
(This is probably because of some minor bacterial co-infection in some folks,
especially those with chronic lung disease). But not by a week, or 2 or 3.
Length of time of symptoms is not an indication for antibiotics for a viral
illness. And that half day? Linder points out that “5% to 25% of patients who will have an adverse reaction. Worse, at
least 1 in 1000 patients who take an antibiotic will wind up in the emergency
department with a serious adverse drug event.” This is, to put it mildly, not good.
Let’s review this: acute bronchitis, much less other “colds”, are viral
and viral infections do not benefit in any way from treatment with antibiotics.
They can, however, last a long time, and make you miserable. These symptoms are
still not indications for antibiotics. The algorithm used by the Geisinger
group, and posted on the walls of their examination rooms, is attached. There
are some people, particularly the old, immunocompromised, and those with
chronic bronchitis (mostly long-time smokers) who can develop pneumonia, which
should be treated with antibiotics. They do not have acute bronchitis.
and viral infections do not benefit in any way from treatment with antibiotics.
They can, however, last a long time, and make you miserable. These symptoms are
still not indications for antibiotics. The algorithm used by the Geisinger
group, and posted on the walls of their examination rooms, is attached. There
are some people, particularly the old, immunocompromised, and those with
chronic bronchitis (mostly long-time smokers) who can develop pneumonia, which
should be treated with antibiotics. They do not have acute bronchitis.
do. Sadly, however, they not only frequently prescribe antibiotics for viral
illnesses because their patients “want them”, but also take them themselves for
the same non-indications. Doctors, nurses, and others are among the greatest
“abusers” of antibiotics (by which I mean taking them when they are not
needed). Amazingly, many of these same health care providers are those who do
not get the influenza vaccine, which they should be getting! The justification
of “I need to stay healthy, and can’t miss work, because I need to care for my
patients and don’t want to transmit illness to them” is wrong on 3 counts: 1)
Taking antibiotics for a virus won’t make you less sick or shorten the course
of your illness, 2) Taking antibiotics won’t prevent you from transmitting a
viral illness, and 3) Taking antibiotics for a viral illness increases the risk
of superinfections (e.g., yeast vaginitis), drug reactions, and the development
bacteria that are resistant to common antibiotics, which you can spread to your
patients. By the way, you also don’t need antibiotics for norovirus or other
viral (or, indeed many forms of bacterial) gastroenteritis.
This Batman-and-Robin cartoon illustrates the frustration that many of us
feel. Obviously, we cannot even think about literally or figuratively treating
our patients that way, but I think one of the interesting parallels is that the
person asking Batman for antibiotics is not a “regular person” but Robin, a
kind of Batman-in-training, and thus Batman’s frustration mirrors that many of
us feel when our own trainees (students and residents) inappropriately use
antibiotics for themselves.
Linder says “We should address
patients’ symptoms, but for antibiotics we need to tell our patients that ‘this
medicine is more likely to hurt you than to help you.’” Those of us
who are
sick and not health care providers need to understand that; those of us
who are health care providers have an even greater responsibility.
feel. Obviously, we cannot even think about literally or figuratively treating
our patients that way, but I think one of the interesting parallels is that the
person asking Batman for antibiotics is not a “regular person” but Robin, a
kind of Batman-in-training, and thus Batman’s frustration mirrors that many of
us feel when our own trainees (students and residents) inappropriately use
antibiotics for themselves.
patients’ symptoms, but for antibiotics we need to tell our patients that ‘this
medicine is more likely to hurt you than to help you.’” Those of us
who are
sick and not health care providers need to understand that; those of us
who are health care providers have an even greater responsibility.
Ref: [1] Gonzales
R, et al., A Cluster Randomized Trial
of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis,
JAMA-Internal Medicine Published
online January 14, 2013. doi:10.1001/jamainternmed.2013.1589
[2]
Linder, J, “Antibiotic Prescribing for
Acute Respiratory Infections—Success That’s Way Off the Mark” JAMA-Internal Medicine Published online
January 14, 2013. doi:10.1001/jamainternmed.2013.1984
Medicine and Social Justice: Delmar Boulevard, Geo-mapping, and the Social Dete...
Medicine and Social Justice: Delmar Boulevard, Geo-mapping, and the Social Dete...: The social determinants of health are those factors that affect people’s health status that are the result of the social situation in whi...
Caribbean medical schools: "second chance" or serving a real need?
“Second
chance med school”, by Anemona Harticollis in the New York Times July 31, 2014,
is the most recent treatment of the topic of for-profit Caribbean medical
schools that train American students who, in most cases, were unable to gain admission
to traditional US-based schools. This is not the first time Ms. Harticollis has
covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical
schools in region fight Caribbean flow”, which focused on the fear of US
schools that these Caribbean schools are willing to pay for the use of clinical
teaching spots in hospitals that these US-based schools have been using for
free. This most recent piece focuses on St. George’s University in Grenada, one
of the more established and better-regarded Caribbean schools. It was briefly
famous when protection of its students was one of the justifications for
President Ronald Reagan’s invasion of that country in 1983. The article also
mentions the other three schools that have been approved for US loans by the
Department of Education. However, beyond this, and despite Harticollis’
efforts, the discussion gets murky on two counts: which Caribbean schools are
under discussion, and what are the issues of concern.
chance med school”, by Anemona Harticollis in the New York Times July 31, 2014,
is the most recent treatment of the topic of for-profit Caribbean medical
schools that train American students who, in most cases, were unable to gain admission
to traditional US-based schools. This is not the first time Ms. Harticollis has
covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical
schools in region fight Caribbean flow”, which focused on the fear of US
schools that these Caribbean schools are willing to pay for the use of clinical
teaching spots in hospitals that these US-based schools have been using for
free. This most recent piece focuses on St. George’s University in Grenada, one
of the more established and better-regarded Caribbean schools. It was briefly
famous when protection of its students was one of the justifications for
President Ronald Reagan’s invasion of that country in 1983. The article also
mentions the other three schools that have been approved for US loans by the
Department of Education. However, beyond this, and despite Harticollis’
efforts, the discussion gets murky on two counts: which Caribbean schools are
under discussion, and what are the issues of concern.
Harticollis notes
that
that
There are more than 70
medical schools across the Caribbean, about half of them catering to Americans.
A handful — including St. George’s, Saba University, Ross University in
Dominica and American University of the Caribbean in St. Maarten, all of which
are for-profit — have qualified for federal financial aid programs by
demonstrating that their standards are comparable to those in the United
States. And they report that high numbers of their test-takers — 95 percent or
more — pass the United States Medical Licensing Exam Step 1, a basic science
test.
medical schools across the Caribbean, about half of them catering to Americans.
A handful — including St. George’s, Saba University, Ross University in
Dominica and American University of the Caribbean in St. Maarten, all of which
are for-profit — have qualified for federal financial aid programs by
demonstrating that their standards are comparable to those in the United
States. And they report that high numbers of their test-takers — 95 percent or
more — pass the United States Medical Licensing Exam Step 1, a basic science
test.
But quality is all over
the map in the Caribbean. A 2008 study in the journal Academic Medicine looked
at 14 schools and found that the first-time pass rate on the exam ranged from
19 percent to 84 percent. Countries whose schools performed lowest were the
Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda
and, the lowest, St. Lucia, which hosted four medical schools at the time. High
performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
the map in the Caribbean. A 2008 study in the journal Academic Medicine looked
at 14 schools and found that the first-time pass rate on the exam ranged from
19 percent to 84 percent. Countries whose schools performed lowest were the
Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda
and, the lowest, St. Lucia, which hosted four medical schools at the time. High
performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
It is irrelevant to the discussion of American medical
students going to the Caribbean to look at the national medical schools in
Caribbean (or any other) countries; it is only relevant to look at those which
were created to educate Americans, and for the purpose of this discussion to
limit it to the four that have Department of Education approval. The next thing
is to understand that what is “good” or “bad” about any of these schools, or whether
they should exist altogether, depends on who is looking and what their interests
are. From the point of view of the individuals or companies that own these
schools, the motivation is profit, but having a high-quality product increases
their enrollment. From the point of view of students enrolling, the motivation is
a chance to become physicians and practice in the US. From the point of view of
those who are responsible for the academics of the schools themselves, it is to
support students, provide a good education, and help them to be successful.
From the point of view of many American medical schools, it may be to limit
competition, whether that is for clinical teaching spots in hospitals such as
those of the New York City public hospitals or for good students.
students going to the Caribbean to look at the national medical schools in
Caribbean (or any other) countries; it is only relevant to look at those which
were created to educate Americans, and for the purpose of this discussion to
limit it to the four that have Department of Education approval. The next thing
is to understand that what is “good” or “bad” about any of these schools, or whether
they should exist altogether, depends on who is looking and what their interests
are. From the point of view of the individuals or companies that own these
schools, the motivation is profit, but having a high-quality product increases
their enrollment. From the point of view of students enrolling, the motivation is
a chance to become physicians and practice in the US. From the point of view of
those who are responsible for the academics of the schools themselves, it is to
support students, provide a good education, and help them to be successful.
From the point of view of many American medical schools, it may be to limit
competition, whether that is for clinical teaching spots in hospitals such as
those of the New York City public hospitals or for good students.
Most US allopathic medical schools, and their trade
association, the Association of American Medical Colleges (AAMC), disparage the
Caribbean medical schools in terms of quality of the students that they accept,
since the majority of those attending such schools have failed to gain
admission to AAMC member schools. However, since most of these AAMC schools
have recently or are in the process of expanding their own classes, they must
believe that there are well-qualified students who are not currently being
admitted, and many of these have ended up in Caribbean schools. When AAMC
campaigns to disparage the Caribbean schools, they tend to lump them all
together, rather than looking at individual schools or only the 4 listed above.
Unquestionably, students even at these four schools have, on average, lower grade-point
averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on
average, not do as well on the USMLE exams as those from US allopathic schools,
but there is great overlap. On the other hand, what is perhaps the most
concerning part of education at the Caribbean schools is their clinical
training – where they learn clinical medicine in the last two years of school.
Are the doctors teaching them and the institutions in which they practice of
high quality? Is there a well-defined curriculum? Is there standardization of
the curriculum so that they can be confident that students are learning what
they need to whether they are doing, say, a surgery clerkship in a NYC public
hospital or a community hospital in Michigan? However, when AAMC schools are
fighting with them about whether they should be able to have spots at the same
places US medical schools use – say, NYC public hospitals – this point is also
moot.
association, the Association of American Medical Colleges (AAMC), disparage the
Caribbean medical schools in terms of quality of the students that they accept,
since the majority of those attending such schools have failed to gain
admission to AAMC member schools. However, since most of these AAMC schools
have recently or are in the process of expanding their own classes, they must
believe that there are well-qualified students who are not currently being
admitted, and many of these have ended up in Caribbean schools. When AAMC
campaigns to disparage the Caribbean schools, they tend to lump them all
together, rather than looking at individual schools or only the 4 listed above.
Unquestionably, students even at these four schools have, on average, lower grade-point
averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on
average, not do as well on the USMLE exams as those from US allopathic schools,
but there is great overlap. On the other hand, what is perhaps the most
concerning part of education at the Caribbean schools is their clinical
training – where they learn clinical medicine in the last two years of school.
Are the doctors teaching them and the institutions in which they practice of
high quality? Is there a well-defined curriculum? Is there standardization of
the curriculum so that they can be confident that students are learning what
they need to whether they are doing, say, a surgery clerkship in a NYC public
hospital or a community hospital in Michigan? However, when AAMC schools are
fighting with them about whether they should be able to have spots at the same
places US medical schools use – say, NYC public hospitals – this point is also
moot.
The most important perspective, of course, is not that of the students,
the owners or faculty of the Caribbean schools, or that of the US schools and
the AAMC. It is that of the American people and whether they will have access
to physicians who will provide excellent care for them. The measures that are
usually used for assessing the “quality” of applicants and students – MCAT and
GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often
argued, they are scarcely relevant to being a good doctor. Does it matter that
a doctor didn’t focus when they were a freshman in college and so got C’s, and
so even after doing well for 3 years had a lower GPA than another? Should the chance
to become a doctor be a reward for having your nose to the academic grindstone
your whole life without surcease, or an opportunity for those with skill,
passion, and commitment? I have often argued that the way to judge a medical
school is by what its graduates do with their lives, and that the percent that
enter primary care and practice in underserved areas is a major criterion. It
is fine to have some of your graduates doing laboratory research or entering
narrow subspecialties, but a school should be judged on its overall output and
how well it provides for the needs of our nation.
the owners or faculty of the Caribbean schools, or that of the US schools and
the AAMC. It is that of the American people and whether they will have access
to physicians who will provide excellent care for them. The measures that are
usually used for assessing the “quality” of applicants and students – MCAT and
GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often
argued, they are scarcely relevant to being a good doctor. Does it matter that
a doctor didn’t focus when they were a freshman in college and so got C’s, and
so even after doing well for 3 years had a lower GPA than another? Should the chance
to become a doctor be a reward for having your nose to the academic grindstone
your whole life without surcease, or an opportunity for those with skill,
passion, and commitment? I have often argued that the way to judge a medical
school is by what its graduates do with their lives, and that the percent that
enter primary care and practice in underserved areas is a major criterion. It
is fine to have some of your graduates doing laboratory research or entering
narrow subspecialties, but a school should be judged on its overall output and
how well it provides for the needs of our nation.
There is some concern that because of recent agreements
between the Accreditation Council for Graduate Medical Education (ACGME), which
accredits allopathic (MD) residencies and the American Osteopathic Association
(AOA), which accredits DO residencies, that osteopathic graduates will be more
welcome in allopathic residencies, tending to crowd out Caribbean graduates. I
would doubt that this will be an issue in the Midwest, where osteopathy is
strong and most residencies already tend to prefer DOs to Caribbean grads, but
it might have an impact in the East, where osteopathy is less present, and
where I hear that information pre-med students get from peers (and perhaps
sometimes pre-med advisors) is that Caribbean schools are preferable to
US-based osteopathic schools.
between the Accreditation Council for Graduate Medical Education (ACGME), which
accredits allopathic (MD) residencies and the American Osteopathic Association
(AOA), which accredits DO residencies, that osteopathic graduates will be more
welcome in allopathic residencies, tending to crowd out Caribbean graduates. I
would doubt that this will be an issue in the Midwest, where osteopathy is
strong and most residencies already tend to prefer DOs to Caribbean grads, but
it might have an impact in the East, where osteopathy is less present, and
where I hear that information pre-med students get from peers (and perhaps
sometimes pre-med advisors) is that Caribbean schools are preferable to
US-based osteopathic schools.
Like osteopathic schools, Caribbean medical schools,
including the 4 DOE-certified schools, place a much higher percentage of their
graduates into primary care than do US-based allopathic schools. Is this just a
result of the fact that primary care residencies are less competitive than many
other specialties, so easier for students from Caribbean schools to get into?
Unquestionably, this is part of the explanation, but there is also more
encouragement for primary care in these schools, which do not boast a huge
research enterprise or maintain tertiary-care hospitals. It also doesn’t change
the fact that graduates of these schools, like many international graduates who
were not US citizens, are serving the needs of our country because the US
schools are not stepping up to the plate. US medical schools are very selective
about taking students with high grades, and putting most of them into
oversupplied specialties.
including the 4 DOE-certified schools, place a much higher percentage of their
graduates into primary care than do US-based allopathic schools. Is this just a
result of the fact that primary care residencies are less competitive than many
other specialties, so easier for students from Caribbean schools to get into?
Unquestionably, this is part of the explanation, but there is also more
encouragement for primary care in these schools, which do not boast a huge
research enterprise or maintain tertiary-care hospitals. It also doesn’t change
the fact that graduates of these schools, like many international graduates who
were not US citizens, are serving the needs of our country because the US
schools are not stepping up to the plate. US medical schools are very selective
about taking students with high grades, and putting most of them into
oversupplied specialties.
The education at Caribbean schools varies, and it would be a
mistake to say that they are doing a better job than US allopathic schools.
However, US schools are doing a poor job of training the doctors America needs,
of ensuring that all people have equal access to quality health care, and the
students graduating from Caribbean schools are often filling the holes that
they leave.
mistake to say that they are doing a better job than US allopathic schools.
However, US schools are doing a poor job of training the doctors America needs,
of ensuring that all people have equal access to quality health care, and the
students graduating from Caribbean schools are often filling the holes that
they leave.
Those who live in glass houses…
Leukaemia risk from mitoxantrone: higher than previously reported
"All the discussion now days, when we
discuss DMTs in MS, is risk benefit. One of the more risky drugs that
is licensed in several countries for treating MS, is the chemotherapy
agent, mitoxantrone. This drug works by inhibiting an enzyme that unzips
DNA and causes mistakes when the DNA strands are spliced and stitched
back together. As a result of the mistakes, mitoxantrone causes a
specific kind of treatment-related leukaemia. This meta-analysis shows
that the risk is higher than previously reported and occurs in 1 in 137
MSers treated. I suspect the risk is actually lower than this due to
reporting bias; i.e. reports are more likely to pick up leukaemia cases.
Despite this, this figure is very high. This sort of leukaemia has a
mortality of ~50%. Hence would you be prepared to take the risk of
developing leukaemia and death associated with this treatment? Prior to
natalizumab and fingolimod arriving on the market we had little option
but to offer mitoxantrone to MSers with breakthrough disease that was
highly active. As a result of the new drugs we have virtually stopped
using this drug. We also had to stop our trial to get rid of NABs to
interferon-beta because it included a single dose of mitoixantrone. When
you mentioned to potential trial subjects the risk of leukaemia and
mentioned that it would potentially put them at high risk of developing
PML if they went onto natalizumab they said 'Thanks, but no thanks.'"
discuss DMTs in MS, is risk benefit. One of the more risky drugs that
is licensed in several countries for treating MS, is the chemotherapy
agent, mitoxantrone. This drug works by inhibiting an enzyme that unzips
DNA and causes mistakes when the DNA strands are spliced and stitched
back together. As a result of the mistakes, mitoxantrone causes a
specific kind of treatment-related leukaemia. This meta-analysis shows
that the risk is higher than previously reported and occurs in 1 in 137
MSers treated. I suspect the risk is actually lower than this due to
reporting bias; i.e. reports are more likely to pick up leukaemia cases.
Despite this, this figure is very high. This sort of leukaemia has a
mortality of ~50%. Hence would you be prepared to take the risk of
developing leukaemia and death associated with this treatment? Prior to
natalizumab and fingolimod arriving on the market we had little option
but to offer mitoxantrone to MSers with breakthrough disease that was
highly active. As a result of the new drugs we have virtually stopped
using this drug. We also had to stop our trial to get rid of NABs to
interferon-beta because it included a single dose of mitoixantrone. When
you mentioned to potential trial subjects the risk of leukaemia and
mentioned that it would potentially put them at high risk of developing
PML if they went onto natalizumab they said 'Thanks, but no thanks.'"
"Just as 'video killed the radio star'
new DMTs kill older therapies. We mustn't forget that the relentless
drive of innovation is changing the face of MS management. Don't expect
innovation to stop the MS development pipeline is deep and rich, which is why I am such an optimist."
Epub: Ellis et al. Therapy-related acute leukaemia with mitoxantrone: Four years on, what is the risk and can it be limited? Mult Scler. 2014 Jul .
Background: Therapy-related acute leukaemia (TRAL) is a significant concern, when considering treatment with mitoxantrone for MS.
new DMTs kill older therapies. We mustn't forget that the relentless
drive of innovation is changing the face of MS management. Don't expect
innovation to stop the MS development pipeline is deep and rich, which is why I am such an optimist."
Epub: Ellis et al. Therapy-related acute leukaemia with mitoxantrone: Four years on, what is the risk and can it be limited? Mult Scler. 2014 Jul .
Background: Therapy-related acute leukaemia (TRAL) is a significant concern, when considering treatment with mitoxantrone for MS.
Methods: We re-evaluated the literature, identifying all case reports and series of > 50 patients reporting TRAL cases in MS.
Results: TRAL was diagnosed in
0.73% of the 12,896 MSers identified. Median onset was 22 months
following treatment. We calculated a number needed to harm of 137.5
exposed MSers, significantly higher than our 2008 analysis. We found
that 82.8% of MSers were exposed to > 60 mg/m2 with a relative risk
of 1.85 (p = 0.018) compared to < 60mg/m2, strongly suggesting a
relationship to dose.
0.73% of the 12,896 MSers identified. Median onset was 22 months
following treatment. We calculated a number needed to harm of 137.5
exposed MSers, significantly higher than our 2008 analysis. We found
that 82.8% of MSers were exposed to > 60 mg/m2 with a relative risk
of 1.85 (p = 0.018) compared to < 60mg/m2, strongly suggesting a
relationship to dose.
Conclusion: MS treatment regimens which limit the mitoxantrone dose to < 60mg/m2 reduce the risk of TRAL.
Vitamin D birth levels do not affect risk of MS
Multiple Sclerosis Research: Vitamin D birth levels do not affect risk of MS: Ueda P, Rafatnia F, Bäärnhielm M, Fröbom R, Korzunowicz G, Lönnerbro R, Hedström AK, Eyles D, Olsson T, Alfredsson L. Neonatal vitamin D s...
Sex and MS
Multiple Sclerosis Research: Sex and MS: Lew-Starowicz M, Rola R. Correlates of Sexual Function in Male and Female Patients with Multiple Sclerosis. J Sex Med. 2014 Jun. doi: 10.1...
Bronchodilators don't help bronchiolitis
Autumn brings the start of another
Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can
cause bronchiolitis in younger children. The wheezing - and sometimes
decreased oxygen saturation - of bronchiolitis can be scary for parents
and physicians alike; since bronchodilators like albuterol help many
older kids and adults with wheezing, it seems intuitive that they would
help bronchiolitis as well. The November 1 issue of AFP discusses
a Cochrane update, however, demonstrating that bronchodilators don't
improve outcomes in most kids aged less than 2 years with bronchiolitis.
Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can
cause bronchiolitis in younger children. The wheezing - and sometimes
decreased oxygen saturation - of bronchiolitis can be scary for parents
and physicians alike; since bronchodilators like albuterol help many
older kids and adults with wheezing, it seems intuitive that they would
help bronchiolitis as well. The November 1 issue of AFP discusses
a Cochrane update, however, demonstrating that bronchodilators don't
improve outcomes in most kids aged less than 2 years with bronchiolitis.
The Cochrane reviewers found
that, in children less than 24 months old with bronchiolitis who were
wheezing for the first time, bronchodilators didn't improve oxygen
saturation, didn't keep children in the Emergency Department from
getting admitted to the hospital, and didn't reduce the length of stay
in children already admitted to the hospital. Unfortunately,
bronchodilators also caused harm; children who received them were more
likely to have tachycardia and decreased oxygen saturation.
that, in children less than 24 months old with bronchiolitis who were
wheezing for the first time, bronchodilators didn't improve oxygen
saturation, didn't keep children in the Emergency Department from
getting admitted to the hospital, and didn't reduce the length of stay
in children already admitted to the hospital. Unfortunately,
bronchodilators also caused harm; children who received them were more
likely to have tachycardia and decreased oxygen saturation.
It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces
that no studied pharmaceutical interventions have demonstrated a
meaningful impact on patient-oriented outcomes. Hydration and
supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.
3
of the 5 Choosing Wisely recommendations from the Society of Hospital
Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:
of the 5 Choosing Wisely recommendations from the Society of Hospital
Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:
- Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
- Don't routinely use bronchodilators in children with bronchiolitis.
- Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.
Pediatrics just published a clinical practice guideline on bronchiolitis that reinforces those points.
If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website.
If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website.
Will this Cochrane review change how you treat young children with bronchiolitis?
BIOMAB: Research Day Antwerp - 24 Oct 2014
BIOMAB: Research Day Antwerp - 24 Oct 2014: Beste Hierbij wensen wij u uit te nodigen op de jaarlijkse onderzoeksdag van de Faculteit Farmaceutische, Biomedische en Diergene...
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