For more information in what’s in this week’s issue of The Lancet please see here and have a great weekend. 

The Editorial is on WHO’s patient-safety checklist for surgery and its possible role in bringing ’a culture of safety to the very centre of patients’ care’ 

A research Article showing female recipients of male donor kidneys have a higher rate of graft failure than other donors and recipients.  Also on the theme of organ transplantation, there is a comment on organ trafficking and transplant tourism by the steering committe of the Istanbul summit, who met at the end of April. 

On the theme of global health:  

A Viewpoint discusses the ethical considerations of conducting smaller trials as part of international research and offer a definition of ‘responsiveness that is useful for study design and ethical review’.   

A Comment looks at the relationship between security and improved health in the context of Japan’s commitment to the human security approach to supporting global health.    

 ‘One of the real heroes of the African AIDS response’ is the subject of this week’s profile, Nelson Sewankambo, who has been involved in HIV/AIDS research both internationally and in Uganda for over 20 years, focusing on effective prevention measures.   

World Reports on:

The victory of TAC and SAMA in the protracted legal battle to overturn the influence of Matthias Rath’s ‘trials’ for vitamins and micronutrients as a cure for HIV/AIDS.  

The control of Chagas’ disease in urban Peru, describing recent work of epidemiologists which combines diagnostic information, patient history and spatial data to model the spread of the disease.

A shocking report from Australia highlighting the disparity between the health of the indigenous population and the wider community, which is increasing even as the rest of the community becomes healthier. 

Finally, linking to last week’s editorial on water and sanitation and Steve Cockburn’s blog which we published earlier this week, there is a profile of the physician, John Snow, regarded by many public health scientists as the father of the discipline.  As well as his work on anaesthetics which contributed to the widespread use of chloroform, by observing the 1848 outbreak of cholera in London, he came to the conclusion that water was the main vehicle of dissemination.  In 1854, another outbreak gave him further opportunity to investigate its spread and in 1855 he published: ‘On the Mode of Communication of Cholera’.  The article quotes a response from the Lancet to his provocative views:

‘The fact is that the well whence Dr Snow draws all sanitary truth is the main sewer’.  

Finally, this is to alert you that from today until November 4th there will be a weekly  blog on the US election on the Lancet Global Health Network.

A profoundly disabled child whose annual growth rate is subnormal approaches your care. The parents ask you to test growth hormone function and to consider an active intervention to help their child attain a larger stature. How should you proceed? Increased growth will surely not benefit a severely brain impaired child, with no trace of body image whatsoever. A larger stature, moreover, will impose a higher burden on his caregivers, hampering their continuous care of their child.

This paradoxical scenario - whether to use medical treatments to increase the final stature of a developmentally-disabled child - is not uncommonly encountered in pediatric endocrine clinics. Rejecting the GH hormonal therapy may portray abandoning an effective medical therapy on the grounds of little or no benefit to the patient. But, is offering parents of severely disabled children proactive measures to attenuate growth an ethical thing to do? The Ashley X case, presented in this article, sparked an intensive public discussion concerning the ethical justification of irreversibly altering the body of a profoundly disabled and nonconsenting child.

Ashley X, the core of the ensuing debate, suffers from static encephalopathy. According to her physicians, she would never progress beyond the developmental stage of a 3 month-old infant. (1),(2) At the age of 6, Ashley is completely dependent in all daily activities, being unable to walk, communicate, eat, sit up, or roll over. Her parents were concerned about her growth, which would make it “untenable for them to care for their daughter at home, despite their strong desire to do so”.(1) The parents and the physicians thoroughly deliberated the condition, and devised a treatment program using high-dose estrogen to attenuate final adult height (box). To reduce long-term complications of puberty, removal of her uterus and breast-buds was considered. An ethics committee carefully analysed the family’s reasons for their requests, and concluded that all were ethically appropriate (table 1).

Table 1

Potential benefits and harms inherent in each procedure of the Ashley Treatment (5), (6), (7), (8)

* DVT - Deep Vein Thrombosis.

** These adverse effects were demonstrated in constitutionally tall adolescent girls that were given high-dose estrogen, in trials done in the 1950’s. (9)

Risks not fully determined

The case of Ashley X was the first to present the question of whether hormone therapy should be used to make children with profound impairments smaller. We may still gain knowledge and perspective if we think about other medical treatments whose risk-benefit calculation may seem comparable to the case we discuss (fig 1). On the one hand, there are risky treatments that are taken prophylactically, in an attempt to avoid a life-threatening condition (i.e. mastectomy in BRCA carriers). Genetically-unfortunate women can weigh the risks and benefits, and reach a decision based on their values and beliefs. On the other side, prophylactic interventions, like immunization, carry high benefits, with risks that are extremely low. Which category could describe Ashley’s condition? You could argue that the risks involved in Ashley’s treatment are substantial, and not in proportion to the possible gains she might get. Or you could say, as her physician did, that “these risks do not seem to be unreasonable and are not out of line with the risks of other medical interventions these children undergo”.(5)

How, then, could risks be quantified, or at least estimated, when there were no children like Ashley undergoing growth attenuation therapy combined with hysterectomy and breast-bud removal? The only similar trials involving high-dose estrogen to stunt growth were treatments of constitutionally tall adolescent girls, wishing to minimize any further gain in height. (10) Ashley’s physicians extrapolated data from these 1950’s studies to support the efficacy and safety of the treatment. But Evidence-Based Medicine principles oblige the medical profession to seek conclusive scientific evidence prior to using a presumably efficient therapy. It was not yet shown that children with significant developmental disabilities who are shorter stay at home longer. In fact, we don’t even know whether keeping Ashley at home has any beneficial effect on her social or health status. Observational studies should test these issues, among others, to gain a better understanding of the therapy’s potential risks.

Parental motives

In most cases, parents are in the best position to make medical decisions for their child. It is believed that they understand and attempt to achieve the “best interests” of their child better than anyone else. Therefore, parents are given the legal and moral responsibility to care for their children. (11) Being Ashley’s legal guardians, her parents asked the doctors to perform an intervention that was neither a medical necessity nor a hitherto-recognized therapeutic option.

Now, try scrutinizing the Ashley case appropriateness through less shiny lenses, such as those of a developmental disabilities professional. It has been claimed that what we have here is an invasive, risky treatment, whose goals are essentially quality of parental life, and with the patient “good” defined by someone other than her.

The American College of Obstetrics and Gynecology (ACOG), in their paper “Sterilization of women, including those with mental disabilities” , notes that involuntary and nonvoluntary medical interventions and surgical procedures in general should only be provided when there are clear health benefits.(8) Ashley’s parents wish to take care of her, and stunting her growth, they argue, will make it easier for them to extend the time they can care for her at home, and enhance their child’s mobility, social interaction and physical contact with them (table 2). (5), (13)

This reasoning of the parents led some to claim that their own convenience was the primary rationale for attenuating Ashley’s size. They could have hired people to help them, or go to the gym, or purchase special devices for their home, instead of surgically modifying their child’s height. But, stating Judith Jarvis Thomson, “nobody is morally required to make large sacrifices, of health, and all other interest and concerns… in order to keep another person alive”. (12) In my humble opinion, as long as motives of convenience form only part of the parents’ justifications, with the child’s benefits as the center of gravity (in choosing the requested treatment), they should not be considered as distinct from those of the child. Consider, for example, a parent bringing a child with a toothache to the dentist, hoping that the child will undergo a lengthy procedure, so that he will earn a few hours of sleep. Do these latent motives make the procedure unethical? Of course not. (13) Further emphasized in a child with developmental disabilities is the complete dependency upon his parents for all his daily care. In circumstances such as this, the child’s interests and needs are intertwined with those of the parents. Defragmenting the family to pieces, to isolate and analyze the needs of the disabled child only, is analogous to prescribing medication based upon mere lab results, without seeing the patient.

Table 2

The pros and cons of the “Ashley Treatment” (5), (13)

Society’s role

In a perfect world, with unlimited social support resources, Ashley could be nursed and cared for in a normal size. In view of the options open to them, Ashley’s parents sought after the possibility that would enable them to improve their child’s (current and future) medical as well as social state.

If we target a fundamental change in the harrowing predicament that parents of such children face, medication is a possible adjunct, but solving the problem requires more funds for community-based living programs. If the collective community response proscribes the Ashley treatment, society must be prepared to provide the caregivers with enough assistance that they would not have to resort to these means. (13) As long as social support is lacking, however, the medical profession may offer its interventions, in cases like Ashley’s, taking into account her natural and social circumstances.

As I view it, what the Ashley Case showed was that there was much more needed discussion about the value of disabled children in our society. Many disciplines in medicine may help translate such challenging dilemmas into reasoned and balanced solutions. Specialists in pediatric endocrinology, neurology, surgery, development, and ethics contribute their perspectives on highly debatable issues such as Ashley’s. An interdisciplinary group of experts of that type may only further emphasize the pivotal discussion we must engage in regarding social attitudes toward people, in particular children, with neurologic and cognitive impairments.

Acknowledgements: I am deeply grateful for the critical and insightful review provided by Zeev Hochberg, MD PhD (Director, Pediatric Endocrinology Unit, Meyer Children’s Hospital, RAMBAM Health Care Campus, Haifa, Israel) as well as for his fascinating perspectives and ideas with regard to the ethical issue at hand.

Ohad Oren, 3rd year medical student, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. ohadoren@gmail.com

References 1-13:

1. The “Ashley Treatment“: Toward a better quality of life for “Pillow Angels”.
2. Coombes R. Ashley X: A difficult moral choice. BMJ 2007;334;72-73.
3. Fancher TK. Some observations on anterior lobe hyperpituitarism. Endocrinology. 1932; 16:611.
4. Kirklin OL, Wilder RM. Follicular hormone administration in acromegaly. Proc Staff Meet Mayo Clin. 1936; 11:121-125.
5. Gunther DF, Diekema DS. Attenuating growth in children with profound developmental disability. Arch Pediatr Adolesc Med 2006: 1013-7.
6. Bladbjerg EM, Skouby SO, Andersen LF et al. Effects of different progestin regimens in hormone replacement therapy on blood coagulation factor VII and tissue pathway inhibitor. Hum Reprod. 2002;17:3235-3241.
7. Girolami A, Spiezia L, Rossi F, Zanon E. Oral contraceptive and venous thromboembolism: which are the safest preparations available? Clin Appl Hemost. 2002;8:157-162.
8. Committe on Ethics, American College of Obstetrics and Gynecology: Sterilization of Women, including those with Mental Disabilities.
9. Lee J, Howell J. Tall Girls; The Social Shaping of a Medical Therapy. Arch Pediatr Adolesc Med. 2006;160:1035-1039.
10. Goldzieher MA. Treatment of excessive growth in the adolescent female. J Clin Endocrinol Metab. 1956; 249-252.
11. Kopelman LM: The best-interests standard as threshold, ideal, and standard of reasonableness. J Med Phil 1997;22:271-289.
12. J. J. Thomson, “A defense of Abortion” in Ethics in practice, ed. by H. Lafollette (Oxford, UK: Blackwell, 1997), 69-78, at 77.
13. S. Matthew Liao, J. Savulescu, M. Sheehan. The Ashley Treatment: Best Interests, Convenience, and Parental Desicion-Making. Hasting Center Report 37, no. 2 (2007): 16-20.

(Image: End Water Poverty)- The ‘knitted river’ - 100,000 people across the UK knitted a blue square to show their support to the campaign, which was sewn together and taken on a march to parliament.

It is just 5 days to go until leaders of 8 of the world’s most powerful countries meet in Hokkaido, Japan, to discuss measures to meet the Millennium Development Goals and (in theory at least) how they will keep the promises on aid and international development made at the Gleneagles G8 Summit in July 2005.

Belatedly forcing its way onto the agenda for the first time in years is the global sanitation and water crisis, the effects of which are well highlighted in Rhona’s previous blog, and The Lancet’s recent editorial.

A staggering 2.6 billion people across the world lack access to safe sanitation,1.1 billion people lacking access to clean water and 5000 children dying of water-related diseases every day. It is both impossible to overestimate the scale of this public health crisis and astonishing that it has taken so long to get in the in-trays of world leaders.

There is no doubt that it has been a struggle. Despite the fact that the sanitation MDG target to halve the number of people lacking access to safe sanitation by 2015 will not be achieved in Africa until 2076, campaigners have had to elbow their way to the top-table. And despite the fact it will be impossible to achieve real progress in providing universal education or reducing infant mortality without real action on sanitation, the risk remains that G8 leaders will pay lip-service to an issue on which progress on global health and development so crucially pivots.

Sadly the sanitation crisis has been a silent killer, hidden away in open slum sewers and behind bushes in rural villages. It has been kept away from the attention of world leaders, leading to neglect in aid budgets, government priorities and international institutions.

Yet hopefully that is changing. 2008 was made the UN International Year of Sanitation and campaigners across the world - many of whom form part of the End Water Poverty campaign - have increased the noise and forced leaders to act.

(Image: End Water Poverty) The Nepal petition - 100,000 petitions were collected by End Water Poverty Nepal.

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Since the Human Genome Project was completed in April 2003, genetics has played an increasingly important role in the diagnosis, monitoring and treatment of disease.  By studying the sequential variations in genomes of different individuals, scientists are identifying the genes responsible for many of today’s common diseases such as hypertension, diabetes and cancer.  However, as the genetic onion is unravelled, something mysterious is found lurking within…Epigenetics…the study of heritable changes in gene function that occur without change to the sequence of DNA…the study of little on-off switches on our genes. The most recognised mechanism to date is DNA methylation- adding methyl groups to the cytosine bases which can silence or activate the gene.  Although recognised as an important mechanism in normal cell growth the consequences of some of these gene switches has also been shown to be a major causative factor of a wide variety of human diseases. 

Ever wondered why identical twins aren’t exactly identical if they have the same genes?  Why we can clone an embryo but not an adult?  Or why we share two thirds of our genes with a nematode?

Only 2% of our DNA codes for proteins and until recently the rest was considered as junk.  Humans seemed to have accumulated more junk than any other species.  Now we know that this junk or non-coding DNA is actually very useful in epigenetic processes even though it doesn’t translate into proteins (a revelation that undermines the central dogma that scientists had previously agreed upon that DNA merely acts to encode proteins and that only proteins do the real work of biology).  Infact, epigenetic changes to our genes, assisted by non-coding DNA are just as important as genetic changes in coding DNA in determining what we look like, how we think and what diseases we are going to get!    Whats more, these epigenetic changes, which occur throughout our lives, in response to what we eat, how we live and how much love our mothers gave us can be passed on to our children and their children etc…but in contrast to genetic changes, they are reversible!

But surely everyone knows that giraffe’s necks didn’t just get longer because they had to stretch to reach the treetops, as Lamarck had suggested?  We agreed with Darwin that we evolved due to genetic mutations in germ line cells that gave us survival advantages over competing species.  Now we are saying that characteristics can be acquired during life and we pass them on to our children?

Yes, and all at the flick of a switch!  Researchers found that baby rats that were not licked by their mums-a rodents form of nurturing-produced more stress hormones as adults due to the flick of a switch!  This was because they had switched off their gene for the glucocorticoid receptor in their brains, which normally controls the amount of stress hormone releases by the adrenal glands.  This effect was then reversed by injecting a chemical into their brains which could switch the gene back on!

Many more possible gene switches have been found in mice and rats with evidence to show that the epigenetic slate isn’t wiped clean with each generation.  If just one generation of rats are given a drug called alloxan, which decreases the body’s sensitivity to insulin, then their offspring and their offspring’s offspring will have diabetes.  If mice are exposed to high doses of morphine then the damage to their nervous systems will persist in their descendants.  And if a rat is given a single injection of thyroxine, then not only will that rat have a permanently depressed level of thyroid stimulating hormone but many of the rats of subsequent generations will too.

The evidence extends to humans as well.  Dutch women who went hungry in the Second World War gave birth to small babies, but their children also had small babies even though they had enough to eat.  We have known about the Barker hypothesis since around the early 1990s, which proposed that starved mothers “teach” their children to be efficient at conserving glucose predisposing them to the so-called metabolic syndrome. This tells us that nutrition in utero is largely responsible for our epigenetic programming and that under nutrition in one generation could explain the rise in obesity, heart disease and diabetes in the next!  It’s a far cry from the popular cultural view that lifestyle changes are the be all and end all determinants of good, or poor health - that everything boils down to personal decision making.  This is not to say that we are pre-programmed to develop disease and there is nothing we can do about it either.  We still think our lifestyle affects our chances of getting diseases-more than ever-because chemicals in our environment can trigger epigenetic switches!  The small task faced by scientists now is working out exactly what chemicals trigger exactly what switches in exactly what diseases!

Cancer Research

Epigenetics has already revolutionised cancer research with some very promising results.  Remember that there are two copies of every gene, one maternal and one paternal copy.  Therefore in order to switch a gene off, both copies would have to be silenced.  This is a lot easier if one copy of a gene has already been switched off early in embryonic development- an imprinted gene.  So far about 100 imprinted genes have been identified in humans, many of which are highly active in the brain.  If an imprinted gene also happens to be a tumour suppressor gene then loss of function becomes more likely as one copy has already been inactivated.  Such imprinted genes have been identified as contributing to a variety of familial and childhood cancers including neuroblastomas, acute myeloid leukaemia, Wilms tumours, rhabdomyosarcoma, paraganglioma, oesophageal cancer, follicular thyroid cancer and breast cancer.              

The battle of the sexes (at the molecular level)

The existence of these unusual imprinted genes is subject to much debate since they are potentially life threatening and yet have withstood evolutionary forces.  The best proposed theory to explain this phenomenon is the conflict theory where mum and dad are in disagreement about the supply of mum’s resources to her foetus.  Mum wants smaller babies to conserve her resources but dad wants big bouncy babies that are more likely to survive to pass on his genes.  Dad switches on his copy of the gene for Insulin-Like Growth Factor 2 (IGF2), a protein that makes big babies.  Meanwhile, mum switches on the IGF2 Receptor (IGF2R) gene so when IGF2 is trying to make her babies grow big and steal all her resources she can mop it up with IGF2R.  The truth is women are selfish, and have every right to be!  Yes, mum does all the hard work, carries us for 9 months, feeds us all the milk we need and looks after us while dads out doing the hunting…she’s so caring right?  The truth is given half the chance she would be out doing the hunting…so, why doesn’t she?  The reason…men have messed with their head!  Yes really!!!  Another imprinted gene called Mest which controls mothering behaviour has been switched on in the female brain by their fathers!

It seems mum and dads fighting doesn’t stop at deciding how big they want us to be but also how clever we are as well.  Areas of the brain responsible for complex thought are packed with cells containing two copies of maternal genes.  This is consistent with the fact that silencing of maternal imprinted genes in Angelman syndrome is associated with mental retardation.  Cells containing two copies of paternal genes tend to accumulate in the hypothalamus, responsible for basic functions such as temperature regulation, sexual function and feeding.  This is consistent with the silencing of paternal imprinted genes in Prader Willi syndrome is associated with an insatiable appetite and compulsive desire to obtain food to the point of retrieving it from dustbins or eating frozen raw meat.  Ongoing research has suggested a role for imprinted genes in a wide variety of common mental disorders such as autism, Alzheimers disease, schizophrenia and depression.

The Human Epigenome Project has begun

There is enormous potential for epigenetic medicine as we are beginning to find out.  Therapeutic reversal of epigenetic inactivation is already undergoing clinical trials in cancer research.  Therefore, the Human Epigenome Project was set up by an international collaboration which aims to identify and catalogue all of the DNA methylation patterns across the human genome and identify which ones are associated with disease.  The future of epigenotyping is so near and yet so much more ambitious than genotyping due to the interplay between environment and genes being so varied and volatile.  This is what makes the Human Epigenome Project so exciting as we can only begin to imagine the possibilities that it could bring for the future of medicine.

Melinda Morrell

References

1.            Egger G, Liang G, Aparicio A, et al. Epigenetics in human disease and prospects for epigenetic therapy. Nature 2004; 429: 457-63

2.            Pray LA. Epigenetics: genome, meet your environment. The Scientist 2004.  (cited 21/06/07)

3.            Sapolsky RM. Mothering style and methylation.  Nature Neuroscience 2004; 7:791-792

4.            Weaver I et al. Epigenetic programming by maternal behaviour.  Nature Neuroscience 2004; 7:847-854

5.            Vines G. Hidden Inheritance.  New Scientist 1998; 2162:27-30

6.            Lumey LH.  Decreased birthweights in infants after maternal in utero exposure to the Dutch famine of 1944-1945. Paediatr Perinat Ep 1992; 6: 240-53

7.            Lumey LH.  Glucose tolerance in adults after prenatal exposure to famine.  Lancet 2001; 357(9254):472-3

8.            Corliss J.  Imprinted Genes Play Role, Change Rules in Cancer. JNCI 1993; 85: 1272-1274

9.            Niemitz E.  Milestone 15- Are You My Mother?  Nature Milestones in Gene Expression 2005

10.        Esteller M. The necessity of a human epigenome project.  Carcinogenesis 2006; 27:1121-1125.

11.        Hunter P.  The silence of genes.  Is genomic imprinting the software of evolution or just a battleground for gender conflict?  Nature 2007; 5:441-443

12.        Curley J.  Imprinting and Behaviour. In: Encyclopaedia of Genetics, Genomics, Proteomics and Bioinformatics. New York (NY): John Wiley & Sons, Ltd; 2005

13.        Brena RM, Huang THM, Plass C.  Toward a human epigenome. Nature Genetics 2006; 38:1359-1360

14.        Human Epigenome Project (Online) Available from: URL: www.epigenome.org (2006?) (cited 21/06/07)

Modernising Medical Careers (MMC) was designed to nationalise and increase the efficacy of postgraduate training via the implementation of the Foundation Programme in 2005 and a revised Specialist Training programme in 2007. Consequently from 2007 there have been two competitive entry points, both to the Foundation Programme and for Specialist Training posts. Additionally, the Department of Health’s stated policy since 1997 has been to increase the number of undergraduate medical school places to sustain the future demands of the NHS. Since the Tooke Report has highlighted a number of concerns regarding MMC, medical students must remain competitive in this unstable period of educational reform.

What can undergraduates do to remain competitive?

The General Medical Council’s pivotal document, Tomorrow’s Doctors, states that ‘factual information must be kept to the essential minimum that students need at this stage of medical education. Learning opportunities must help students explore knowledge, and evaluate and integrate (bring together) evidence critically. The curriculum must motivate students and help them develop the skills for self-directed learning’. (1) These skills are of paramount importance to successful clinical practice, providing invaluable skills that will be applicable throughout not only the remainder of your undergraduate medical course but also your professional career. Whilst the GMC recognises the limitations of the undergraduate medical courses in encouraging autonomous study and the ability to critically appraise information, an intercalated degree programme develops these skills. Moreover, a prospective longitudinal study by McManus and colleagues[iv] found that students that pursue an intercalated degree often find that their approach to independent study is enhanced.

What do I need to consider?

It can be a difficult and daunting process to decide if intercalating is the best choice for you and to find the most suitable course. As with any decision, there are many factors to consider. These differ with personal circumstances and with the wide variety of courses available nationally (summarised in Box 1).

For many UK medical schools, intercalated programmes comprise a mandatory component of the undergraduate curriculum. Even where such courses are not obligatory, some schools provide comprehensive information on the programmes available. Others, however, do not, and students without this impetus to intercalate or the appropriate support to research relevant information may therefore be at a disadvantage, and indeed many students have found sourcing information to aid their decision time-consuming and frustrating. These perceived obstacles may discourage many prospective students from intercalating despite the ease with which they may be overcome. This phenomenon may also impact upon dental and veterinary students.

Where is this information available?

As a result of our own experiences in making this important decision and the difficulties that we have encountered, we have been involved with the development of a project that brings together details of every intercalated course that is available nationally, both at BSc and MSc (or equivalent) level. This web-based resource has been designed to facilitate the decision to intercalate, and help you find a course that is most suitable for you quickly and effectively.  This website does not require registration or subscription and is available here. 

Reflections on intercalating

In our experience, early research was a significant help in making the best decision regarding intercalating and we found that finding information on funding and scholarships was fundamental in making our choice. Initially this information was difficult to find, but prolonged investigation yielded a number of organisations that provided generous funding to intercalating medical students, which have been detailed on the aforementioned website along with information on the points listed in Box 1.

Although it was more difficult to overcome these hurdles than we had anticipated, now considerably easier since this project has been launched, our experiences from intercalation have only been positive. Although we undertook different degree courses, the transferable skills that we have acquired in the past year are already apparent. We feel confident that when we recommence our medical studies the knowledge that we have gleaned will complement our clinical practice and ease the transition into postgraduate medical education.

Sarah Shore, third year HYMS medical student, BSc Sarah.Shore@gmail.com

Claire Spolton Dean, third year HYMS medical student, BSc

(1) McManus, IC, Richards P, Winder BC (1999) Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students. British Medical Journal, 319: 542-546

We just wanted to draw your attention to Friday’s podcast which was posted today, where we have another brief chat on the concept of the Responsibility to Protect and other updates on the website.

Sophie and Christine

Lancet Editorial: How to prevent a tenth of the global disease burden

In the 19th century, two public health engineers discovered that the reduction in child mortality brought about by improvements in water and sanitation exceeded the number of deaths that could be attributed to diarrhoea alone-the Mills-Reincke phenomenon. Unfortunately, until very recently, the world has ignored this phenomenon. Now several key reports emphasise the dramatic health (and economic) benefits that can be gained from improvements in water, sanitation, and hygiene and give plenty of incentive for the political will that we called for in our Editorial on March 29. (more…)

There has been a lot of interest in the ‘Power, Politics and Global Health’ magazine collaboration between Medsin-UK and The Lancet Student which was announced a few weeks ago, and we want to encourage you all to keep sending us your ideas and article submissions! To inspire potential article ideas, here is the list of general conference topics:

Plenary 1: Politics

A pressing question for those in global health is how political systems impact on health and health equity. How do different national political systems approach the question of health? And which is most effective?

This plenary will also address the means by which these vastly different national systems integrate into the international systems of governance affecting the global health agenda.

This plenary will focus on the following questions:

• How political systems affect population health and equity
• Is democracy good for health?
• Do we need a global democracy?

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Crash Course: Paediatrics, Bhathalvalsa

Clinical Examination, Epstein

150 ECG Problems, Hampton

Surface Anatomy: The Anatomical Basis of Clinical Examination, Lumley

Crash Course: General Medicine, Parker

Crash Course: Physiology, Shahid

In the setting of the upcoming elections, my Senator, Jim DeMint, recently wrote a letter of opinion to the Washington Times opposing a global HIV/AIDS, tuberculosis and malaria bill that will provide life-saving medications and prevention against infectious disease in the developing world. Though the white house and a broad bipartisan coalition of legislators and community groups support this bill, his statements suggest that he considers this bill a superfluous, expensive government investment.When DeMint has called for our leaders to reduce the program’s funding beyond the scope, even, of his own countering bill, he also calls against extensive grassroots efforts based in South Carolina - his own constituents. Though every Senator has the right to block a bill, my Senator’s radical stance, out of touch with the desires of his base, threatens the democratic process to which the heart of America is so attuned.

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The journal is available at: http://www.globalpulsejournal.com

All of us at Global Pulse (GP) are excited with this issue. We received incredible
submissions from medical students, literally around the world, and from
other disciplines as well.

Here is just a sample of what we feature in this issue:

An exclusive, in-depth interview with Dr. Joxel Garcia, the Assistant
Secretary for Health of the U.S., the Medical Director in the Regular
Corps of the Public Health Service, and official U.S. representative to
the World Health Organization (WHO)!

WHO’s Global Initiative for Emergency and Surgical Care

Telemedicine in Bhutan

Accounts from Kenya

A (fantastic) photo essay from Guatemala

Additionally, we have added a blog to the website.  We will update the blog, and the website, in the next couple of days.

GP is completely funded by AMSA (not sponsored by other third parties),
entirely run by medical students (that have to study for boards and work
the wards!), and like every AMSA project, we are passionate about what
we do! Click on the “about us” section to learn more.

Julio Bracero & Preeti Kaur Rajpal
Editors-in-Chief, Global Pulse

email contact: jbracero@globalpulsejournal.com

Surface Anatomy: The Anatomical Basis of Clinical Examination

John S.P. Lumley

For a Thursday it’s unusually quiet on the wards and so you take the opportunity to see Eleanor an elderly lady who’s been admitted this morning with pneumonia.
‘Good morning, my names Dr Rochester, and how are we this morning?’ you enquire whilst at the same time making a mental note to say ‘you’ rather than ‘we’ since you fear it sounds condescending.

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Crash Course in Physiology
Mohammad Shahid
ISBN-13: 978-0723433880  

Crash Course: General Medicine

Robert Parker and Asheesh Sharma 

Also a couple of reports I want to highlight this week. The first is the latest report from the African Progress Panel which reminds the G8 that they must keep its existing pledges towards Africa’s progress. This year’s G8 Summit starts on 7th July in Japan. The next is a brilliant new report and web initiative from the Access to Medicine Foundation that has created an access to medicines index that ranks the world’s top 20 pharmaceutical companies according to their efforts to increase universal access to medicines. GlaxoSmithKline comes top. Pfizer, the world’s largest drug company comes out a disappointing 17th, and Schering Plough languishes at the bottom. Check it out for yourselves! That’s all from me for now. Hope you have a great weekend. Rhona

A Personal Reflection

Over the past year, I have written several articles for the Lancet Student on the growing prevalence of chronic noncommunicable diseases (CNDs) in developing countries.  Major studies have indicated that diseases and risk factors such as hypertension, diabetes, tobacco use, and asthma are increasing in low- and middle-income countries in all regions of the world (1,2).  Recognizing these trends, the World Health Organization (WHO) has recently begun to address this new global health priority (3,4).  Researchers and advocates have pointed out that more investment in prevention, screening, and treatment will be needed to avert the resulting unnecessary disability and mortality (5,6).  These reports indicate that CNDs will be a major item on the global health agenda for the duration of our careers.

Most of the research, including the recent series published by The Lancet (7), has been predicated on epidemiology, economic impact, health systems, and potential interventions.  Less has been said about the non-technical implications of a transition to chronic disease in the developing world.  This is unfortunate as “health” extends far beyond the biomedical realm; it is intertwined with sociological structures and culture.  A shift from acute infections and traumas to chronic, often asymptomatic ailments, thus presents a paradigm shift in the notion of what it means to be a healthy person.  This is a serious adjustment that deserves careful consideration.  For how can we expect people to take medicines or alter lifestyles if they don’t believe that they are ill?

I personally saw the anthropological and cultural challenges of the epidemiologic transition when I worked with the Ethiopian Israeli community in 2005.  Arriving in urban Israel from rural Ethiopia in the 1980s, the immigrants had a conception of health that largely revolved around the acute infections and malnutrition endemic to poor countries. Within ten years, though, the prevalence of Type 2 diabetes rose from 0.5% to 17% in some cities.  Similarly, asthma, blood cholesterol levels, blood pressure, and red meat consumption soared.

The Ethiopian immigrants had no word in their common language for diabetes.  I spoke with a man with longstanding diabetes who had never heard of the pancreas.  He didn’t believe he was sick.  As the deleterious elevation of blood glucose is often asymptomatic early in the disease course, it was exceedingly difficult to convince patients to adhere to therapy.  Even worse, the language used to explain diabetes can be very confusing, as the notion of “high sugar” led some patients to believe that sugary foods were the cause of the condition.  Miscommunication between the Israeli primary care providers and the Ethiopian patients, compounded by poverty and power disparities, led to distrust and very poor quality of care.  And this was in a country with a well-financed health system designed to address chronic noncommunicable diseases.

Indeed, the entire notion of chronic disease resulted in confusion and frustration for some Ethiopian immigrants.  “Why can’t the doctor cure me?  Why doesn’t he give me a shot?” asked one.  “He must just be a bad doctor, or maybe he doesn’t treat me because I am Ethiopian.”  I heard similar confusion about the concept of lifelong drug therapy.  One mother, for example, refused to give her son an asthma inhaler, lest he become “addicted” to it like tobacco.  Another, however, wanted constant steroids to treat his mild asthma, because “they make me feel good.”

My discussions with the Ethiopian immigrants and Israeli health workers also hinted at the complexity of advocating lifestyle changes to prevent chronic disease.  Lifestyle is the product of thousands of choices, many of which are heavily influenced by economics, sociocultural norms, and status.  People in developing countries may aspire to eat Western foods high in saturated fats and may choose to smoke American cigarettes to indicate their wealth.  Being overweight or obese, even having some diabetes, may be lauded as a sign of success.  These attitudes can be deeply ingrained, and modifying them will require interventions informed by a nuanced understanding of local culture and health beliefs.  If chronic diseases are not presented in terms that make them believable, most people will be hesitant to significantly alter their lifestyles in order to “prevent” an abstraction.

Over the past few years, attention has been increasingly paid to the coming epidemic of chronic noncommunicable diseases in the developing world.  These diseases can lead to devastating consequences, both physically and economically.  It has thus been recognized that many disciplines will need to be rallied in order to adapt health systems for chronic care, re-train workers, ensure access to medicines, and design cities amenable to physical activity (2-7).  Yet the barriers to the effective prevention and care of these diseases cannot be lowered through the technical expertise of biomedicine or policy alone.  Rather, my experiences have taught me that it will require a more holistic understanding of how individuals adapt to a revolution in the conception of health, illness, and healing.  To do so, I think we first will need to learn how to be better and more patient listeners.

Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York, USA

jschumar@gmail.com

(1) Lopez AD, Mathers CD, Ezzati M et al. Global and regional burden of risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57

(2) Jamison D, Breman J, Measham A, Alleyne G, Claeson M, Evans DB et al. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press and the World Bank, 2006.

(3) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002

(4) Preventing chronic diseases: a vital investment.  Geneva: WHO, 2005

(5) Leeder S, Raymond S, Greenberg H, Liu H, and Esson K. A Race against Time: The Challenge of Cardiovascular Disease in Developing Countries. New York: Trustees of Columbia University, 2004.

(6) Yach D, Hawkes C, Gould CL, Hofman K.  The global burden of chronic diseases: overcoming impediments to prevention and control.  JAMA 2004; 291:2616-2622.

(7) Horton R. Chronic disease: the case for urgent global action. Lancet 2007; 370:1881-82.

Everyone knows about measles, but do we perhaps take it for granted, thinking it an unproblematic and easily avoidable issue? A disease most prevalent amongst young children between the ages of one to four, it is highly contagious - particularly in the four days before any sign of physical symptoms - and has been responsible for millions of deaths worldwide, mostly through the various complications it is liable to cause including hepatitis, conjunctivitis, encephalitis and severe respiratory infection (1).

Thank goodness, then, for the measles vaccine, which costs around GBP 0.17 including safe injection equipment and has been around for 40 years (2). Furthermore, the vaccine has been proven to be both safe and effective - so why does the disease continue to take lives even today across the whole world?

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We’ve been enjoying leaving the office this week and yesterday we attended the media launch of the second Action For Global Health report. Action For Global Health is an advocacy network of European NGOs. The aim of this year’s policy report is to consider how European aid for health is delivered, and to create a strategy for increasing the quantity of aid, and the quality of its delivery. The 2007 report focused on aid effectiveness, and yesterday’s report addressed the question of ‘Why Europe must deliver more aid, better spent to save the health Millenium Goals’.

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If you would like to read more on the experiences of refugees we recommend Caroline Moorehead’s Human Cargo- A Journey Amongst Refugees (2005).  She tells the stories of refugees she met during two years travelling in countries including Egypt, Australia, the USA, Italy, Lebanon, Finland and England.  Sophie

Last night, we (note from Rhona: that’s Sophie and Christine, our current Lancet Student interns!) had the opportunity to attend a talk by Antonio Guterres, UN High Commissioner for Refugees (UNHCR), which marked the start of Refugee Week here in the UK.  The talk was hosted by the International Rescue Committee, a non-profit, non-governmental organization that provides emergency relief and humanitarian aid to more than 15 million refugees and conflict-affected people around the world.  The theme of High Commissioner Guterres’ talk was “People on the Move: The Challenges of Displacement in the 21^st Century”.

One of the key challenges facing the international community in the next decade that Guterres spoke about is the need to manage migration flows and the movement of peoples within and across borders.  Specifically, the concern is in distinguishing persons that are forcibly displaced and urgently need asylum and refuge from those who migrate for non-forcible reasons.  Persons who are forcibly displaced require a higher level of protection - protection that the international community is bound to provide under the conventions of the Universal Declaration of Human Rights (UDHR).  In many instances, this commitment to international protections is in stark contrast to the common practice of states, with many European countries offering limited protection.  Guterres said that 0% of Iraqis in Greece currently enjoy protection as refugees; as Greece is the main entry point to Europe, it is often the country to which other European countries send those whose claims for asylum have been rejected.  This can be compared with the 170,000 Burundians offered Tanzanian citizenship after their citizenship rights had been dissolved when they did not return following the 1972 conflict. 

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Introduction

The term “doctor” is derived from the Latin word “doctus” which means “erudite” or “highly educated”. In some aspects however, doctors today, or rather medical practitioners, are afar from being “well-educated”. As the world grows together due to economical, political, technical, social and cultural globalisation, health problems become globalised, too [1]. Strategies to solve these problems in national boundaries are predestined to fail, as it can be seen in different fields from emerging infectious diseases and communicable disease control to intellectual property rights [2,3] or ethical issues like illegal human organ trade. Thus, national health systems transform increasingly into melting pots for global problems.

Medical education, however, has not kept pace with this transformation [4], hence it can be assumed that future medical practitioners will lack essential knowledge in issues of Global Health (GH). The future generation of doctors, in contrast to the original meaning of their title will be “uneducated” concerning social, political and economic determinants of health [5,6], if medical schools continue to focus strictly on curative medicine of individuals, overlooking the importance of global public health for the wellbeing of individuals.

In Germany, the Globalisation and Health Initiative (GandHI) has been founded in 2006 by student activists in order to close the existing gap in Global Health education. The following article aims to describe the strategy of our initiative and inspire students from other countries, to adopt or develop similar strategies, in order to promote and establish GH education in their respective country.

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