Greece is a third world country…

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Within a fridge in a clinic in Perama, Greece, medicines are stocked right next to the feta cheese.

Food collection and distribution never formed part of Medecins du Monde (Doctors of the World) projects, but more and more people have been asking their medical doctors for food along with medication. Doctors at Medecins du Monde have even been documenting people having to choose between insulin and food.

In 2012, Medecins du Monde ran 312 programmes in 79 countries, including over 160 health programmes across Europe. During that time what they witnessed was a staggering picture of a social health care ecosystem struggling to hold its head above water — an inevitable crisis signposted by soaring unemployment rates, people losing their homes due to insolvency, and large-scale migrations.

In recent years, increasing numbers of European citizens are being pushed to the edges and towards economic migration, both within Europe and beyond. The financial crisis has generated austerity measures that have had a deep impact on all social welfare and safety nets, including healthcare provision. And nowhere in Europe is that more apparent than in Greece.

Since the beginning of the financial crisis, Medecins du Monde has multiplied its areas of action and set up two new health centres in Perama and Patras. In Athens, homelessness is a new phenomenon — a direct result of the crisis. Their mobile units help out where they can with sleeping bags and food.

Today, Greece could almost be described as a third world country, with increasing numbers of people excluded from its healthcare system. Medecins du Monde reports that brutal attacks and hate crimes against ethnic minorities have become a daily phenomenon in Greece — the seriousness of the problem getting worse in the wake of Greece’s financial crisis — and exploited politically by xenophobic extreme right-wing groups. Hate groups that are getting away with it.

In the first nine months of 2012, 87 incidents of racist violence against refugees and migrants were documented — not by state or government officials but by a broad civil society coalition. The Human Rights Watch report, Hate on the streets: xenophobic violence in Greece, documents failure of the state — both police and justice systems — to prevent and punish the rising numbers of attacks on migrants.

Last year marked the country’s sixth consecutive year of economic contraction. In an economic climate where 2% growth is seen as anaemic, economic contraction has meant that Greece has sacrificed all in the name of austerity. In 2012, in an effort to achieve specific targets, the Greek Government surpassed their bailor’s requirement for cuts in hospital operating costs and pharmaceutical spending. Across Europe, Greece’s public spending for health is one of the lowest — with less than any of the other European Union members. The consequences are far reaching.

The other side of the coin — amidst an impending health crisis, two bailouts, turmoil, tripling unemployment — has been a deep and cutting austerity measure that has flung Greece back several decades. HIV infections among injecting drug users rose from 15 in 2009 to 484 in 2012. TB infections had also gone up. Greece had not recorded a case of malaria since 1974, in 2012 around 70 cases were reported. There was a 19% increase in the number of low birth weight babies, 21% rise in stillbirths between 2008 and 2011, which is attributed to reduced access to prenatal health services for pregnant women.

The result, apart from four health ministers in little over a year, is an unmet medical need — one that Medecins du Monde is currently struggling against — and one with no answer. Even as the financial crisis passes, it is unlikely to provide a respite. As most understand that the public-health system was broken long before the crisis by years by mismanagement and corruption.

Image — source.

Social media is bad news for bad drugs in China…

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In the war against substandard drugs in China, social media has become a new battlefield.

In 2009, only two months after twitter and facebook were banned in China, the chinese microblog Sina Weibo came into existence, and is now having significant impacts on the quality of drugs sold on the chinese market. Sina Weibo has now become China’s most popular social media network and microblog platform, boasting 300 million registered users. In 2012, it was averaging 100 million posts per day.

In an autocratic China, people take to social media to vent frustrations and alert each other whenever they come across a bad drug.

Counterfeit and substandard drugs make up more than 10% of the global medicine market, and it’s an increasing problem — with up to 25% of fake drugs ending up in developing countries. The vast majority of counterfeit drugs originate in China — ending up in Africa, but some don’t make it out and circulate within the Chinese system.

Recent research has examined the impact of the introduction of Sina Weibo on the quality of drugs on the market. Scientists at the Institute for International Economic Studies at Stockholm University use the amount of bad drugs found by China’s Drug Administration (SFDA) as a proxy for drug quality. They explore the variation in bad drugs before and after Sina Weibo’s introduction to obtain the quantitative estimate of the impact of Sina Weibo.

Results suggest that introduction of the microblog significantly reduced the amount of bad drugs on the market, of which the size of the effect was substantial. Sina Weibo, as much of social media, is a relatively new occurrence, and the amount of drug data collected by the Chinese SFDA predates it. The introduction of the social media network in China coincided with a clear declining trend for the number of bad drugs found.

“Attention is power, and circusee is changing China”

The chinese use the word “circusee” to describe Sina Weibo, which refers to the power of Weibo to make millions of people to focus on one issue together.

In March of 2010, the Beijing-based China Economic Times reported that four children had died over the past four years from improperly stored vaccines. The vaccines had been improperly stored and distributed throughout Shanxi Province and resulted in the death of several children and seriously injured many others.

When the scandal broke, users took to Sina Weibo to vent frustrations. Information flooded the microblog across China, and thousands of parents called for joint action and refused to have their children vaccinated by official disease control centres.

The effect of increased attention has the added benefit of China’s Drug Administration putting in more effort and deters the production of bad drugs. The SFDA is found to work harder in checking drugs around where there is more social media buzz.

The SFDA samples and tests specific drugs from around 300 prefectures across China. Sampled drugs come from clinics, disease control and prevention center/anti-epidemic stations, drugstores and hospitals, wholesalers and intermediary drug companies. The users on Sina Weibo post information revealing the stores or producers of bad drugs. As information sparks on Sina Weibo, more bad drugs are brought to the attention of authorities and screened out — eventually deterring the producers from producing the bad drugs.

“Behind the great firewall of china, information wants to be shared”

Even within an autocratic society, Sina Weibo represents a cheap and readily accessible type of free media, that is relatively free from censorship. When information can circulate quickly, censorship struggles to keep up.

The day after the 2010 vaccine scandal, the State Information Office ordered the deletion of all newspaper stories that covered the scandal. The Central Propaganda Department required traditional media to only use official news releases from Xinhua News Agency. However, information was still freely flowing on social media.

In a country like China, a microblog is an especially cheap, accessible and relatively free type of media. Sina Weibo can circulate information among millions of users widely and quickly. Once a bad drug is found and posted on the microblog, followers and re-posts can spread the information immediately and informed consumers can respond.

Even with censorship a post can be read by thousands of people before it is deleted. The deeper truth is that China cares about social welfare and thus censorship has taken a back seat to using such information to rectify the problem of bad drugs — even if they unveil government corruption in the process.

Image — source

All the science that’s fit to print…

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Between August 10, 1978 and November 5, 1978 a multi-union strike shut down the three major New York City newspapers — one of which was the New York Times. This blip in publishing history serves as an important data point for how the media plays an important role in science literacy and science communication.

For those few months, no editions of The New York Times were printed — outside of a parody rag “Not the New York Times” — a prank alternative that was handed out in big cities around the country full of news stories imagined by comedy’s liberal elite of the time.

Internally, the New York Times continued to prepare an “edition of record” that was not distributed and showed all the news stories that would have been fit to print during the strike. The newspaper kept a list of articles they intended to cover. And when you take a look at that list in the light of hindsight, what you see is how print media effects citations of scientific articles. An effect we don’t often hear about, and one we assume to work in the other direction.

New England Journal of Medicine articles covered by the New York Times received 72.8% more citations than articles that were not covered (one year after publication). This effect was not present for articles that the New York Times intended to cover (and couldn’t because of the strike).

It seems that media coverage encouraged and helped articles garner future citations. Something that can’t be fully attributed to the fact that, simply, the New York Times chose to cover more influential articles.

Today, with science communication heavily dependent on the press release, the question has to be asked as to how much does science reporting ultimately skews the playground — cementing ‘not-so-good-science’ not only in the eyes of the public but also in terms of the impact factors and citations of ‘not-so-good-science’.

My use the term ‘not-so-good-science’ is deliberate hyperbole. But recent research has shown that newspapers are more likely to cover observational studies and less likely to cover randomized trials. And when the media does cover observational studies, they select articles of inferior quality.

And in case you didn’t know

“The randomised controlled trial (RCT)  is one of the greatest inventions of modern science — a tool that allows you, more reliably than any other, to compare two or more interventions and determine which is more effective for a given purpose.”

The research covers 75 clinically-oriented journal articles that received coverage in the top five newspapers (by circulation) and compares them against 75 clinically-oriented journal articles that appeared in the top five medical journals (by impact factor) over a similar timespan.

The investigations receiving coverage from newspapers were less likely to be randomized controlled trials and more likely to be observational studies. The observational studies from the media frequently used smaller sample sizes and were more likely to be cross-sectional.

The crux is where weak reporting, or rather, reporting on weaker science, comes at the expense of the complex and throws out the nuance in favour of simplicity. The age-old debate of “dumbing down.” Science is hard in every sense of the word. The dazzling myriad of complexity in breaking everything down to its basic components and putting it back together to look at the grand scheme of all things cannot really be fully communicated to a lay audience.

Perhaps the better question would be how much of the science that reaches print and online media is an accurate reflection of science in its entirety?

Image — source

Eradicating Sleeping Sickness…

After much stillness and quietness on the blog for a long time, scienceleftuntitled is back in action, this time in the digital pages of The Guardian…

Sleeping sickness: a health scourge that refuses to be put to rest

“This approach is in direct contrast to how the disease has been fought up until now – through an intensive and expensive system of detection and treatment. As the number of cases continues to fall, the elimination of sleeping sickness rests on the ability for control activities to be integrated into wider health systems. The challenge with integrated service delivery is that it reveals organisational, logistical and technical deficiences shortcomings.

Zambia too has be lauded for its success in fighting sleeping sickness but a recent study, which investigated the state of health care facilities for sleeping sickness management in the district of Mpika, showed that even here, where infection rates are low, much could still be improved. The country exemplifies what problems are faced by local health authorities, particularly when the disease begins to be forgotten.”

Life of an epidemic: Australian dengue

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It is always a bad sign when crowds gather. On the morning of Wednesday March 21 in the year 1900, a crowd began to gather in Sydney. A thousand people had gathered outside the offices of the Board of Health in Macquarie Street. They had gathered because bubonic plague had broken out. People had already started to die from the Black Death. Panic was the only course of action.

The Government had stockpiled Haffkine’s serum (named after the Russian bacteriologist that developed it in a makeshift laboratory in a corridor of Grant Medical College) — a new plague vaccine, and had used it to inoculate front‐line health workers, new plague victims and anyone who might have come in contact with them. The panic was because the Sydney papers had been campaigning for a public vaccination program.

When the Board of Health finally opened its doors that morning, the crowd overran the place. In the melee property was damaged. Not much happened to inoculate people that day. In the end, the public inoculation campaign was abandoned. It would be another two decades before Australia was free from plague.

Australia has a long history of epidemic and pandemic encounters. Smallpox, polio, scarlet fever in 1830 that lasted for half a century, intermittent and regular bouts of influenza, and encephalitis lethargica.

Like it or not we are in the midst of a number of epidemics, not just in Australia. There are the fast moving ones that happen with many newspaper column inches like SARS and MERS — whipping up a frenzy of unpredictability. There are those that have become a part of the conversation like HIV/AIDS. And there are those that go under-reported like Dengue fever.

dengue virus

dengue virus

Explosive dengue

From November 2008 to May 2009 Cairns, Queensland was struck by an explosive epidemic of dengue virus (DENV-3). One that exceeded the capacity of the highly skilled dengue control teams to control it.

Australia is no stranger to outbreaks of this nature. A dengue outbreak had already occurred previously — in 1992. One of the consequences of that large multi-city outbreak was the development of the Dengue Fever Management Plan (DFMP) by Queensland Health in 1994.

Between 1995 and 2012, there were 42 outbreaks comprising of 3,086 confirmed dengue cases and three deaths; the majority (37 outbreaks and 2,364 cases) have occurred since 2000.

Piecing together the fragments of an epidemic

The weather can predict disease, and create the perfect set of contitions for an epidemic to take hold. The climate in the months leading up to the outbreak of the epidemic was apt for the spread of the vector — the Aedes aegypti mosquito. The Cairns dry season, from May to November, customarily has low rainfall. In 2008, rainfall at the time was significantly more than usual, with heavy rains towards the tail end of September.

The heavier than usual rain was thought to have hatched mosquito eggs leading to the rapid escalation of mosquito numbers, serving as a primer for the outbreak that was yet to come.

For this epidemic to take hold and spread, it required a some-what perfect sequence of events. Unseasonably warm weather, with daily mean temperatures exceeding 30°C, occurred in late November and would have shortened the incubation period of the virus and enhanced transmission.

Researchers analysed case movements early in the outbreak and found that the total incubation period was as low as 9 days. They replicated and confirmed it in a lab setting and it took just 5 days.

27 days passed without the Queensland Health authority knowing about the outbreak. This allowed the virus to amplify and spread unchecked through its first month in Australia. Human-mediated dispersal were the words they used to describe it. The seasonal movement of people around that time most likely also enhanced the spread of the virus.

In all the virus had an unusually rapid transmission cycle that allowed it outpace control efforts.

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Patient Zero

Sometime before the 3rd November 2008, a flight landed in Cairns. The flight brought back with it, among many other things, a passenger who had visited Kalimantan in Indonesia the previous month. Two days after the flight landed the passenger was to fall sick. It wasn’t yet clear it was dengue. Later it became clear that the passenger was the index case — importing the virus and initiating the outbreak. There had been no reported cases of DENV-3 in Cairns since an outbreak in 1998.

Researchers discovered that the first group of cases in the epidemic all came from within 200 metres of the index case. By day 17 of the outbreak there were already 6 local cases.

By the following spring, the rate of infection had dropped dramatically. Despite health services playing catch-up for most of the epidemic, ending the outbreak was a tour de force. The outbreak received widespread media attention — motivating a well-informed public to remove any water-holding containers that could act as a breeding ground for mosquitoes.

The public health effort was cyclopean. State emergency services went door to door, delivering information kits and cans of pyrethroid surface spray to residents in suburbs at risk. A SMS texting service sent messages to mobile phones warning residents of active virus transmission within their residential area. Man power was mobilised. After declaration of the epidemic in January 2009, additional vector control personnel were employed.

There was hardly any suburb in Cairns that had not reported cases of dengue, and had not been subject to vector control by April of the following year.

In the end, the outbreak caused 931 confirmed cases and one single death on 4 March 2009. And cost Queensland Health somewhere in the region of 3 million australian dollars.

What would eventually become evident was that even with what seemed like a highly professional contingency system in place to deal with an epidemic such as this — this time round, the disease got the better of them. This time round the epidemic was different. Different in the way it moved through the population.

“The apparent speed of transmission and its rapid geographic spread overwhelmed what had been a successful, organized first world dengue control program”

Image — source, source


What had I twaught…


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