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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?

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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”

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Public Health in the Age of Austerity

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“Care of the public health is the first duty of the statesman”

In 1932, the American Public Health Association, publishing in the American Journal of Public Health, called on their government not to forget about them. The consequences, they claimed, would be dire. They described it as a present state of emergency.

At the time, they felt that the situation in the United States, during the heights of the depression, had got to such a state, that it warranted immediate action. They sought to call attention to the inherent dangers involved in slashing public health budgets, reducing personnel, and limiting health programmes. They cited preventive campaigns against diphtheria and typhoid fever that would suffer.

It was the time of the Great Depression. The decade that immediately preceded it — the roaring 20s — saw runaway economic growth providing prosperity for all. The end of the decade and the 30s, however, began to stagnate, signposted by the stock market crash of October 1929. The collapse of Wall Street was followed by a steep decline in economic activity — gross domestic product was counted in negative numbers, and unemployment was at an all-time high — reaching a historical maximum of 22.9% in the US in 1932.

The idea has always been that an economic downturn also led to a downturn in public health. Historically, there has been no greater spur of health and wellbeing than a prosperous nation. The wealthier the nation then the more it spent on the health of its citizens. It may seem counter-intuitive to think that the era of the Great Depression was a time that actually saw declining death rates in Europe and in the US. During the Great Depression, life expectancy rose significantly from 57.1 years of age in 1929 to 63.3 years in 1933. Rates of infant mortality declined during the 1920s and 1930s. Within those two decades the only years that saw an increase in mortality were years that coincided with short bursts of strong economic growth. Famously, the most notable cause of death during this period was suicide. Death by suicide peaked with unemployment.

“It is futile to quote the great men of the past, statesmen, as well as scientists, to prove what health means to any nation.”

This is a recurring theme over the course of history. One that we don’t pay much attention to. As the health of a nation gets better we tend to forget of the vigilance and strife that was needed the first time round. Eventually, health is a given. So much so that it is only when a scandal hits that we see how much we take it for granted. Comparing developed against developing nations is where we see the greatest contrast. Vaccinations are part and parcel of a newborn life in some countries. Children cannot go to school without it. This seamless integration of public health into everyday life does not exist everywhere.

Fast forward to today’s economic recession, where the US is witnessing a decline in its public health laboratories. These public health laboratories provide testing for drinking-water testing, sexually transmitted diseases, HIV screening, blood lead screening, substance abuse monitoring to support treatment programs, and detection of bioterrorism agents in environmental samples and isolates from humans.

A decline that is due in part to deficient state and local tax revenues resulting from loss of taxpayer jobs and income tax revenues and loss of homeowner and business property tax payments due to foreclosure. Decreased funding has resulted in loss of public health jobs due to layoffs and attrition, program cuts and reductions.

When the University of Michigan’s Center of Excellence in Public Health Workforce Studies, together with the Association of Public Health Laboratories, assessed the workforce and program capacity in US public health laboratories back in 2011; they found that almost half of laboratories anticipated that more than 15% of their workforce would retire, resign, or be released within 5 years.

In Michigan, they lost more than 300 years’ worth of employee experience over the course of 3 months. In attempts to control budgets, state and local governments incentivized retirement. Resulting in loss of the most experienced, expert employees and additional burden of work for remaining employees.

Cuts and straitened times seems part and parcel of today’s economic downturn. Little discussion takes place on how this will ultimately shape the health and wellbeing of nations. Demand for services from an ageing population and increased costs created by new clinical  and pharmacological technologies, will all put upward pressure on health spending. This is the case in the US and in the UK.

Some see it as an opportunity, however. An opportunity to finally bring two opposing forces together — public health and medicine. Writing in the New England Journal of Medicine, researchers argue for simple population-based approaches to address fundamental health problems. Obesity tackled at the population level rather than at the individual level. A focus on the population as a whole rather than simple service delivery of intervention medicine.

“Perhaps paradoxically, the current push for austerity could bring together clinical medicine and public health in unprecedented, mutually beneficial ways that could improve population health and reduce spending”

The idea is simple and looks to do more with less. Such is life in the age of austerity.

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Australia’s evolving drug landscape

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This year we saw Australia put into force a new patent law. An intellectual property system that was Australia’s most comprehensive in over two decades. It came into effect on 15 April 2013 and no one knew exactly what to expect from it.

We have seen with cases like India, how one country’s patent laws can send ripples and disrupt the entire system. And, in the case of Thailand, how a country can take matters into its own hands to enact a public good.

It really all centres around compulsory licensing. A compulsory license, in simple legalese, is the use of a patented innovation that has been licensed by a state without the permission of the patent title holder. This started over a decade ago, when the World Trade Organization adopted the “Declaration on the TRIPS Agreement and Public Health” at its 4th Ministerial Conference in Doha. At the time, many anticipated that this would lead nations to more frequently claim compulsory licenses for pharmaceutical products.

The TRIPS Agreement allows governments to license the use of patented inventions to someone else without the consent of the patent owner. It does not and should not prevent nations from taking measures to protect public health — that was the way it was billed and sold. In dealing with public health epidemics, such as HIV/AIDS, tuberculosis and malaria, countries such as Brazil, India, Thailand, Indonesia and Ecuador have used compulsory licensing to reduce the prices of pharmaceutical drugs for their citizens. What has been seen is a significant spike in use of compulsory licensing in years since Doha.

So where does Australia sit in this spectrum?

Last month, the Australian Parliament was debating a bill on patent law and public health called the Intellectual Property Laws Amendment Bill 2013. It is said that the legislation gives Australian governments greater powers to exploit patents without authorisation from the patent owner via stronger provisions for Crown use and compulsory licensing. Perhaps something more along the lines of what Thailand enacted in 2007. Thailand played the global system to their advantage, exploiting a clause in the 1995 World Trade Organisation agreement on intellectual property that gives governments a large amount of freedom to bypass patents on drugs if they face any kind of health crisis.

Begging the question; in this day and age — aren’t we always under a health crisis? Whether it be from the scourge of tropical diseases in developing countries or the rise of affluent afflictions like heart disease and cancer.

Recently, the Sydney Morning Herald reported that the bill was likely to pass. Going further to state that this would allow Australia to export generic versions of patented drugs to developing countries to tackle outbreaks of diseases such as malaria, HIV and TB. Perhaps becoming the second “pharmacy of the developing world” alongside India. It seems the right balance was achieved between helping people in poor countries and safeguarding intellectual property.

There is another side to outwardly-looking medicine laws in a country. And that is the inwardly looking.

Australia has a drug subsidy scheme, that provides subsidised prescription drugs to residents of Australia — ensuring that all Australians have affordable and reliable access to a wide range of necessary medicines. The scheme has come under some recent controversy.

In 2011 and in 2012, the number of new medicines placed on the nation’s drug subsidy scheme was the lowest seen in two decades. This drop, despite no reduction in new therapies being proposed but just because of a higher rate of rejection by the advisory committee in charge of approving subsidies.

The drop brings up the question of where does this leave patients? With the scheme put in place to ensure that even the poorest of patients can get life-saving medicines the whole “Access to Medicines” debate is revisited. In this case, a slightly shifted one than the usual Big Pharma profit story. Numerous examples exist where the inability to get drugs directly influences patients.

In the ever-increasingly complicated world of drugs, medicine, and economics… the right to a healthy well-being is also being tested.

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What had I twaught…


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