Catching (up with) MERS

Today a MERS case was announced in another country — Italy, where the patient is a man who recently traveled to Jordan (it’s being reported that one of his sons there has similar symptoms). This makes at least fifty known patients with greater than 50% mortality rate. Time to introduce our latest potentially large-scale viral adversary.

Middle East respiratory syndrome coronavirus (MERS-CoV) is one of several coronaviruses humans contract.  In fact, about 30% of cases of the “common cold” are caused by coronaviruses, but with  coronaviruses SARS and MERS, the illness can be far more severe.  Under the electron microscope, MERS looks like this:

Image source: Cynthia Goldsmith/Maureen Metcalfe/Azaibi Tamin, via cdc.gov

Image source: Cynthia Goldsmith/Maureen Metcalfe/Azaibi Tamin, via cdc.gov

It’s deadly.  As of May 29th, the WHO knew of 49 confirmed cases and 27 deaths. That’s a 55% mortality rate compared to the <10% rate of SARS.  (Reuters today says 51 patients with 30 deaths: 58% mortality.)

It can progress quickly. This slide from an article in the New England Journal of Medicine shows the rapid change in four patients, a family cluster of four men who became sick last fall. Two of them died.

We don’t know where it came from, how it can be transmitted, or much else.  The assumption is that there’s an animal source, but that hasn’t been found.  We know it can be transmitted from person-to-person, but not exactly how that happens or how contagious MERS is.  Those aren’t the only puzzles. As Laurie Garrett wrote about the case above, “The cluster of cases in this family presents a list of mysteries: Why were all the sick and dead men? With 28 people in this three-building urban household, why were these four infected, and the other 24 spared? The family lived in a big city, had no animals, ate supermarket food and had jobs that offered no contact with the virus. How did they catch MERS?”

The incubation period may be substantial.  A study of French cases of MERS released online by The Lancet yesterday estimates one incubation period as 9-12 days. This calls for longer isolation than expected and raises the risk that the virus will spread as people who don’t yet feel sick travel.

It’s centered in a troubled area.  It’s called Middle East respiratory syndrome for a reason: all currently known cases originated there (one transmission is known to have taken place outside of that region, but from a patient infected there). Millions of Syrians have been displaced during their civil war and many refugees are crammed together in camps, like this one in Jordan that was featured on yesterday’s PBS Newshour.  If the virus were to get a foothold in a place like that, it could quickly overwhelm the medical resources for refugee care.

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World No Tobacco Day

Today is the World Health Organization’s World No Tobacco Day

WHO World No Tobacco Day

I’m not entirely comfortable with the WHO’s approach, though I agree with the goal.  Another poster asks, “Are you being manipulated?” which could suggest tobacco users are gullible, weak-willed followers.  It’s standard to refer to tobacco use as an epidemic and that has been the case for decades, but I struggle with drawing a line between what is and what is not an epidemic.  And, I’m skeptical about the lure to imitate movie smokers nowadays, but that could be an ethnocentric view: I grew up in a culture where the damage caused by smoking was well-known and taught to us at an early age — making movie smoking nothing more than character development — and at a time when TV and radio ads were banned.  It was a long way from 1950:

1950-cigarettes-that-soothe-your-throat

On a related note, this seems like the perfect opportunity to link to Quit Tobacco International, a project focused on tobacco use in India and Indonesia and founded by, among others, anthropologists Mark and Mimi Nichter.  From the site:

Over the next two decades, deaths due to tobacco will soar to 4.2 million annually in Asian countries, nearly twice that of more developed regions. The wealth of research knowledge and lessons learned about tobacco cessation from high income countries cannot be simply transferred into low and middle income countries (LMICs) given the vast differences in cultural norms, tobacco products and use patterns and health care and public health systems.

MSF Scientific Day live this Friday

Médecins Sans Frontières/Doctors Without Borders (MSF) will stream their Scientific Day conference live at no charge this Friday [watch here].  The conference takes place in London but they have also published a schedule in Eastern Standard Time.

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Highlights of this year’s conference include:

  • The keynote speech by international health expert, co-founder of theGapminder Foundation and TED talks alumnus Hans Rosling on the synergy and conflict between research and advocacy. This will be followed by a panel discussion on the impact of MSF’s research.
  • Treatment in conflict and emergency settings including TB in Somalia and hepatitis E in South Sudan
  • New approaches to preventing malaria in Mali and Chad, cholera vaccination in an outbreak in Guinea, and preventing malnutrition in Niger by cash transfer and food supplementation
  • Challenges for MSF including the introduction of a medical error reporting system and parenteral artesunate for severe malaria
  • The role of social media and health looking at the effect of MDR-TB patients blogging about their experiences

Viewers can use the Twitter #MSFSci hashtag to participate during the event on Friday and follow @MSF_UK for more info. The video archive from last year’s event can be found here on Vimeo

Haiti, Fukushima, Chernobyl: What do we learn from disasters?

It is now two years since the Tohoku earthquake and subsequent triple meltdown at the nuclear plant in Fukushima.  Sarah Phillips, an anthropologist who has spent most of her professional life studying Chernobyl and the Ukraine, has a very thoughtful piece on how similar the two nuclear disasters turn out to be.  It’s a long article, so here’s the tl;dr:

Pripyat

“Fukushima is Chernobyl. Independent of the system (Japanese, Soviet), nuclear technology requires disregard for the public, misleading statements, and obfuscation in multiple domains (medicine, science and technology, governance). As anthropologist Hugh Gusterson notes, “The disaster at Fukushima has generated cracks in what we might call the ‘social containment vessels’ around nuclear energy—the heavily scientized discourses and assumptions that assure us nuclear reactors are safe neighbors.” Comparing the nuclear accidents at Chernobyl and Fukushima shows that “peaceful” nuclear technology is anything but.”

Fukushima

This week, in Maternowska’s Reproducing Inequities, we have also been reading about Haiti and the spectacular failures of development organizations to effect significant or lasting change for poor Haitian women.  It has now been more than three years since Haiti’s massive 2010 earthquake, and life for many Haitians is not better.  The cholera epidemic that began in the country in October 2010 continues to claim Haitian lives.  The same patterns Maternowska identifies for Haiti’s reproductive health and family planning policy have played out in the wake of Haiti’s natural and unnatural disasters: a lot of money spent very unwisely, and then a discourse that blames Haitians and “culture” for the lack of results.  We are left with the sense that Haiti, like other regions of extreme poverty, is hopelessly undevelopable, and so funding is limited to basic humanitarian interventions addressing immediate needs, rather than addressing the underlying structural factors that relegate Haiti to perpetual vulnerability to the next disaster.

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Paul Farmer and Catherine Maternowska both identify this sense of hopelessness for what it is: a disavowal, a racist cop-out, and a justification for continuing the same development strategies that fail to address the actual long-term needs of poor people, despite overwhelming evidence of their inadequacy.  The real tragedy that emerges from reading Maternowska, or following Farmer’s tremendous success in the country with his clinic and with Partners in Health, is the recognition that developing Haiti and alleviating poverty is not actually that difficult.

The last lepers, and the lack of African surgeons: two articles in The Atlantic

The Atlantic had two good articles out over the winter break that I’m just getting to now; I’m posting them here not because they’re extraordinarily well-written or insightful, but because they’re about topics that deserve greater attention.

The first considers leprosy and the difficulty of eradicating a disease.  In medical anthropology class, I had mentioned that in human history we have successfully eradicated only one disease (of humans) globally: smallpox.  Given our resources in global health in the 21st century, why is it so hard to accomplish the eradication of disease?

Leprosy is a good example of how hard this push can be.  It’s hard to study and the routes of transmission aren’t that well understood (not unlike its close relative, Buruli ulcer).  Worse, it develops very slowly, is easily misdiagnosed, and treatment efficacy is limited.  And social stigma, although its role can easily be exaggerated (something we’ll be thinking about in class), has also played a significant role in rendering the disease and its victims invisible.

The second article concerns a topic that badly needs more discussion: the astounding lack of qualified medical personnel to treat sub-Saharan African populations (the article references a study that finds 9 surgeons per 6,000,000 people in Sierra Leone; I would guess that this is only slightly lower than the West African average).  The results are predictably horrific: inadequate care, malpractice by the undertrained and/or under-equipped, and a system that has little power to retain the qualified.  It’s not a perfect article, but I’m glad that it does two things beyond simply raising the subject: it references Paul Farmer and Jim Kim’s paper on the need for surgeons in the developing world; and it mentions that half of US foreign aid in global health goes to getting ARVs for the HIV+, but a negligible amount goes to training qualified surgeons in poor countries.  Many doctors I work with themselves note this strange disparity between funding and the most pressing medical needs.

On ice cream, lead, and murder

On this blog in the past, we have looked at some intriguing ways in which social issues such as violence may be considered as epidemics.  We have also looked at some of the problems in public health with confusing correlation with causation; a classic statement of the fallacy is often given as follows: in summer ice cream sales go up, and murder rates go up.  Therefore, eating ice cream causes murder.

The example of ice cream and murder is absurd, but it points out just how difficult it can be to ascribe causation definitively in matters of public health.  Clearly, both ice cream sales and murder rates are independently affected by the same actual cause (heat waves), but one could easily imagine compelling data showing that ice cream sales go up just before each wave of violence.  And in fact, a fascinating new piece in Mother Jones has been getting a lot of attention in public health circles this week because it shows exactly that kind of compelling relationship between violence and a different factor: leaded gasoline.

Through a pretty careful analysis of past publication, the article makes an extraordinary claim: “Gasoline lead may explain as much as 90 percent of the rise and fall of violent crime over the past half century”.  But it has the data to back it up, and what’s really intriguing is that these correlations hold from the macro- all the way down to the neighborhood level.  In neighborhoods where lead is removed, crime rates drop a predictable number of years afterward.  If there really is a causal relationship between lead exposure and violent crime, we should be making the removal of lead from the environment a top priority- and maybe we should also be reconsidering the effectiveness of the police campaigns that are claiming the credit for the tremendous decline in violent crime America has been experiencing in recent decades.

But is this really ice cream and murder all over again? Scott Firestone has an excellent blog post about the MJ piece that does a nice job discussing why we might temper our enthusiasm about these findings somewhat (although he also finds the data very compelling), and it’s worth reading just to think more about how hard it can be to prove anything with certainty, even when the evidence is extraordinary (think of how successful tobacco lobbyists were for so long in creatively interpreting the data on the health effects of smoking).  There’s a brief and well-executed discussion this week in Scientific American about just how hard it can be to establish causation in health on another issue:  whether even very moderate amounts of drinking during pregnancy has any negative effects on babies.  This should be easy to establish, but it isn’t: in part because of ethical considerations (you can’t set up a control for potentially harmful behavior), in part because of the reliability of self-reports, and in part because of confounding variables like “lifestyle” associations (the same arguments tobacco lobbies make).

Infectious homicide in Newark

New research from Michigan State confirms that homicide and infectious disease have similar patterns of spread.  The team applied public health tracking software and methods to analyze data about homicides in Newark, NJ between 1982 and 2008.

Principal researcher April Zeoli, an assistant professor of criminal justice, points out that this methodology could be applied in real time to help law enforcement be more proactive about addressing new “outbreaks”.  She also indicated that some areas remained free of homicides despite being surrounded by hot spots.  From the MSU press release:

“If we could discover why some of those communities are resistant,” Zeoli said, “we could work on increasing the resistance of our communities that are more susceptible to homicide.”

Sounds like time to call in the anthropologists.

The HIV/AIDS epidemic in China

If I were asked to guess a country where AIDS is exploding, China wouldn’t come immediately to mind, but it should.  There was an 8.6% increase in the number of AIDS-related deaths in China last year; of those that were reported and/or acknowledged.  The percentage of cases might appear low in a country with an enormous population, but the number of affected people is high: over 68,000 new cases of HIV/AIDS reported in the past year.

CNN: Chinese students show their hands painted to look like red ribbons during a World AIDS Day event on November 30.

CNN: Chinese students show their hands painted to look like red ribbons during a World AIDS Day event on November 30.

CNN provides an overview of the current situation in China, touching on the years that the government denied there was a problem and their current policies, in the article The price of blood: China faces HIV/AIDS epidemic.

For more information on the current state of global HIV/AIDS, the 2012 report from UNAIDS is full of interesting data and impressive infographics.

“You don’t like to call your friends cannibals”

The Global Mail has a profile of Professor Michael Alpers, a medical professional who investigated kuru among the Fore for almost three decades.

Professor Michael Alpers, photo by Tony Ashby

There have only been eight deaths attributed to kuru in this century and it’s thought that those were the result of incubation periods near fifty years in length.  That extended incubation period is worrisome far beyond New Guinea, as kuru is closely related to the “mad cow” outbreak of the 1990s. So little is known about the disease that people who may have been exposed to Creutzfeldt-Jakob during that period cannot donate blood via the American Red Cross (that includes me, as I was on a US military base that may have used tainted beef).

What isn’t an epidemic?

Ben’s post on violence, and my response, have got me thinking about one of the (many) questions we raised in class but never really answered: does it always make sense to think of health concerns driven by behavior (rather than, say, microbes) as epidemics? We see this all the time in the media and in the academic literature: the obesity and tobacco epidemics, most famously.  And then there are a host of “epidemics” of behaviors that have been medicalized or psychopathologized to fit into the disease model, but I’m pretty sure it would have sounded absurd to refer to them as epidemics until fairly recently: sex addiction, for example.

What are the problems with using the label “epidemic”? Should the term be potentially applied to any set of behaviors that lead to adverse health consequences, or are there limits? We have discussed some examples where it seems more productive to think of behavior in terms of epidemics even when we may find that behavior abhorrent: needle exchange programs have been very successful in limiting the spread of AIDS and hepatitis, for example, even if some feel that they condone illegal behavior.  The term is also a useful way of undermining the medical tendency to blame the patient: as we know, behavior occurs within a socioeconomic context (cf. structural violence), pretty much every disease results from a complex interaction between behavior and pathogens, and many forms of behavior have a genetic component.  Maybe there are good reasons to use the blanket term “epidemic” to erase the distinction between passive (victim) and active (deviant or unsanitary citizen) when we talk about health.

But there are political consequences of the “epidemic” label as well: to use a current example, Bloomberg has been using the term to justify his attack on soft drinks in New York.  Whether we agree with the soft drink ban or not, it raises the question of how far government control of the behavior of its citizens should extend in the name of addressing a public health concern… and has some uncomfortable resonances with the state-of-exception, war-on-terror rhetoric used to justify the erosion of civil liberties post-9/11.  If violence is an epidemic, should we get rid of the Second Amendment in order to reduce the virulence of the disease?

Thoughts? Can you think of a recent “epidemic” that you don’t think merits the name? This one, maybe? Where and why do you draw the line?