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How Australia is faring on global indices

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park yourself here?

 

Many Australians were greatly relieved at the change of Federal government from May 21 2022. Australia hadn’t been faring well on the international stage, especially with respect to the global warming crisis, but also regarding political governance and other issues. Of course the Labor government has only been in office for three months, so I don’t expect judgements to have turned around significantly at this point. The purpose of this piece is to describe Australia’s position on a number of international surveys, and then to return to those surveys in about twelve months’ time to see if and how the view of Australia internationally has changed.

I was motivated to write this by a passage in David Brophy’s book China Panic, in which he mentioned two such international surveys, the CIVICUS monitor, which apparently measures democratic credentials, and Transparency International’s Corruption Perception Index. I’d never heard of these surveys, which is hardly surprising for a dilettantish autodidact. Three surveys I have monitored are the Economist Intelligence Unit’s Democracy Index, the OECD’s Better Life Index and the UN’s Human Development Index. So now we have five, and counting. What follows is my attempt to summarise their most current findings.

The CIVICUS monitor. CIVICUS is, as far as I can tell, not an acronym. Based in Johannesburg, the organisation describes itself as:

a global alliance of civil society organisations and activists dedicated to strengthening citizen action and civil society throughout the world…. Our definition of civil society is broad and covers non-governmental organisations, activists, civil society coalitions and networks, protest and social movements, voluntary bodies, campaigning organisations, charities, faith-based groups, trade unions and philanthropic foundations. Our membership is diverse, spanning a wide range of issues, sizes and organisation types.

According to Brophy, the CIVICUS monitor downgraded Australia’a democratic status (in the broad sense described above) from ‘open’ to ‘narrowed’ in 2019. The latest findings, from 2021, are unchanged. To explain, the monitor divides the world’s nations into 5 levels, which, top to bottom, are open, narrowed, obstructed, repressed and closed. On further inspection, I’ve found that there’s a ‘live rating’, last updated for Australia on 25/5/22, a few days after the election. Hopefully things will have improved by 2023. To compare a few other countries – New Zealand, Canada, Ireland, Uruguay, Suriname, Taiwan, Portugal and most Northern European countries are classed as ‘open’. Other ‘narrowed’ countries include Namibia, Italy, France, the UK, Japan  and Bulgaria. Obstructed countries include the USA, Brazil, South Africa, Ukraine, Poland, Indonesia and Morocco. A colour-coded map provides an at-a-glance reference to any country of interest. The repressed and closed countries can generally be guessed at. China, Vietnam and most Middle Eastern counties are classed as ‘closed’.

The Corruption Perceptions Index (CPI). The CPI is a product of Transparency International, which advertises itself thus:

Transparency International is a global movement working in over 100 countries to end the injustice of corruption. We focus on issues with the greatest impact on people’s lives and hold the powerful to account for the common good. Through our advocacy, campaigning and research, we work to expose the systems and networks that enable corruption to thrive, demanding greater transparency and integrity in all areas of public life.

First set up in 1993 by an ex-World Bank official, Peter Eigen and like-minded associates, first-hand witnesses of global corruption, the organisation was established in then recently re-unified Berlin.

An article in The Conversation, posted in late January 2022, points out that in 2012 Australia ranked level with Norway in 7th position as to ‘cleanness’. The 2021 index, to which The Conversation refers, sees Australia as having slipped to 18th while Norway has risen to 4th, out of 180 countries. Much of what Brophy writes in China Panic is an account of why the country I happen to have ended up in has fallen so far so fast. The Economist Intelligence Unit, which publishes the Democracy Index, is one of the sources for this index, along with Freedom House and the World Justice Project. The three equal top countries on this index are New Zealand, Denmark and Finland, and the bottom three are Somalia, Syria and South Sudan. Anyway, re Australia, this one will be worth watching over the next few years.

The Democracy Index. I’ve written about the Democracy Index, inter alia, in a previous piece. It’s produced by the Economist Intelligence Unit, associated with The Economist magazine in the UK. Here’s their raison d’être blurb:

The EIU Democracy Index provides a snapshot of the state of world democracy for 165 independent states and two territories. The Democracy Index is based on five categories: electoral process and pluralism, civil liberties, the functioning of government, political participation, and political culture. Based on their scores on 60 indicators within these categories, each country is then itself classified as one of four types of regime: full democracy, flawed democracy, hybrid regime or authoritarian regime

Australia ranks a fairly creditable 9th on the Democracy Index list for 2021, well below NewZealand (2nd) but also well above the country we’ve been showing so much allegiance to in recent decades, the USA, which ranks 26th and is considered a flawed democracy. According to the index’s ratings, the world is inching towards hell in a hand basket – 70% of the world’s nations have become less democratic in the last twelve months, and this downward trend has prevailed for some years. Australia, though, has been faring worse than most. I don’t have access to the previous rankings, but each nation is given an annual score out of ten. Australia’s 2021 score is 8.90, compared to 8.96 in 2020. The score has regularly dropped from a high of 9.22 in the years 2010-2012, the period of the Rudd-Gillard Labor Prime Ministerships.

The OECD Better Life Index. This measures the ‘life experience’ of an ‘elite’ group of about 40 of the world’s wealthiest countries, members of the Organisation for Economic Cooperation and Development, according to eleven different criteria, including education, environment, safety and health. When I first accessed the index, about 6 or 7 years ago, Australia was ranked number 2 across all criteria, behind the ever-triumphant Norway, and well ahead of the US in around 12th spot. Currently Australia is ranked 7th, and the USA 8th. Norway still ranks first.

On looking into Australia’s ranking for each criterion (the 11 criteria are housing, income, jobs, community, education, environment, civic engagement, health, life satisfaction, safety and work-life balance) I can’t help but scratch my head at some of the results. Australia ranks 1st for ‘civic engagement’, but 20th for ‘community’ (!!??). I would have thought that one entails the other. Also, Australia ranks 2nd for housing (but city rental has become unaffordable for most young people), and 2nd for education, which again surprises me from a general persecutive, though our post-grad sector definitely punches above its weight. At the other end of the spectrum, Australia ranks 30th for safety, another surprise. The OECD claims that the average homicide rate for member countries is 2.6 per 100,000 inhabitants. According to the Australian Institute of Criminology, Australia’s homicide rate for 2019-20 was 1.02 per 100,000, the highest in nearly ten years, but clearly well below the OECD average. Of course, homicide is only one measure, but I’ve not heard of Australia having a high crime rate in general. Strange. But the worst ranking is 33rd for work-life balance!? But having rarely worked a day in my life, I couldn’t possibly comment.

The UN Human Development Index (HDI). Here’s the blurb about this one:

The Human Development Index, or HDI, is a metric compiled by the United Nations and used to quantify a country’s “average achievement in three basic dimensions of human development: a long and healthy life, knowledge and a decent standard of living.” Human Development Index value is determined by combining a country’s scores in a vast and wide-ranging assortment of indicators including life expectancy, literacy rate, rural populations’ access to electricity, GDP per capita, exports and imports, homicide rate, multidimensional poverty index, income inequality, internet availability, and many more.

The HDI website only provides information from 2019 and places Australia in a tie with The Netherlands at 8th in the world, with a score of .944 on a scale from 0 to 1. Norway again gets top spot, just ahead of Ireland and Switzerland. Interestingly, Australia ranks higher than four countries it likes to compare itself with, the UK, New Zealand, Canada and the USA, but little explanation is given for the ranking, which appears to be have been stable for a few years.

So, to summarise, I don’t know what to make of all these indices, which I suspect subtly influence each other in their ratings. We appear to always make the top ten, but rarely the top 5. If we could take advantage of our climate and resources to be be a greater power in renewables, instead of lagging (except in domestic rooftop solar) as we have done over the last decade, we could really make the world pay more attention to us, for better or worse.

References

David Brophy, China Panic: Australia’s alternative to paranoia and pandering, 2021

https://monitor.civicus.org

Global Ranking

https://en.wikipedia.org/wiki/Democracy_Index

https://www.oecdbetterlifeindex.org/#/11111111111

https://worldpopulationreview.com/country-rankings/hdi-by-country

Written by stewart henderson

August 24, 2022 at 4:04 pm

a post to send you to sleep, or not

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Häggström, Mikael (2014). “Medical gallery of Mikael Häggström

 

Canto: Anything interesting you’ve learned lately?

Jacinta: Well, there’s so much, it’s hard to keep track of it all, before it slides down the slippery slope into a past of fragmented memories.

Canto: A pasta of memories? That’s food for thought. I know you’ve been reading up on sleep, among all your other heavy reading. Tell me.

Jacinta: Yes, I’ve been reading up on feminism and misogyny as you know, which is mostly depressing, but this sciencey but very accessible book, Why we sleep by Matthew Walker, is not so much depressing as worrisome, for those of us whose sleep patterns are all over the place, like mine. He’s a big-time sleep researcher, and what he says about sleep deprivation is all bad – even for a wee bit of it.

Canto: So, those dreams of doing away with sleep, of zapping your brain for a few seconds to provide the instant reinvigoration that sleep takes eight hours of wasteful oblivion to achieve, allowing us that much more time to ruin the biosphere and all, or just to read more books and shit, those dreams are just a waste of sleep?

Jacinta: No zapping will ever replace the complexity of sleep, with all its REMness and non-REMness, let Mr Walker assure you. Sleep is a restorative and builder, which has complexly evolved with the complex evolution of our brains and bodies. And by ‘our’ I don’t just mean humans, but every complex or not-so complex evolved organism. They all sleep.

Canto: Well, there are many questions here. You’ve mentioned REM sleep, which I think has something to do with dreaming – your eyes, presumably under their lids, are rapidly moving about. Why? It doesn’t sound healthy.

Jacinta: They’re responding to brain signals, and it’s perfectly normal. More specifically, they seem to be responding to the brain’s changing visual representations while dreaming. They used electrodes in the brain to discover this – which sounds Frankensteinish but in this case they were patients with epilepsy preparing to have very invasive treatment to stop their seizures. They looked at activity in the medial temporal lobe, a region deep in the brain which includes the hippocampus and amygdala, and is involved in encoding and consolidating memories, and found fairly clear-cut connections between that activity and patients’ eye movements.

Canto: But how could they ‘see’ the eye movements?

Jacinta: Oh god, I don’t know, for now I’m more interested in sleep deprivation, which raises concerns for everything from diabetes to Alzheimer’s. And, although I haven’t measured anything carefully, my guess is that I average 6 to 7 hours’ sleep a night, and I need to amp that up.

Canto: And you’ve recently been diagnosed as pre-diabetic, so do you think more sleep can help with that? It’s usually pretty strongly correlated with diet isn’t it?

Jacinta: Less time sleeping, more time for eating, Walker writes. I’m certainly trying to lose weight, but only by eating less. I think my diet’s not too bad, less wine though. And I suppose if I slept more, which is easier said than done, I wouldn’t eat so much. I’ve found in the past that just reducing the quantity of food I ingest, without changing its make-up – in other words, being more disciplined – can take the weight off quite quickly. The key is to make it life-long.

Canto: More fibre is good, I think. For the microbiome.

Jacinta: So type 2 diabetes is generally about blood sugar levels and their regulation, or lack thereof. In a healthy person, eating a meal adds glucose to the blood, which triggers the hormone insulin, produced in the pancreas, to somehow bring about cellular absorption of the glucose as an energy source. In the case of diabetes, there’s usually a break-down in the cellular response to the insulin signal, I think, and so you become hyperglycaemic – not that this has ever happened to me, so far.

Canto: So how does this relate to lack of sleep, apart from giving you more time to guzzle sugar?

Jacinta: Walker describes a series of studies, independent from each other, in different continents, which found high rates of type 2 diabetes in people who reported sleeping for less than six hours a night on a regular basis. They controlled for other factors such as obesity, alcohol use, smoking etcetera. But of course correlation isn’t causation so they investigated further. They conducted experiments with a bunch of healthy people – no blood glucose problems or signs of diabetes. Firstly, they mildly tortured them – they permitted them only four hours of sleep per night over six straight nights. Then they tested their ability to absorb glucose, and found a 40% reduction in that ability. This would immediately classify them as pre-diabetic, and these studies, I’m assured, have been replicated numerous times.

Canto: That sounds incredible. And these guinea pigs quickly recovered? Or are they now full-blown diabetics? Doesn’t sound like mild torture to me. And do they know why a week’s sleep deprivation had such a dramatic effect?

Jacinta: Ha, well, Walker doesn’t mention the afterlife of the experimental subjects, but I’m assuming normality came bounding back after they recovered their sleep. As to the mechanism of action, Walker describes two options – sleep loss may have blocked the release of insulin by the pancreas, providing no signal for cell absorption to take place, or it may have interfered with the released insulin’s message to the cells. And though it seems that sleep loss probably had an effect on both, it was clear from biopsies taken from subjects that it was the latter, the cells’ lack of response to insulin, their ‘refusal’ to take up the blood glucose, that was the principal problem.

Canto: Just looking at the Sleep Foundation website, and they seem to get things the other way round, that diabetics are suffering from sleep loss. I must say, that, off the top of my head, I’d find being pre-diabetic easier to manage than my sleep behaviour. I mean, I can imagine changing my diet and exercise habits easily enough, but my sleep habits not so much. How do you turn off your brain?

Jacinta: Well, Mr Walker has some suggestions on that, which we’ll explore next time. And by the way, there seems to be tons of videos and websites providing knowledge and advice on the issue, which always makes me feel superfluous to requirements as a human being…

Canto: Well, try not to lose sleep over it.

References

Why we sleep, by Matthew Walker, 2017

https://www.sciencealert.com/scientists-have-worked-out-why-your-eyes-move-when-you-re-dreaming

https://en.wikipedia.org/wiki/Sleep_deprivation

https://www.sleepfoundation.org/physical-health/lack-of-sleep-and-diabetes

 

Written by stewart henderson

November 7, 2021 at 3:56 pm

covid19 – the European CDC shows the way

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poverty and crowding in Peru – BBC picture

Canto: The US response to the pandemic continues to be massively hampered by political muzzling of and interference with the science, especially at the federal level, but the Medcram updates continue to inform us, and to be, or pretend to be, indifferent to this political interference.

Jacinta: Yes, and update 109 has introduced us to the European CDC’s website, which provides us with a wealth of information, on the progress of the pandemic itself in European countries, but also in the political response to it, and how those two things interact. 

Canto: The country overview page, and it’s currently updated to week 39 of the pandemic, is as data-rich as anyone can imagine, a statistician’s wet dream, but interpretation of the data needs to be handled carefully. 

Jacinta: Dr Seheult does some interpretation of some of the data in his medcram update 109, but there’s so much more in there, and so much more to say. So let’s take a European country at random – Denmark – and look closely at the stats.  

Canto: But before that, let’s look at some general European trends they report. It’s fascinating:

  • By the end of week 39 (27 September 2020), the 14-day case notification rate for the EU/EEA and the UK, based on data collected by ECDC from official national sources, was 113.6 (country range: 9.9–319.9) per 100 000 population. The rate has been increasing for 70 days.

So the EU is the European Union and the EEA is the European Economic Area. I’m not sure what is meant by ’14-day’ but I presume the case notification rate is simply the case rate, as far as they can ascertain from the data supplied to them – the cases they’ve been notified about. It’s good that they make that distinction, shifting the onus on the notifiers. So it’s 113.6 cases per 100,000 population over the whole region, and has been rising for over two months – a second wave. 

Jacinta: I think ’14 day’ just means the rate over the previous 14 days. They report every seven days for the previous 14 days, so there’s a 7-day overlap. That data is not only dependent on the reliability of particular reporting countries, it’s also dependent on testing levels, obviously. So in the general trends they tell us which countries are doing the most testing. Highest is Denmark, followed by Luxembourg, Iceland, Malta and Cyprus. Small countries, unsurprisingly. 

Canto: With all this, it’s interesting from Dr Seheult’s analysis of the data that the death rate isn’t mapping with  the case rate, thankfully, and that the age of people contracting the virus in the second wave is much lower, which seems weird.

Jacinta: Probably explained by an increase in testing since the early days. Now they’re catching milder and asymptomatic cases. It suggests, of course, that the case rate was much higher during the first wave, when the testing regime was still being put together. So let’s look at Denmark, and now we have data for week 40. There are four graphs, and in the first we see the case notification rate experiencing a big bump peaking in April with the death notification rate mapping pretty closely with that bump. Then there’s a gradual falling away in both figures, until August when the case rate starts to rise again, but not the death rate. Then in September that case rate rises very sharply, rising well above the April bump, though in the last week it seems to have leveled off at this high level. But the death rate has stayed pretty well level and quite low. Now that raises questions that the other graphs might help to answer. The second graph looks at the testing rate – tests per 100,000. The testing rate was pretty flat and low from February into April, but after the April rise in cases the testing began to rise from late April into May. It flattened and even dipped a bit into June. It stayed fairly steady through the northern winter, but of course at a high level compared to the earliest period, then it started to rise in August, presumably in anticipation of a rise in cases as the colder weather arrived. That rise in testing peaked at a very high level in late September, but has dropped quite sharply in the the last week or so. 

Canto: Interesting, so that does strongly suggest a sharp rise in mild cases being ‘caught’, and presumably dealt with, as the death rate hasn’t spiked at all. 

Jacinta: Yes, though we don’t know how well those cases have been dealt with – people are talking about ‘long covid’, people possibly having long-term issues. The two graphs don’t really give us granular detail – hospitalisation rates for example. So the third graph breaks the notified case numbers into age groups, and the results are fascinating. The first wave bump shows that most of the cases recorded were in the older age groups, particular those at 80 or over. There were cases in all age groups, but very few under 15. However, in the second wave, the cases found were predominantly in the young. In fact the 15-24 age group was way out in front, followed by the 25-49 group. Even the under 15s were well above the oldest age groups. So what does this mean? It seems to suggest that the older, and perhaps wiser, are recognising the dangers, especially to their age group, and taking fewer risks, and that the younger are still not very sick but can be carriers of the virus and more than ever a danger to the older generation. 

Canto: I wonder is Denmark ‘typical’ in this regard?

Jacinta: There are variations of course, but the general trend is much the same. The fourth graph shows test positivity – the percentage of people who tested positive. There was a massive spike in positive test results in March, up to around 16 -17%, but this dropped as sharply at it rose, due presumably to the rapid rise in testing from that period. By May it was around 1% and it has remained much the same since, as the number of tests administered has never been higher, in spite of the recent drop I mentioned. It’s still much higher than it was pre-September. 

Canto: But there are more than four graphs as we’ve found. We’ve looked at the data for notification rates and testing, there are other graphs which look at ICU and hospitalisation rates, public health response measures, and which break the nation down into specific regions. 

Jacinta: Yes, it’s particularly important to look at public health measures – restrictions on mass gatherings, closures or partial closures of public spaces, workplaces and schools, the mandating or recommendations around face masks, and map them against notification rates, hospitalisations and so forth. The picture that emerges is generally pretty clear, though sadly some countries, such as the USA and Brazil, aren’t paying heed to the fact that public health measures save lives as well as a lot of suffering. 

Canto: Well we should be talking about the governments rather than the countries, when we’re talking about public health measures. So I’ve assumed that the CDC in the USA has been hobbled by the Trump debacle, so I’ve gone to the Johns Hopkins site to see what detailed info they provide. Indeed they do have a lot of useful data both for the USA and other countries, though little on the effect of public health measures. An interesting graph they present on mortality shows that, in terms of deaths per 100,000 persons – and they show only the top 20 nations – Peru is on top, followed by Brazil, Ecuador, Spain, Mexico, the USA and the UK, in that order. 

Jacinta: Well we know about the macho governments of Brazil, the UK and the USA – not that government is always entirely to blame, but it’s a key indicator – so what about the national governments of those other countries? 

Canto: Well other key indicators would be the country’s wealth, or lack thereof, and its healthcare infrastructure, but as to government, Peru had a federal election in January this year – it’s a multi-multi-multi-party system with the most popular party getting only 10% of the vote. The result was that Martin Vizcarra retained the presidency. He appears to be a genuine reformist who has tried to implement stay-at-home orders, but widespread poverty and overcrowding are major problems there. Brazil we already know about. Ecuador’s current President is Lenin Moreno, a right-wing figure who has slashed government funding and seems obsessed with destroying political opponents. He has a popularity rating of 8%, according to an article in Open Democracy, and his mishandling of the pandemic has been extreme. Spain is a ‘parliamentary monarchy’, and its current Prime Minister is Pedro Sanchez, leader of a leftist coalition. Currently there’s a battle with right-wing local authorities, especially in Madrid, to enforce lockdowns as a second wave hits the country. So it’s the usual problem there of non-compliance, it seems. And Mexico is, as is I think well known, a country with a lot of poverty and a lot of problems. Its governmental system has long been a minefield – in fact I’d love to learn more about its chequered history. Currently the President is Andrés Manuel López Obrador, a veteran politician who has been a member of various parties and is essentially a political centrist. So again it’s about lack of political control, poverty, lack of services, overcrowding and so forth. As to the UK, years of conservative government have gutted the NIH, there has been a ton of mixed messaging from the top… I’m getting sick of all this. I want to go to Taiwan.

Jacinta: Hmm. How’s your Chinese? Things are pretty covid-safe here in South Australia. Here’s hoping a safe and effective vaccine is ready by next year, and some big improvements are made in certain countries, with a return to justice and human decency…

References

Coronavirus Pandemic Update 109: New Data From Europe As COVID 19 Infections Rise

https://www.ecdc.europa.eu/en/covid-19/country-overviews

https://coronavirus.jhu.edu/us-map

https://www.bbc.com/news/world-latin-america-53150808

https://www.opendemocracy.net/en/democraciaabierta/political-tirals-electoral-bans-battle-ecuador-democracy/

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31955-3/fulltext

https://www.bbc.com/news/world-europe-54478320

Written by stewart henderson

October 11, 2020 at 1:50 pm

reading matters 11 – encephalitis lethargica. Will it return?

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Asleep, by Molly C Crosby, 2010

Canto: This was one of the saddest books I’ve read in a long time. It’s about a disease that arose, and was recognised, at around the time of the ‘Spanish flu’ of 1918, though it was more sporadic and long-lasting, and rather more mysterious. It’s also a kind of cautionary tale for those among us who downplay the impact of diseases and their effects, which are so often long-term and horrifically devastating. It’s humbling to realise that we just don’t know all the answers to the pathogens that strike us down. 

Jacinta: And could revisit us, in mutated and perhaps even more deadly form, some time in the future. This book is about encephalitis lethargica, a disease that was personal to the author, as it infected her grandmother, whose entire life, though she lived to a goodly age, was clearly stunted by it. She was struck down at the age of 16, and slept for 180 days, and though she lived almost 70 years afterwards, she was robbed by this brain-blasting illness of the life of the mind, the rising above ourselves and grasping of the world that we’re attempting in this blog. Through sheer bad luck. 

Canto: And as Crosby points out, her grandmother was far from being the worst-affected victim of this disease. People died of course, but others were disastrously transformed.

 Jacinta: So let’s go to a modern website, a department of the USA’s NIH, the National Institute of Neurological Disorders and Stroke, for a definition:

Encephalitis lethargica is a disease characterized by high fever, headache, double vision, delayed physical and mental response, and lethargy. In acute cases, patients may enter coma. Patients may also experience abnormal eye movements, upper body weakness, muscular pains, tremors, neck rigidity, and behavioral changes including psychosis. The cause of encephalitis lethargica is unknown. Between 1917 to 1928, an epidemic of encephalitis lethargica spread throughout the world, but no recurrence of the epidemic has since been reported. Postencephalitic Parkinson’s disease may develop after a bout of encephalitis-sometimes as long as a year after the illness.

Canto: Yes, and having read Crosby’s book and knowing about the worst symptoms and a few heart-rending cases, the sentence that most strikes me here is, ‘The cause.. is unknown’. Apparently Oliver Sacks’ book Awakenings, which we haven’t read, is all about patients who have ‘awakened’, permanently damaged, from this bizarre disease, and that’s a book we now must read, though of course it will provide us with no solutions.   

Jacinta: And no arms against its future devastation, should it return – and why wouldn’t it? Crosby and others have suggested that ‘fairy stories’ like Sleeping Beauty and Rip van Winkle may have been inspired by outbreaks of the disease. Of course this is conjecture, and only if the disease returns will we be able to attack it with the technology we’ve developed in the intervening century. As the neurologist Robert Sapolsky points out in his mammoth book Behave, (so mammoth that I can’t find the quote), the number of papers published on the brain, its activity and functions, in the 21st century, has grown exponentially. We might just be ready to counteract the long term horrors of encephalitis lethargica next time round, if it comes around. 

Canto: Crosby’s book is organised into case histories, featuring people who fell into this bizarre torpid state for long periods, and when aroused, often behaved in anti-social and self-destructive ways that in no way resembled depression, between bouts of a ‘normality’ that was never quite normal. And one of the saddest features of these case histories, richly described in the notes of famous figures in early neuropsychology, such as Constantin von Economo, Smith Ely Jellife and Frederick Tilney, is that the victims disappeared into the void  once it became clear that no known treatment could save them.

Jacinta: Yes, some may have died soon afterward, others may have lived on in a limbo, locked-in state for decades. In fact the symptoms of this disease were bewilderingly varied -various tics, hiccupping, catatonia, salivation, schizoid episodes… Encephalitis literally means swelling of the brain, and it doesn’t take a medical degree to realise this could cause a variety of effects depending on which area of the most complex organism known to humanity is most affected. 

Canto: Encephalitis is usually caused by viruses, and of course viruses hadn’t been fully conceptualised when von Economo wrote his 1917 paper on what was to become known as encephalitis lethargica, as the role of DNA and RNA was unknown. However, von Economo was the first to recognise the vital role of a tiny, almond-shaped section near the base of the brain, the hypothalamus, in the distorted sleep patterns of these patients. He also wondered if there was a connection between the so-called Spanish flu and this sleeping sickness.

Jacinta: Yes, and this brings to mind the current nightmare pandemic. People, including of course epidemiologists, are wondering about the long-term effects of this virus, especially in those who seem to have recovered from a serious infection. Crosby writes of the situation a hundred years ago:

The war had provided the first opportunity encephalitis lethargica had to crawl across the world with little notice from the medical community. And by 1918, the pandemic flu had given it the second opportunity, stealing worldwide attention, infecting and killing millions. Epidemic encephalitis moved with the flu, almost like a parasite to a host, often attacking many of the same victims, receiving very little notice at all. 

Of course there has been no sign of a return of encephalitis lethargica – as yet – from a medical community that is somewhat forewarned, but it’s clear that inflammation can have very diverse effects, especially when it involves the brain. 

Canto:  But it’s like an undefeated enemy that has gone into hiding. We’ve defeated smallpox; tuberculosis and polio are in heavy retreat; leprosy seems as remote to us as the Bible, but this sleeping sickness, some of the victims of which have died within our lifetimes, has tantalised us with its bizarre and devastating effects, but has never really given us a chance to fight it.

Jacinta: Yes fighting is what it’s all about. The anti-vaxxers and the natural health crowd seem to want to leave everything to our immune system, to let diseases take their course, killing and maiming a substantial percentage of the herd to let the remainder grow stronger. If they were to read some of these case studies, to witness the lives of young Rosie, Adam and Ruth, they would surely think differently, if they had a modicum of humanity. 

Written by stewart henderson

September 18, 2020 at 11:01 pm

covid19: corticosteroids, male susceptibility, evaluating health, remdesivir, coagulation factors

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from The Lancet, ‘the four horsemen of a viral apocalpse’

 

Canto: So short-course use of some steroids was being advocated in the medcram update 88, though without thorough RCT evidence. 

Jacinta: Well, data was presented from the Oxford RCT on those on oxygen or on ventilators showing a statistically significant reduction of mortality from short-course (up to 10 days) low dosage of dexamethasone, a freely-available steroid medication. The study involved some 2000 patients, but only those severely afflicted were helped by the medication. 

Canto: An interesting aside to the data is that in the study males outnumbered females by almost 2 to 1, and that accords with the overall ratio of male to female covid19 patients Dr Seheult is finding, which rather shocked me. Why would more males be coming down with the disease? Presumably that’s not the infection rate, but the rate at which they need to be hospitalised. 

Jacinta: Yes, you’re right, according to this Australian site (unfortunately undated):

Reports continue to emerge that men are significantly more vulnerable to COVID-19 than women. The commonly held perception that more men smoke and this makes them more susceptible along with other lifestyle factors does not tell the whole picture. White House COVID-19 Task Force director Dr Deborah Birx highlighted a “concerning trend” that men in all age brackets were becoming seriously ill from the virus at a higher rate than women, including younger males.

They’re suggesting more research needs to be done on this gender difference, for health issues in general. Some are claiming that estrogen makes a difference. In any case I think cardiovascular problems are more common in males – but maybe not so much in younger males. 

Canto: So update 89 is fairly short, and deals with US data about cases and deaths, most of it out of date now, and more on corticosteroids and the dangers of unsupervised use. Update 90 introduces us to a tool I’ve never heard of called ‘Discern’. Very useful for we autodidacts in helping us, for example, to enlighten our doctors as to our condition. Discern is a tool for evaluating internet health info, such as medcram’s updates on youtube, or anything else on youtube. The instrument asks you to evaluate the material according to 16 different criteria. Interestingly, this tool has been tested on covid19 material by a study out of Poland done in March. The results weren’t so good, especially for news channels. 

Jacinta: Yes, physicians’ information did best – but of course we don’t go to news channels for health information, and we’d advise against anyone else doing so. The study evaluated the Discern tool itself and found it excellent, then used the tool to evaluate health information, specifically on youtube. Of course know that there’s ‘viral misinformation’ from various news outlets that gets posted on youtube. And good to see that the medcram updates were some of the most highly rated using the Discern tool. 

Canto: So we’re now into reporting from early July with update 91. It starts by looking at a ‘covid risk calculator’ in which you can type in your age, gender, BMI, underlying conditions, waist circumference, and other data which you might need a full medical checkup to find out about (and that’s overdue for me), including, for example, %FMD, a measure I’ve never heard of, but which has to do with endothelial function. 

Jacinta: FMD stands for fibromuscular dysplasia. The Johns Hopkins medicine site describes it as a rare blood vessel disease in which the cells of some arteries become more stiff and fibrous and less flexible. This leads to weakness and damage. Not sure how it relates to covid19 but surely any pre-existing blood vessel damage is a danger for those contracting the virus. 

Canto: Right, so it’s unlikely anyone will know offhand their percentage of FMD. I don’t even know my HDL and LDL levels, never mind my HbA1c or lipids. I’d love to be able to take measures of all these myself, without visiting a doctor.

Jacinta: Typical male control freak. So all of this is to measure your risk of covid19 hospitalisation, ICU admission or mortality. Fun times. So next the update looks at Gilead, the makers of the antiviral remdesivir, who donated all their supplies of the drug to the USA in early May. But of course they kept manufacturing the drug and have to recoup the money they spent researching, developing and trialling it etc. The Wall Street Journal reports that a typical course of the drug will cost over $3000 per patient. Interestingly the Trump administration is wanting the drug to stay in the USA as much as possible, rather than be available overseas, and is spending money to that effect. 

Canto: Hmm. Is that protectionism? 

Jacinta: Yes I suppose. It’s not surprising that a country wants to look after its own first, especially via a product produced within its own borders. But I suspect this government would’t be interested in helping any other country – unless there was a quid pro quo. And there’s another antiviral, favipiravir, currently being trialled in Japan and the USA (I mean as of early July), and a vaccine, developed in China, is being used on the Chinese military in what seems a rather rushed and somewhat secretive fashion – we don’t know if they got the soldiers’ permission on this seemingly untried vaccine. At least at the phase 3 level.

Canto: Very CCP. 

Jacinta: So onto update 92, and we revisit the electron transport chain, with four successive electron transfers converting molecular oxygen into water. Problems within this chain can produce reactive oxygen species (ROS) such as superoxide, hydrogen peroxide and hydroxy radicals, which are destructive in excess. We also look, yet again, at covid19’s impact on angiotensin and particularly the production of superoxide, which in turn causes endothelial dysfunction, increased von Willebrand factor activity, which leads to thrombosis. People were presenting as ‘happy hypoxics’, looking and feeling fine but with very low oxygen levels, and autopsies revealed ‘microthrombi in the interalveolar septa’ of victims’ lungs. All this leading to a paper published in The Lancet which looked at factors in this process of coagulation and thrombosis:

We assessed markers of endothelial cell and platelet activation, including VWF antigen, soluble thrombomodulin [a marker of endothelial cell activation], soluble P-selectin [a marker of endothelial cell and platelet activation], and soluble CD40 ligand [a marker of platelet and T-cell activation], as well as coagulation factors, endogenous anticoagulants, and fibrinolytic enzymes.

So this was about getting to the bottom of the increased clotting. And the results were hardly surprising, but the final discussion section is worth quoting at length, as it seems to capture much that we know about covid19’s effects (at least short-term effects) at the moment: 

We therefore propose that COVID-19-associated coagulopathy is an endotheliopathy that results in augmented VWF release, platelet activation, and hypercoagulability, leading to the clinical prothrombotic manifestations of COVID-19-associated coagulopathy, which can include venous, arterial, and microvascular thrombosis. The factors responsible for this endotheliopathy and platelet activation are uncertain but could include direct viral infection of endothelial cells, collateral damage to the tissue as a result of immune infiltration and activation, complement activation, or any number of inflammatory cytokines believed to play a role in COVID-19 disease.

They suggest anti-platelet therapy and endothelial cell modification treatments as well as anticoagulation treatments, and they suggest some agents ‘which might have therapeutic potential’.

Canto: Potential? You’d think they’d be onto all this by now. 

Jacinta: Well there’s also potential for untried medications – at least untried in this context – to go terribly wrong. And it’s also likely that some hospitals are already onto using the safer forms of treatment. Dr Seheult speaks of the antioxidant N-acetylcysteine (NAC) in this context, as it has been shown to be a thrombolytic when used intravenously. There are studies pending on the effects of NAC in treating covid19 patients. 

Canto: Now, I’ve just been watching something on monoclonal antibodies as perhaps the most promising treatment yet, short of a vaccine. Can you explain….

Jacinta: Yes I’ll try, maybe next time.

References

Coronavirus Pandemic Update 88: Dexamethasone History & Mortality Benefit Data Released From UK

Coronavirus Pandemic Update 89: COVID 19 Infections Rising in Many States; Dexamethasone Cautions

Coronavirus Pandemic Update 90: Assess The Quality of COVID-19 Info With A Validated Research Tool

Coronavirus Pandemic Update 91: Remdesivir Pricing & Disparities in Drug Availability

Coronavirus Pandemic Update 92: Blood Clots & COVID-19 – New Research & Potential Role of NAC

amhf.org.au/covid_19

http://www.discern.org.uk

https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(20)30216-7/fulltext

 

Covid 19: hopes, failures, solutions

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under pressure

Covid-19 continues to be devastating, especially in the USA, where there are vastly more cases than anywhere else, and vastly more deaths, though the picture there is complex. The hardest-hit region, the New York area, is seeing devastation in poorer districts such as Queens, where the Elmhurst public hospital is inundated with uninsured, critically ill patients. New York has suffered almost half of US deaths. Some other states and regions, especially physical outliers such as Alaska, Hawaii and the Virgin Islands, have very low numbers, and it would be hard to explain why the spread of cases across the mainland has been so uneven. Of course it’s obvious that there has been no federal leadership on the pandemic.

Here in Australia, where the numbers seem to be improving (we’re 33rd on the list of total cases, down from 18th when I first started paying attention to the list about three weeks ago, and 52nd on the list of total deaths), our conservative federal government is keen to open up the country again, and has released modelling to the effect that the virus will be eliminated from the mainland if we maintain current physical distancing measures, though it’s likely to take weeks rather than months:

The model suggests that every 10 people infected currently spread the virus to five more people, on average. At that level, the virus would eventually be unable to circulate and would die out within Australia.

Sydney Morning Herald, ‘Australia in course to eliminate Covid-19, modelling shows’

Australia’s current reproduction number (R0) is just a little over .5. A maintained R0 of 1 or less will eventually eliminate the virus. Of course, there will be fluctuations in that number, so it will be difficult to project a time when things are ‘all clear’. Another difficulty with modelling is that the number of infected but asymptomatic people is unknown and difficult to estimate. For example, recent Covid-19 testing of the entire crew of the aircraft carrier Theodore Roosevelt found that a substantial majority of those who tested positive were asymptomatic, casting doubt on previous estimates (already worrying for transmission) of one in four cases being asymptomatic.

The asymptomatic/presymptomatic transmission issue was addressed by Bill Gates in this article back in February. It’s what makes SARS-CoV-2 a much more serious threat than the previous SARS and MERS viruses. Gates, in this very important article, also provides an outline of what needs to be done globally to fight this pandemic and to prepare for inevitable future ones. If only…

It’s worth comparing Gates’ call for national and global co-ordination, and more expenditure, in the fields of epidemiology and disease prevention, with another more recent article, also published in the New England Journal of Medicine, which tells a tale of Britain and its NHS, gutted by years, in fact decades of ‘reforms’ and budget cuts:

Thanks to government “reforms” of the NHS, it has become highly decentralized, with over 200 commissioning groups in England that can make independent decisions about staffing and procurement of equipment — far from the monolithic “socialist” health care system it is often assumed to be. The devolved governments in Wales, Scotland, and Northern Ireland have substantial health system autonomy. At a time when central management of staff and resources might be most helpful, the decentralized decision-making structure leads to competition for resources and inconsistent policies.

One can hope that the travesty of this virus, especially in places like the US and the UK, will lead to a rethinking of the importance of a well-funded, centralised, co-ordinating and interventionist government in modern states, with particular emphasis on the healthcare system. But I suspect that, in the USA at least, things will go the other way, and the government-hating and government-blaming will only intensify. I’d love to leave this topic and look at solutions – that’s to say I’d love to focus more on the science, but I’m barely equipped to do so. Still, I like to have a go. A very technical and comprehensive review review of pharmacological treatments has been posted recently on the JAMA website, which includes an account of how SARS-CoV-2 enters host cells and utilises those cells for reproduction.

The review claims that currently the most promising therapy is the antiviral drug remdesivir. So what is it and how does it work? I’ll try to answer that question next time.

References

https://www.news.com.au/world/coronavirus/global/epicentre-of-the-epicentre-this-queens-ny-hospital-is-coronavirus-ground-zero/news-story/6d0213ab9d5dd82fa12339f551be99ce

https://www.theguardian.com/world/ng-interactive/2020/apr/16/coronavirus-map-of-the-us-latest-cases-state-by-state

https://www.smh.com.au/national/australia-on-course-to-eliminate-covid-19-modelling-shows-20200416-p54kjh.html

https://www.nejm.org/doi/full/10.1056/NEJMp2005755?query=recirc_artType_railA_article

https://www.nejm.org/doi/full/10.1056/NEJMp2003762

https://jamanetwork.com/journals/jama/fullarticle/2764727

Written by stewart henderson

April 18, 2020 at 1:18 pm

My current health condition 1: it’s bizarre

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I can bear any pain as long as it has meaning

Haruki Murakami

stuff to learn about

I haven’t written for a while because I have a new health problem which flared up last Saturday, February 29, 2020. I had been feeling mild pain in my shoulder and I was lying on my bed reading when I tried to get up. Shooting pain from my shoulder down my left arm was so excruciating that I fell back on the bed and and lay down for a while before trying to get up again. Again I couldn’t get up because of the pain. I called for help but even with two of us it was difficult. I may have had a panic attack and exaggerated the pain of rising – I was gasping a lot. To cut a long story short Sarah called an ambulance (and the paramedic got me into a sitting position easily enough). I spent the next few hours in emergency at the Royal Adelaide Hospital.

Due to being given Panadol in the ambulance, and a long wait in reception while the painkiller took effect, by the time the friendly, efficient and strikingly beautiful (oh dear) young intern saw me, the pain, my only symptom, had much reduced. She found that, yes, I could move my arm above my shoulder, flex my elbow and my wrist, and no, I couldn’t precisely describe the nature or location of the pain. She checked my arm for swelling or redness (none), and asked about any recent history of injury to the region (none). I was beginning to feel like a fraud, a malingerer, a milquetoast.

So after some more prodding and questioning and advice from higher authorities, I was released with a report for my local doctor.

I’m very left-handed, so this left arm pain is quite a problem for me. I was due to work on the Monday and I needed some pain relief. It would have to be over the counter at first. The report’s only solid conclusion was ‘skeletal-muscular pain’. Since I needed to work on Monday and Tuesday I could only get to the GP on Wednesday. So on Sunday I started doing what research I could. I’ve never taken regular medication for anything, and I’ve never experienced regular pain like this. The only over-the-counter treatments for pain are ibuprofen and paracetamol as far as I know. Only ibuprofens is an anti-inflammatory. Paracetamol works on pain centres in the brain. Which one would work best? Was it all in my mind? But don’t we always feel pain via the brain? Isn’t that how the nervous system works?

I obtained both medicines. Over the next day or so I experimented with both, singly and in combination, and I got through Monday and Tuesday’s work. The pain never went completely away, though the teaching days, when I had to concentrate on and interact with my students and other teachers, helped to distract me from it, which gave me that guilty ‘it’s all in the mind’ feeling.

Even so, on Wednesday (March 4), the pain came roaring back. My subjective sense told me that the paracetamol was much more effective than the ibuprofen, another surprise. I visited my GP, who smiled at the hospital report, saying, ‘yes, they wanted you out of there as soon as possible – they’re there for acute, intensive care stuff, it’s understandable – a GP can refer you to a specialist, and we can go from there’. So he filled out a referral form for St Andrews Hospital, for an x-ray and an ultrascan. I rang them and organised an appointment, for Friday, March 6 at 11am.

I was still in pain, though. The OTC medication had reduced the pain to more bearable levels, but I still hadn’t worked out which worked best. Unlike me, Sarah was on many medications, for pain and other problems, including Prodeine (paracetamol plus codeine) and a set of tablets which combined paracetamol and caffeine. I was taking the tabs at the upper level of what was recommended, and beyond. I was trying to monitor the pain, what it felt like. It was always a low-level throbbing, which increased and became a shooting pain if I used the arm too much. It was a strange delayed pain – I would engage in a flurry of physical activity, such as preparing a quick meal, and then lie down, knowing that the pain would rise up as a result of the activity, then slowly subside. I had difficulty sleeping, and I dreaded dressing myself in the morning. Typing this is giving me an ache, and I’m experimenting with dictation – I find the Apple dictation system a pain (mentally speaking). I have to learn more about how to use it effectively.

Stupidly, I hadn’t asked my GP about stronger prescription medication. The day after the consult (Thursday, March 5) I had Sarah ring the surgery – I was experiencing bouts of serious pain, and was finding it hard to track what medication was working, or not. The doctor wrote a prescription, which Sarah collected and had made out at the pharmacy around the corner. It was for ibuprofen (200mg) and codeine phosphate hemihydrate (12.8mg). I was skeptical about the efficacy of ibuprofen, and I had been researching anti-inflammatories, and inflammation generally.

What, exactly, is inflammation? There are, supposedly, five signs of it, remembered under the acronym PRISH – pain, redness, immobility, swelling and heat. My only symptom was pain. There was certainly no redness or swelling. Immobility wasn’t a real problem either. I could move my arm above the shoulder, I could flex my elbow, etc, but some pain would come afterwards. Heat wasn’t something I could measure, but it didn’t seem an issue. Only pain. And I hadn’t pinpointed any cause of all this. I remembered what I’d said, quite often (or at least I thought I did – maybe I was mostly saying it to myself) to the intern at emergency: ‘It’s bizarre!’

Anyway, I’ll wind up this piece, and start on a new one, dealing with my time at St Andrews Hospital, the x-ray and the ultrasound.

Written by stewart henderson

March 8, 2020 at 12:43 pm

Covid 19, bird flu, etc – why China?

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Covid 19 under the microscope

The recent coronavirus now has an official name, Covid 19, and the death toll at present is a little under 2000, considerably more than that for the SARS coronavirus of 2003. It has spread to at least two dozen countries according to ABC reporting. I note that the WHO are emphasising how co-operative the Chinese authorities have been, I suspect as an attempt to keep those channels of communication and co-operation open, or to open them wider. The infamously over-controlling Beijing government is faced with a dilemma as its economy is taking a major hit – it desperately wants to get over this epidemic, which means downplaying it as much as possible, but its dependence on international trade means having to co-operate with those over whom it has no control. The Middle Kingdom has always been sensitive about this issue of control and dominance, which clashes with the co-operative spirit of modern global trade relations. 

Having said that, Chinese authorities have certainly learned from the reaction to their fairly disastrous early handling of the SARS coronavirus outbreak in 2002. In terms of the really essential stuff, co-operation and information-sharing have rapidly improved – motivated by the apolitical spirit of research, detection and problem-solving that constitutes science’s unique value.  

Of course, one of the questions being asked, with Covid 19, the SARS virus, and other viruses such as H7N9 avian influenza virus (which had a very high mortality rate), is ‘Why China?’ An article from late 2017 in the Smithsonian magazine provides a plausible if shocking answer. 

It seems imprinted in Chinese culture that freshly killed-birds and other animals are tastier and somehow healthier than anything frozen or otherwise processed. The Chinese government has, in the past, been reluctant to interfere with the demand for freshly slaughtered produce, and it’s likely that, even if it enforced a clamp-down, the market would go underground. Melinda Liu, author of the Smithsonian article, described the scene at one of these markets, in the Sichuan city of Chingzhou:

Half a dozen forlorn ducks, legs tied, lay on a tiled and blood-spattered floor, alongside dozens of caged chickens. Stalls overflowed with graphic evidence of the morning’s brisk trade: boiled bird carcasses, bloodied cleavers, clumps of feathers, poultry organs. Open vats bubbled with a dark oleaginous resin used to remove feathers. Poultry cages were draped with the pelts of freshly skinned rabbits. (“Rabbit meat wholesale,” a sign said). These areas – often poorly ventilated, with multiple species jammed together – create ideal conditions for spreading disease through shared water utensils or airborne droplets of blood and other secretions.

Flu viruses can crop up and mutate anywhere – for example, the H5N2 flu strain which broke out in the USA in 2015 led to the slaughter of 48 million poultry – but China’s mixed farming habits, in which poultry and other livestock live in close proximity with their keepers, together with the taste for freshly slaughtered and disturbingly exotic meat, and the conditions in many markets and slaughter-yards, presents a massive cultural problem for China’s huge and increasingly mobile population. The country will have to come to terms with these issues, sooner rather than later, if it wants to recapture and grow beyond the leading economic role it led before the advent of Covid 19.

References

https://www.smithsonianmag.com/science-nature/china-ground-zero-future-pandemic-180965213/

https://www.who.int/emergencies/diseases/novel-coronavirus-2019

https://www.who.int/influenza/human_animal_interface/influenza_h7n9/en/

Written by stewart henderson

February 19, 2020 at 9:15 pm

Posted in China, covid19, health

Tagged with , ,

coronavirus – a journey begins

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this is an electron micrograph of 2019-nCoV – ref JOHN NICHOLLS, LEO POON AND MALIK PEIRIS/THE UNIVERSITY OF HONG KONG. The cell is infected with the virus (the little black dots), which migrates to the cell surface and is released

Lots of information and disinformation around the recent outbreak of coronavirus, and my own occasional workplace, a college that teaches academic English to overseas, predominantly Chinese students, is naturally affected by the precautionary procedures and the possibly OTT concern.

This is a new strain of coronavirus, first detected late in 2019. It hasn’t been given a specific name, as far as I’m aware (apart from 2019-nCoV,  which I doubt will catch on) so lay people tend to think this is the one and only coronavirus, since most have never heard the term before. These viruses are zoonotic, transmitted between animals, from bats to humans. My interest is most personal, because when I read that the signs are ‘respiratory symptoms, fever, cough, shortness of breath and breathing difficulties’, I recognise my life over the past several years. I wouldn’t go as far as to say I have a fever, but all the other signs are just features of my life I’ve become inured to over time. I’m reluctant to even talk to people lest my voice catch in my throat and I have to give myself up to hideous throat-clearing, which I do scores of times a day. I’m also afraid to get too close as I assume my breath smells like rotten meat. I should probably wear a face mask at all times (hard to get one for love or money at this point). My condition has been diagnosed as bronchiectasis, possibly contracted in childhood, but I’m fairly sure it was exacerbated by a very severe bout of gastro-enteritis in the late eighties, which left me bed-ridden for several days, too weak to even get to the toilet. When I eventually recovered enough to drag myself to the doctor, she arranged for me to go to the hospital next door for blood tests. It was unspoken but obvious to me she thought I might have AIDS, which I knew was impossible given my non-existent sex life and drug habits. It seems to me, but I might be wrong, that my life of coughing, sniffling and raucus throat-clearing took off from that time.

All this by way of explaining why these types of illness catch my attention. WHO advice is for people to, inter alia, wash hands regularly, cook meat and eggs thoroughly, and keep clear of coughy-wheezy-sneezy people like me. 

Coronaviruses are RNA viruses with a long genome, longer than any other RNA virus. According to Sciencealert they’re so called because of the crown-shaped set of sugar-proteins ‘that projects from the envelope surrounding the particle’. This one is causing perhaps a larger panic than is warranted, when you compare its fatalities (and the numbers should be treated with skepticism at this stage) with those associated with regular flu season. Of course, the difference is that this coronavirus is largely unknown, in comparison to seasonal flu, and fear and wariness of the unknown is something naturally ‘programmed’ into us by evolution.  

There’s an awful lot to be said about this topic, biochemically, so I’ll write a number of posts about it. It’s not only of great interest to me personally, but of course it fits with my recent writings on DNA and its relations, including RNA of course, and to a lesser extent epigenetics. I’m becoming increasingly fascinated by biochemistry so it should be an enjoyable, informative journey – for me at least.

References

Cases of the new coronavirus hint at the disease’s severity, symptoms and spread

Updated: Your most urgent questions about the new coronavirus

https://www.who.int/health-topics/coronavirus

Written by stewart henderson

February 8, 2020 at 10:57 am

Posted in coronavirus, health, RNA, viruses

Tagged with , , ,

a brief history of radical mastectomy

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Dr William Halsted

Siddhartha Mukherjee is an oncologist, an academic and an astonishingly gifted writer and story-teller, in the Indian tradition of seemingly effortless, self-effacing wordsmiths. I read, and learned heaps from, his 2016 book The Gene a while back, and now I’m being educated by his first book The Emperor of all Maladies, a history of cancer. 

The book twists together different threads of cancer treatment in the modern era, most notably various forms of chemotherapy, and surgery. I’m focusing solely on surgery here, as it pertains to breast cancer, because it highlights the relation between experts (very predominantly male) and sufferers (exclusively female).


The term mastectomy is a bit of a mystery, at least to me. The suffix –ectomy is clear enough, meaning ‘cutting out’, or surgical removal, and ‘lumpectomy’ is a slightly dismissive term for the surgical removal of lumps (from the days when full-blown excision was king) . Maybe mastectomy refers to the removal of a mass of tissue, though why it wouldn’t be called massectomy or masectomy, and why it refers only to the breast, I don’t know. It has nothing to do with mast cells.


The radical mastectomy – the concept refers to ‘root’ as in rooting out, rather than quasi-political radicalism – is most associated with an American physician, William Halsted, though radical surgery in the treatment of cancer was far from unknown when Halsted began practising in the 1870s. Cancer at the time was recognised as the growth and spread of malignant tissue, at mysteriously varying rates, and the surgical removal of that tissue seemed the obvious response. Nineteenth century developments in anaesthesia helped to make the procedure more bearable for all, but operations in the US were often ad hoc and unsanitary. In the late 1870s Halsted made a trip to Europe, which radically changed his outlook and practice. He encountered and absorbed the ideas of various pioneers in surgery and anatomy, including Joseph Lister, Theodor Billroth, Richard von Volkmann and Hans Chiari, then returned to the US, and in the 1880s he quickly established a reputation for boldness and skill as a surgeon. Having become familiar with cocaine, which he recommended as an anaesthetic, he soon became addicted to the drug, which gave him seemingly boundless energy. He tried using morphine to kick the habit, and then found himself in a struggle with both drugs, but this barely damped his work-rate.

Hasted had become particularly interested in Volkmann’s surgical work on breast cancer, and noted that, though the surgeries became more extensive, the cancers returned. An English surgeon, Charles Moore, was experiencing the same problem. Moore’s painstaking analysis of the operations and the following relapses showed that malignant cells had begun to proliferate around the edges of previous surgeries. It seemed clear to him that the surgeries just weren’t extensive enough, and by limiting the surgery to the clearly evident cancerous tissue, and not widening the margins to ensure that the malignant region was properly cleaned out, surgeons were exercising ‘mistaken kindness’. Of course, the problem with this argument was that more radical surgery could itself be life-threatening as well as permanently disfiguring and debilitating. What was also not known at the time was the detailed mechanism of cancer’s metastatic spread throughout the body via the blood and lymph systems. However, this was a time when medical expertise tended to go unquestioned. Halsted and his surgical followers were considered heroes, and the delayed return of the cancers tended not to be dwelt on. The surgeons certainly did buy time for their patients, but often at great cost. Volkmann, for example, had taken breast surgery further by removing not just the breast but the muscle beneath it, the pectoralis minor, to try to ensure the complete removal of the cancer. Impressed, Halsted took things to the next level, cutting through the more vital pectoralis major, essentially killing off movement of the shoulder and arm. Radical mastectomy had now truly arrived, and was to become even more radical, with the collarbone and the group of lymph nodes beneath it becoming the next target, and it didn’t stop there, as cancer kept recurring. As Mukherjee describes it:

A macabre marathon was in progress. Halsted and his disciples would rather evacuate the entire contents of the body than be faced with cancer recurrences. In Europe, one surgeon evacuated three ribs and other parts of the rib cage and amputated a shoulder and a collarbone from a woman with breast cancer.

Siddhartha Mukherjee, The Emperor of all Maladies, p65

There were, of course, no female surgeons at this time, and precious few female doctors, and the male-female power imbalance was coupled with that of the expert and his suffering if not panicking victim to create a kind of juggernaut of largely unnecessary suffering. It took years to reverse this radicalising trend. Nowadays, radical mastectomies are very rarely performed, but with so many giants in the field – who often controlled the nature of clinical trials related to cancer – having earned their reputations through their surgical expertise, change was slow in coming, in spite of a gradual increase in often heroic dissenting voices. For example, Rachel Carson, the author of Silent Spring, refused to undergo a radical mastectomy, which would in any case have offered only brief respite as the cancer had already spread to her bones. Changing attitudes to experts and their secret and superior knowledge was of course a feature of the sixties and seventies, when the turning point really occurred. Developments in the field of course played their part. The knock-out blow for the procedure is largely associated, according to Mukherjee, with another surgeon, not unlike Halsted in energy and drive.

Bernard Fisher had been analysing the data of Halsted’s critics, notably Geoffrey Keynes in England and George Crile in the US, and became increasingly convinced, for a number of reasons, that radical mastectomy was a wrong-headed approach. In 1967, Fisher became the chair of a national consortium in the US, the National Surgical Adjuvant Breast and Bowel Project (NSABP), and began an uphill battle to run large-scale trials to test the efficacy of different treatments of breast cancer. Patients were reluctant to engage, and most surgeons were hostile. The process took years, but results were finally made public in 1981. Here’s Mukherjee’s summary.

The rates of breast cancer recurrence, relapse, death and distant caner metastasis were statistically identical among all three groups [i.e treated with radical mastectomy, with simple mastectomy, or with surgery followed by radiation]. The group treated with the radical mastectomy had paid heavily in morbidity, but accrued no benefits in survival, recurrence or mortality.

Siddhartha Mukherjee, The Emperor of all Maladies, p201
Dr Bernard Fisher

So. Richard Feynman once famously/notoriously said ‘science is the belief in the ignorance of experts. When someone says science teaches us such and such, s/he’s using the word incorrectly – science doesn’t teach us, experience teaches us.’ I agree. Science isn’t a person, let alone an expert person. Science is, to me, an open-ended set of methods based on experience. Experience creates new methods out of which new experiences are created, and we move on, trying to right the wrongs and to minimise the damage, while always maintaining our skepticism.

Reference

The Emperor of all Maladies: a biography of cancer, by Siddhartha Mukherjee, 2011

Written by stewart henderson

December 22, 2019 at 3:01 pm