KOLAHUN

Vaccines

The prospect for an HIV vaccine seems to be diminishing with the failure of two more trials, even as we spend $800 million or so on research.  As quoted in the perspective, Anthony Fauci states that:

"To be brutally honest with ourselves, we have to leave open the possibility . . . that we might not ever get a vaccine for HIV. People are afraid to say that because they think it would then indicate that maybe we are giving up. We are not giving up. We are going to push this agenda as aggressively and energetically as we always have. But there is a possibility, a clear finite possibility that that's the case."

The last decade has seen only two more classes of anti-retrovirals, fusion inhibitors and integrase inhibitors, added to the arsenal.  Meanwhile, a friend saw Dr. Fauci give the keynote address at an international conference of HIV researchers and essentially come to the conclusion that we're simply still thinking 'in-the-box' and that our entire thought process has to be radically altered.  How do we do this?  Where do we start? 

To mix analogies, it's like going down a straight road and being told we need to change directions.  Well, we've got 359 degrees of other choices - each very expensive.  And, not to mention, the z-axis (up and down) gives us even more permutations.  It's all fairly terrifying to be lagging behind a virus which can understand our tactics and form defenses quite efficiently. 

And if this happens in the developing world where there's only a 'first-line' medicine (Troimune), even the updated lower world-wide prevalence won't avoid a catastrophe.   

New Year's Resolution - Smoking Cessation

Matthew Yglesias writes about his efforts to quit smoking a year ago tomorrow and his advice for others intent on pursuing a similar resolution this year:

"I think my main piece of advice to people considering a similar pledge for 2008 would be to consider not doing it. The reality is that the first week or so of withdrawal is incredibly awful and then it remains really hard for a while after that. Last year, I saw several friends put themselves through the incredibly awful part and then go back to smoking. That's no fun, and really something worth avoiding."

Right.  The process of quitting smoking takes time and effort and a simple New Year's Eve contemplation of such an act can be fraught with fairly bad side effects and further frustration.  There's a pretty good article from the American Family Physician dealing with the whole process of helping some one quit.  Here's their algorithm (the only medicine they leave out of the article is Chantix)...and as can be seen, quitting smoking can't usually be a one-day decision.  It takes some time to get going and prepare oneself for the psycho-physio torment of the first few weeks:

   

Left-handed Word

Abscess

Ithaca, a Poem

Ithaca

When you set out on your journey to Ithaca,
pray that the road is long,
full of adventure, full of knowledge.
The Lestrygonians and the Cyclops,
the angry Poseidon -- do not fear them:
You will never find such as these on your path,
if your thoughts remain lofty, if a fine
emotion touches your spirit and your body.
The Lestrygonians and the Cyclops,
the fierce Poseidon you will never encounter,
if you do not carry them within your soul,
if your soul does not set them up before you.

Pray that the road is long.
That the summer mornings are many, when,
with such pleasure, with such joy
you will enter ports seen for the first time;
stop at Phoenician markets,
and purchase fine merchandise,
mother-of-pearl and coral, amber and ebony,
and sensual perfumes of all kinds,
as many sensual perfumes as you can;
visit many Egyptian cities,
to learn and learn from scholars.

Always keep Ithaca in your mind.
To arrive there is your ultimate goal.
But do not hurry the voyage at all.
It is better to let it last for many years;
and to anchor at the island when you are old,
rich with all you have gained on the way,
not expecting that Ithaca will offer you riches.

Ithaca has given you the beautiful voyage.
Without her you would have never set out on the road.
She has nothing more to give you.

And if you find her poor, Ithaca has not deceived you.
Wise as you have become, with so much experience,
you must already have understood what Ithacas mean.

(picture form flick.com user CiaoChessa - modified from original)

Darfur and Malnutrition

From the New York Times, comes this article about increased malnutrition rates in Sudan:

"Child malnutrition rates have increased sharply in Darfur, even though it is home to the world’s largest aid operation, according to a new United Nations report.  The report showed that 16.1 percent of children affected by the conflict in Darfur, a vast, turbulent region in western Sudan, are acutely malnourished, compared with 12.9 percent last year. For the first time since 2004, the malnutrition rate, a gauge of the population’s overall distress, has crossed what United Nations officials consider to be the emergency threshold."

For such a short article, there's a lot to chew over.  First, as we've recently learned from the UNAIDS/WHO HIV prevalence fiasco, estimating disease rates in developing countries can be laced with layers of methodological errors.  And, as expected, the prevailing powers in the Sudanese government object to the conclusion. 

Second, the article goes on to say that "the increase [in malnutrition] has occurred despite the efforts of more than 13,000 relief workers in Darfur, who work for 13 United Nations agencies and some 80 private aid groups, and draw from an annual aid budget of about a billion dollars."  This is one of the troubling aspects of aid work in developing countries - it's infrastructurally very difficult to get things done.  Roads don't work, electricity may not be reliable, cell phone service cuts off easily, and so forth.  An MSF friend used to say that even with the resources of armies, it's very difficult to affect things on the ground of a disaster within 24-48 hours.  The necessary items for a particular disaster or locale may not be pre-packaged, roads may be impassable, and airports/runways non-existent.  Extrapolate that to an area as large as Darfur, with such few resources and a consistently violent environment and it may not be that hard to understand why progress isn't being made.

And finally, the article just glances over the whole concept of malnutrition.  But as a field of medicine, it may be as complicated and difficult as any other.  Imagine a child who's malnourished who comes to your clinic.  She's too weak to be febrile, so she may have an underlying infectious cause, but you don't know.  There are no labs available as you're in a conflict zone, so there's no white cell count.  The child may be dehydrated, but without baseline electrolytes giving IV fluids may cause severe pulmonary edema.  Perhaps she has HIV - but she was breast feeding so the current antibody tests may just be the mother's antibodies.  What about TB as a cause for the malnutrition?  Unfortunately, children get extrapulmonary TB more frequently than adults...and moreover, there's no xrays anyway out in the field.  And then you still have to differentiate malaria exposure, kwashiorkor, nephrotic syndrome, etc - all with very limited labs or xrays.

Multiply this by a few hundred children with malnutrition in a conflict zone and one enters the reality of a therapeutic feeding center...and, quite likely, Darfur.

 

New Orleans Hours

There's a reason this wonderful city of New Orleans can also be called the City that Care Forgot.  Let's say, for example, you're in Algiers on the West Bank and want to get a soda.  Perhaps you've run into Bobby D's grocery and want to find out what time it's open.  Well, here's the sign detailing when they're open:

Underreported Humanitarian Stories - 2007

Doctors Without Borders (aka Medicines Sans Frontieres) puts out an annual list of stories which may not have gotten just attention.  Here's the list for 2007.  It includes an array of stories, though many deal with the bystander effect of wars and politics.  From the junta in Myanmar (Burma) suppressing humanitarian aid, to continuing/new war zones in Somalia and the Congo...from increasing drug resistant tuberculosis to a possible new tool against malnutrition,  the list will accomplish its goal of increasing awareness...if you click over and read the whole thing. 

Barbers - First Surgeons, Now Internists?

As I've begun numerous readings on the latest paradigm buzzwords in public health - 'the social determinants of health care' - a few anecdotal stories come to mind which, perhaps, may be relevant (or not - we'll soon see):

• Dr. BB, after a few years at a community health center in Chicago, decided to go to Boston for her Public Health degree.  Not having a car and being forced to take the highly erratic Boston public transportation, she mentioned recently that she'll have a much greater empathy for late arriving patients.
• For patients who are seen at our clinic and given instructions to eat healthier - um...there are literally no grocery stores within a couple mile radius of the Treme neighborhood.
• Finally, as a way to extend health care outside walled clinics into places where people actually spend time comes this unique study from Dallas:

"Barbershops have long stood at the center of social life for black men. Using a medical team in a pilot project ("Cut Your Pressure") sponsored by the Texas Higher Education Coordinating Board, researchers from UT Southwestern's Dallas Heart Study showed that barbershops can be effective places to improve detection and treatment of high blood pressure in African American men. This spin-off program will now be turned over to barbers. Eight barbers in the Dallas area have already agreed to offer a free blood pressure check during every haircut, followed by education and, if needed, appropriate referral to medical care."

(picture from flickr.com user Bumpkin78)

New Orleans and Baltimore

These two cities have always had a kinship in character, stemming from their port-city economies to mixed-economy neighborhoods.  And Bunk Moreland, played by New Orleans native Wendell Pierce, conjoins the two both fictionally and non-fictionally.  Here's part of a brilliant, widely-encompassing interview of him by the Baltimore City Paper:

CP: People like to compare Baltimore and New Orleans. Are there any similarities?

WP: In the past three years that I’ve worked there, I’ve always felt that Baltimore is very similar to New Orleans. First of all, a bar on every corner and a church on every other—that’s New Orleans. There’s that blue-collar work ethic. The evolution of the politics of class is very reflective of New Orleans. There’s the tax base that is outside the city, yet everyone works in the city, so you take the money out of the city and it leaves this hole of poverty in the center, and we all try to pretend that there’s no connection, but it is so glaringly clear. The sociopolitical aspects of The Wire speak volumes about New Orleans.

And his take on the development and destruction of a black middle-class in New Orleans:

CP: Where is everybody now? I mean, now that you have your parents in a home, people are safe and being taken care of, is the question of what’s next being left unanswered the hardest part?

WP: Waiting to hear is such an overwhelming thing. What is happening with the levees? Are we finally going to build the SELA Program that I grew up 40 years hearing about? Or are they just rebuilding them to the state they were before Katrina?

The psychological thing is what I’m worried about with my parents. My father is 80 years old, he bought this house with the GI Bill when he got back from World War II. I was born and raised in that house. My father, when he [came back] to the house, he got out of the car, came around to the front, and he lifted his head and it just knocked the wind right of him. And he said, “My whole life.”

And I had to think about it—here was this young man at 30 years old, in a segregated New Orleans, finds this neighborhood where there’s black Realtors selling to black GIs, who automatically get a mortgage with $10 to hold the contract. We had a little three-par golf course in the middle of the neighborhood. Back in the 1950s, Dixieland tours literally used to bring buses through the “first Negro subdivision in New Orleans.” They’d say, “Look, they’re barbecuing!”

It was that sort of unity made this neighborhood a great place of substance and survival. The first black New Orleans mayor came out of the neighborhood. Terence Blanchard, the great trumpeter, came out of the neighborhood. What Sweet Auburn was to Atlanta or Lafayette Square to Baltimore . . . just a classic midcentury black neighborhood, where working-class folks got together and said, “We’re going to give our kids a piece of this American pie.” And now we, the generation who benefited, are coming together to say we owe it to them to take care of them now. And there’s a battle between the bottom line and the second line.

Most people who watch the Wire end up falling in love with Bunk.  He's a filthy scoundrel, but one with a heart of gold and brains to match.  And yet Bunk's character can't really be understood outside the influence of Wendell Pierce's life - and his ability to transfer his New Orleans sensibilities to its sister city, Baltimore. 

Reversal of Destiny

My dad, who metamorphasized from a young agitprop who almost got himself arrested to a Limbaugh-conservative later in his life, used to quote the following:

"if you're not a liberal when you're twenty you have no heart and if you're not a conservative when you're forty, you have no brain."

I, on the other hand, was a fervent conservative when I was twenty, but as I age, am sliding into a stark and proud liberal.  Matthew Yglesias, discussing the Wire in 2006, encapsulates my reasoning:

"Another, deeper problem, however, is that in a prosperous society people simply deserve better living conditions than that. It's unjust that living conditions of the sort portrayed in the show exist. Unjust that people live in neighborhoods that are unsafe and deprived of basic civic service. Unjust that people -- even people without noteworthy talents and abilities -- lack the opportunity to obtain a reasonable standard of living through legal means."

Look...the problems in the US aren't that bad.  In other parts of the world, celebrating a first birthday marks a monumental accomplishment.  Staving off war and pestilence takes up the better part of the day.  And so forth. 

Nonetheless, it's still simply 'unjust' that we shove people to the edge of civilization in this country - easily the richest in the world.  A country whose riches surpass the next four countries in the world combined (Japan, Germany, China and the UK).

(the picture above is of dukie weems, from the Wire - click on his name to understand his story if you haven't seen the wire)