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January 2008

January 28, 2008

MSF Press Release - 3 Deaths in Somalia

From the Doctors Without Borders homepage on 1/28/2008.  Shitty.  Just shitty. 


Three MSF Aid Workers Killed in Serious Incident in Kismayo, Somalia

Nairobi/Amsterdam, January 28, 2008 - It is with great sadness that we confirm that three staff from Doctors Without Borders/Médecins Sans Frontières (MSF) were killed this morning in the Somali town of Kismayo, not far from the hospital where MSF works.

The victims are a Kenyan doctor, a French logistician, and a Somali driver. Victor Okumu was a 51-year old surgeon who had previously worked with MSF in several missions such as Darfur, Sudan, and Sierra Leone; Damien Lehalle was a 27-year-old logistician in his second mission with MSF; Billan was the Somali driver of the car. Another member of the team was lightly wounded.

The bodies of the victims were transported to the Kismayo hospital and later taken by plane together with the rest of the international team to Nairobi. The rest of the staff is unharmed.

The exact circumstances of the dramatic incident are not yet clear, but for the moment our priority is to take care of those most affected by this tragedy, in particular the families of the victims.

We will miss Victor, Damien, and Billan greatly and again we extend our heartfelt sympathies to their families and friends.

MSF opened an emergency surgical project in Kismayo in September 2007, providing among others, emergency obstetrics surgery. MSF has worked continuously in Somalia for more than 16 years and is currently providing medical care in eleven regions in the country. There are some 60 MSF international staff and more than 800 national staff now working in Somalia, performing more than 300,000 outpatient consultations and admitting an estimated 10,000 patients every year.

January 27, 2008

Mardi Gras 2008

BarkusSeparated from the traditional, oxymoronically staid, Mardi Gras parades come a couple of eclectic ones.  It was a bit too cold to enjoy the innuendo-laden Krewe du Vieux but today's the day for Barkus.  This year's poster is on the left.  For a few laughs at the ridiculous pomp of dogs-on-parade-in-costume, nothing beats Barkus. 

I Do Watch, Damn It!

History gives us many examples of books that people own but have never read (my own personal contribution being Stephen Hawking's a Brief History of Time - which even over multiple copy ownerships I could never get past the time-cone).  Now the Onion dastardly claims this is true of this blog's favorite show, The Wire:

"NEW YORK—Despite heaping lavish praise on the HBO crime drama The Wire, television critics across the country admitted Monday that not one of them has ever sat down to watch an entire episode of the show. "The Wire has done what no other television program has come close to achieving—namely, presenting the life of a decaying American city and doing so with the scope and moral vision of great literature," said New York Times critic Virginia Heffernan, who was surprised to hear that the groundbreaking series had already started its fifth and final season in early January. "It sounds fantastic. I really wish I had HBO." Many reviewers from top media outlets assured reporters that they would start watching the Peabody Award–winning show just as soon as the first season reaches the top of their Netflix queues."

Um...screw you, The Onion and your wit.  I have seen every episode, own each season on DVD, have even bought Season 1 for my sister in Chicago and my friend Dr. TM in Mozambique.  (But given the lack of HBO, I've been absent for this the fifth and final season...and carefully avoiding any discussion.)

On a related note, David Simon recently wrote a scathing editorial in the Washington Post lamenting the decline of the newsworthiness of modern day newspapers.  Maybe through the 80s and 90s, his words may have encompassed rightful critiques.  But in the modern day internet/blog days, don't we have access to much of the local beats that he laments losing?  For example, regarding the local scene here in New Orleans the following describe the scene in at least as good a way as a newspaper metrosection might:

and so on and so on.  And the new information doesn't need to be filtered through the lenses of the 'smoky' rooms of newspapers.   

January 26, 2008

Google and Literature Searching

The role of Google over Pubmed searching came up during discussions with one of the local higher-up doctors.  Apparently, Google has taken over much of the work that Pubmed used to accomplish.  Take, for example, this NEJM letter from 2005:

To the Editor: At a recent case conference with a distinguished visiting professor, a fellow in allergy and immunology presented the case of an infant with diarrhea; an unusual rash ("alligator skin"); multiple immunologic abnormalities, including low T-cell function; tissue eosinophilia (of the gastric mucosa) as well as peripheral eosinophilia; and an apparent X-linked genetic pattern (several male relatives died in infancy). The attending physicians and house staff discussed several diagnostic possibilities, but no consensus was reached. Finally, the visiting professor asked the fellow if she had made a diagnosis, and she reported that she had indeed and mentioned a rare syndrome known as IPEX (immunodeficiency, polyendocrinopathy, enteropathy, X-linked). It appeared to fit the case, and everyone seemed satisfied. (Several weeks later, genetic testing on the baby revealed a mutation in the FOXP3 gene, confirming the diagnosis.)

"How did you make that diagnosis?" asked the professor. Came the reply, "Well, I had the skin-biopsy report, and I had a chart of the immunologic tests. So I entered the salient features into Google, and it popped right up."

"William Osler," I offered, "must be turning over in his grave. You googled the diagnosis?"

Where does this lead us? Are we physicians no longer needed? Is an observer who can accurately select the findings to be entered in a Google search all we need for a diagnosis to appear, as if by magic? The cases presented at clinicopathological conferences can be solved easily; no longer must the discussant talk at length about the differential diagnosis of fever with bradycardia. Even worse, the Google diagnostician might be linked to an evidence-based medicine database, so a computer could e-mail the prescription to the e-druggist with no human involvement needed. The education of house staff is morphing into computer-search techniques. Surely this is a trend to watch.

Printing_press The letter prompted this much longer British Medical Journal editorial which showed who referred visitors to the BMJ, with Google and Google Scholar referring about 350,000 combined in 2005 versus the Pubmed portals offering up a paltry 25,000 visitors.  Is this good or bad?  On the whole, probably good.  It's hard to argue with the vast dissemination of information.  The process started in 1426 with Gutenberg and exploded exponentially in the past few decades with computers and the internet. 

That being said, we'll still need a professional class of information distillers (i.e. health care workers) who can explain to the lay person what all the information means and which are reliable sources.  Which ends up back with the Google phenomenon and its rightful criticism in the BMJ editorial - the inherent bias in its information as a for-profit portal (even as much as its goal is to 'not be evil).  In the end, then the least likely biased source is the National Library of Medicine and its medical literature search tool - Pubmed.

Health care workers still need to understand how to use it such that they can evaluate the sources of information that patients and other providers find on Google.  Granted, it seems that Pubmed is harder for the health care worker to use than say, Lexis-Nexis for the journalists and legalists, but there have been vast improvements over the past few years, including the following features:

January 23, 2008

The Bottom Line

There's a flashy new paper in the latest JAMA, which, no surprise, found it's way to the front pages of the New York Times (and by extension all the other major news outlets).  It's a whole article based on the use of a gastric banding to eliminate diabetes (type 2).  It seems promising.  But I won't read the article because of the Financial Disclosures at the end of the article:

Financial Disclosures: Dr Dixon reported having received research grants from the National Health and Medical Research Council, Allergan Health, and Novartis Australia; having received compensation for serving on the speakers panel of Novartis Australia and Allergan Health; and serving on the medical advisory board of Novartis Australia and Allergan Health. Dr O’Brien reported receiving research grants from the National Health and Medical Research Council, Allergan Health, and Novartis Australia; having received compensation for serving on the speakers panel of Allergan Health; and serving on the medical advisory board of Allergan Health. Dr Chapman reported receiving travel grants and honoraria from Eli Lilly, Novo Nordisc, Sanofi Aventis, and Alphapharm. Dr Proietto reported serving on the medical advisory boards of Novartis Australia, Eli Lilly Australia, Abbott Australia, and Sanofi-Aventis Australia. No other disclosures were reported.

Funding/Support: This study was funded by Monash University, which has received an unrestricted grant from Allergan Health. The laparoscopic adjustable gastric bands (Allergan Health) and the laparoscopic ports (Applied Medical) were provided without charge by the manufacturers.

Role of the Sponsors: Allergan Health and Applied Medical had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. (emphasis added)

Gastricbanding Right.  Allergan Health had 'no role'.  You know, I tend to have a general bias towards less expensive, more public health oriented expenditures in health care.  But sometimes, there are expensive alternatives that really do help patients more then less expensive ones (inhaled steroids and long acting insulin come to mind) and pharmaceuticals and entrepreneurs need to be justly compensated. 

This article, however, isn't one of those cases.  When the financial underwriters of the study would also profit heavily from adoption of the results of the study has no positive value.  If, on the other hand, the study had concluded that lap banding had no effect, it would likely be valuable given regardless of the funder...but of course those studies don't get published (see this article on bias in unpublished articles by drug companies). 

But I don't need to waste my time when a profiteer says its study proves the value of its product...I could just guess that would be their outcome and save myself 20 minutes. 


(image from flickr.com user jacquiscloset)

January 22, 2008

Pimps and Prostitutes

A few nights ago, friend of Dr. CJ and I had a long discussion of Sudhir Venkatesh's book, Off the Books - a pretty cool outsider's insight into the underground economy, where people don't have 'official' credit, can't get bank accounts/credit cards and essentially find a shared model of living through hustling, cheating, scamming, begging, borrowing...and prostituting.  The topic then moved on to Venkatesh's most recent article, co-written by Steven Levitt (of Freakonomics fame) and presented here in New Orleans 2 weeks ago, about the micro-economics of prostitution in Chicago.  Here's the abstract:

"Combining transaction-level data on street prostitutes with ethnographic observation and official police force data, we analyze the economics of prostitution in Chicago.
Prostitution, because it is a market, is much more geographically concentrated than other
criminal activity.  Street prostitutes earn roughly $25-$30 per hour, roughly four times
their hourly wage in other activities, but this higher wage represents relatively meager
compensation for the significant risk they bear.  Prostitution activities are organized very
differently across neighborhoods.  Where pimps are active, prostitutes appear to do
better, with pimps both providing protection and paying efficiency wages.  Condoms are
used only one-fourth of the time and the price premium for unprotected sex is small.  The
supply of prostitutes is relatively elastic, as evidenced by the supply response to a 4th of
July demand shock.   Although technically illegal, punishments are minimal for
prostitutes and johns.  A prostitute is more likely to have sex with a police officer than to
get officially arrested by one.   We estimate that there are 4,400 street prostitutes active in Chicago in an average week."

27798886_33f64685f4_m_3 The article in full form can be linked to from porfolio.com.  Meanwhile, here are some other pretty good recent prostitution links (and I apologize, but I can't remember where I first read these and so can't give due credit):

why prostitution isn't more legal in Las Vegas

free sex with prostitutes in Prague (really!  all you have to do is accept to get videotaped with them for an internet sex site)

An Important Article on Internationl Health

Index_betrayaln_hardback Not being plugged into the policy world of international health, it's hard to know where Laurie Garrett fits into the matrix.  But she penned an amazing history of infectious disease during the twentieth century called The Coming Plague: Newly Emerging Diseases in an Emerging World where she blended the intimate (individual index cases of diseases) with the broad (painting the environmental impacts on health).  She then penned another well received book indicting the global powers called Betrayal of Trust: Collapse of Global Public (which, I admit is one of they many books on the yet-to-be queue).

Now she's written a fairly amazing treatise describing the arguments in the international health realm.  From the crises of HIV/AIDS to the influx of money over the past 15 years to the "Dutch" effect of this money and the lack of good metrics in measuring health outcomes other than a nominal number of individuals on certain medicines (say...ARVs) and including the developed world's mining of the health care workers and it's effect on fundamental health infrastructures in developing countries, she writes with awesome passion and clarity. 

It's a bit too big of an article to discuss en mass, so I'll try to break it down bit by bit over the next few days.  In the meanwhile, here's how she throws down the gauntlet:

"Less than a decade ago, the biggest problem in global health seemed to be the lack of resources available to combat the multiple scourges ravaging the world's poor and sick. Today, thanks to a recent extraordinary and unprecedented rise in public and private giving, more money is being directed toward pressing heath challenges than ever before. But because the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases -- rather than at public health in general -- there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground."

My initial reaction to her argument is that well...look, there's a hordes of people actively dying from HIV/AIDS/TB/malaria and we've got to do something now.  But reading through the numerous pages, Ms. Garrett makes a convincing argument a) we may be fighting the wrong battles, b) just going in to 'do something' may even in the short-term be a bad idea, and c) we've barely begun to understand the complexities of what we're trying to fight/improve. 

(Read the whole thing...especially if you're one of my 3 loyal readers who's lived/worked in Botswana! - it's got a whole discussion on the use of Botswana as a 'model' country for aid.)

January 21, 2008

Rhetoric

There's a good deal of MLK blogging going on today, especially the posting of his Letter from Birmingham.  It's too long to post in its entirety, but here's an excerpt:

I think I should indicate why I am here In Birmingham, since you have been influenced by the view which argues against "outsiders coming in." I have the honor of serving as president of the Southern Christian Leadership Conference, an organization operating in every southern state, with headquarters in Atlanta, Georgia. We have some eighty-five affiliated organizations across the South, and one of them is the Alabama Christian Movement for Human Rights. Frequently we share staff, educational and financial resources with our affiliates. Several months ago the affiliate here in Birmingham asked us to be on call to engage in a nonviolent direct-action program if such were deemed necessary. We readily consented, and when the hour came we lived up to our promise. So I, along with several members of my staff, am here because I was invited here I am here because I have organizational ties here.       

But more basically, I am in Birmingham because injustice is here. Just as the prophets of the eighth century B.C. left their villages and carried their "thus saith the Lord" far beyond the boundaries of their home towns, and just as the Apostle Paul left his village of Tarsus and carried the gospel of Jesus Christ to the far corners of the Greco-Roman world, so am I. compelled to carry the gospel of freedom beyond my own home town. Like Paul, I must constantly respond to the Macedonian call for aid.

Read the whole thing.  And if you'd like to be inspired by even more speeches, head over to American Rhetoric, where they poll some of the best US speeches, including some MLK, JFK, FDR and Malcolm X speeches.

 

January 18, 2008

A Post of Its Own

Many of you, my three loyal readers, may have missed JVM's comments on the earlier post about the Wire, so here it is in full - unedited and unencumbered with commentary:

OK…you asked for it….

My 1st response to an entry in your blog….

I was thinking about movies and television shows the other day….Why are Romans always played by the British?  Ever notice Jewish actors get to play EVERYBOBY and seldom get stuck with “Jewish” roles? On a planet where so many people are Asian, why is the future so full of white people?  How come all the leading-women in that geisha movie were Chinese? Why is the black cop always the side-kick?  Why was it in high school I had to beg to be Lear, but was automatically chosen to be Othello?

I guess the audience comes to the stage with their beliefs, and the players must speak to them in way they understand – and that how tickets get sold.

It is not a “false argument”.  It is a very real argument that the media portrays people in a stereotypical fashion that those who tune in will be comfortable with.  And without many alternative characterizations, they may come to perceive this as the “one-and-only-true” reality of the diverse life in this country.  Let’s face it, many non-black people have little personal contact with the community and family life of black people….or Asian people, or Latino people and others, for that matter. But they do know what they usually see on t.v. or in the movies.  To give them something different, is to serve an audience that’s ready for something different.  The networks are only interested in that when the size of this audience is big. And we all know how that usually goes.

When I heard about “The Wire”.  I wanted something different.  I knew it wouldn’t be different. Oh, I was sure it was going to have interesting characters and plots and writing, and somebody was going to get an award for it, and HBO would make a lot of money off of it.  But shine a new and different light into the reality(-ies!) of African-American life?  I wasn’t so sure about that.

I was sure that I didn’t want to watch a show that would likely owe its recognition to further developing the drug dealing, crooked cop, single-mother, poem writing prostitute, philandering preacher, almost went pro characters that you’ll remember from the last t.v. show/movie you and I both saw about black people.  I just got tired of that feeling…that empty feeling – knowing something was missing.

I got used to telling people that I grew up poor, to single-parent, who struggled to make ends meet so I could be the first in my family to go to college. It was hard at first, but it got easy.  I appreciated the notion my audience would just look at the color of my skin and believe every word of it, without question.  I figured most of what they know about me, and people who look like me, came from t.v., the movies, or what they read in the newspaper. As long as my story matched the award winning drama they saw on HBO (brought to you by the creator of that other award winning drama about black people in the inner-city) I’d be accepted.

But I knew that I’m leaving things out.  Important things out.  The same things that Elijah Anderson knows I’m leaving out.  The same things the people behind “The Wire” know they are leaving out.  Things that would challenge the comfortable beliefs that the viewers took so long getting used to.  But sometimes it’s just easier and faster to leave things out.  When they were looking for a poor kid from the projects to give that scholarship to.  When they need a dark face to sit on their advisory committee.  When they want to be sure that they’re handing a check to someone from the community to which their donation was intended, don’t bog them down with the WHOLE story. They’ll change the channel.  And so it goes…

Like HBO, in order for me “to make the sale” I got to give the audience what they want.  They don’t want their comfortable beliefs about black people challenged.  To do that would be to upset all those other assumptions they made, subsequently. My show would never make it to primetime – if I actually challenged the viewer. 

I knew it be a struggle to convince people that I could be Zhivago, James T. Kirk, the Last Samurai, or King Lear.  But, there’d always be work as Othello, the Moor.  The audience insists that Othello “look” like a Moor. They will not recognize him, unless he "looks" like a Moor.  They won’t know which way to look when Othello is speaking, unless he "looks" like a Moor. They didn't pay all that money to see someone "play" a Moor, they want him to "look" how they believe a Moor should look. Get the picture?

Yes, NWA didn't describe every black man's world in the 80s and Ice Cube didn't speak for all gangsters post-Rodney King.  John Singleton and the Hughes twins did make wonderful thug life movies – but they knew how the audience expected Moors to look, and they delivered what they were being paid to see.  Most of their audience NEVER spent life as a black man in Los Angeles, so for the viewer, unless bombarded with an equal quantity and quality of alternative media representations, the only picture they get, becomes the entire picture.

They may not know that Zhivago is actually an Arab, Kirk’s farm boy from Indiana is played by a Canadian Jew, or that the Japanese geisha played by a Chinese actress named Ziyi, is actually a girl named Zhang.  They may not know what a Moor is, but they when the see that Othello is black and Desdemona is white, they’ll understand that no goods gonna come of it.  That’s why I always play Othello, to make the picture complete.

I’ll always remember “The Cosby Show”, where people lived in a house, with a mom and a dad, and bothers and sisters, and we usually caught up with them between school and work, enjoying each others company, laughing, crying and learning life’s little lessons. I know why black people loved that show.  Finally, somebody was showing the rest of us to all of you.

“I’ll Fly Away”.  It was my favorite show, about people and race. The audience was reminded that black people and white people weren’t getting along so well in the past and that much hasn’t changed since then. It won 3 Emmys, 2 acting Golden Globe awards for Regina Taylor and Sam Waterson, 5 NAACP Image Awards, a Peabody Award and a Humanitas Award.  It was cancelled after two seasons.

I think these two shows did seek to portray that other, unseen, or rather… untelevised world where I think most black people, most white people, most every people actually live. I didn’t believe that “The Wire” would be that kind of show.  To be fair, I didn’t expect it to be.  To be fair, I’ve never watched it.  I just want to see something different. Something that shows more about who black people are, not just going deeper into who the media expects them to be.

I do not believe that any one or a handful of programs or movies can or should be responsible for showing us all the diversity that exists in the lives of the more than 12 million African-American people.  But I am worried for those who do, or attempt to.

The study of a television program to understand a people is no substitute for actually getting to know those people.  At best, the programming is a study of what the creators think the audience is comfortable seeing.  For me, it is comfort with an inner-city of black people consumed by drugs, poverty, crime and violence, Italian-Americans in New Jersey, Asian people running that DNA sample in the crime lab, Latinos being questioned by the police, Indians being wise and mystical (Native-American and South Asian, conviently) and every aspect of life from drama, to comedy, horror, game-shows, news, documentary, reality shows, etc – dominated by the presence of white people. And if the science fiction shows are any predictor, the trend continues well into the next few centuries – here on Earth and on most every planet we’ll discover; which should come as great news to white people everywhere, and the Jewish actors who play them on t.v.

If this is the beginning of the process of understanding our place in the world then, my brothers and sisters…let the church sing…

“Some glad morning when this life is o'er, I'll fly away;
To a home on God's celestial shore, I'll fly away (I'll fly away).

I'll fly away, Oh Glory
I'll fly away; (in the morning)"

When I die, Hallelujah, by and by,
I'll fly away (I'll fly away)…”

Capital Punishment

Writing on this topic had been on the queue for a few weeks, but alas, the New England Journal of Medicine got in an editorial before I had a chance.  The specific issue the editorial addresses is the role of the professional medical worker on assisting the state in taking an individual's life - brought on by the upcoming Supreme Court case, Baze v. Rees .  Clearly, the editorial argues against it:

"We are concerned that, regardless of its decision in Baze v. Rees, the Court may include language in its opinion that will turn again to the medical profession to legitimize a form of lethal injection that, meeting an appropriate constitutional standard, will not be considered "cruel and unusual punishment." On the surface, lethal injection is a deceptively simple procedure, but its practical application has been fraught with numerous technical difficulties. Without the involvement of physicians and other medical professionals with special training in the use of anesthetic drugs and related agents, it is unlikely that lethal injection will ever meet a constitutional standard of decency. But do we as a society want the nation's physicians to do this? We believe not."

I find it hard to believe that any medical professional would accept the duty to help the execution of a prisoner.  But it's still good idea for the NEJM to express the sentiment to its non-medical audience.  That being said, this case won't end the barbaric practice of capital punishment, just merely find a more 'humane' way to perform an 'inhumane' act.