A Plague on All Your Houses



I still remember a seminar I went to years ago in university. It was part of a nebulous course on ‘Health’ that some of us took as a soft route on the way to a bachelor’s degree. It was reputed to consist of essays and a true or false final examination. Also, because the class was small, it was amenable to division into even smaller numbers for several interactive sessions.

There were five of us and a teacher’s aide at the one I remember so well. We were all fresh from high school and, at least in those faraway days, used to being lectured at, rather than actually contributing to the subject matter. The topic that day was Disease, and I remember being mildly interested, but expecting only a list of the usual culprits, complete with causes and treatments -memory fodder for later regurgitation, I suppose.

“What is disease?” the TA started, as soon as we were seated around a rather small wooden table.

One of us -I don’t remember his name now- rolled his eyes and smiled. “Sickness,” he answered, rather smugly.

She smiled in return, as if he’d fallen into her trap rather too easily. “Okay, but haven’t you just used a synonym -defined it in terms of itself?”

He stared at her for a moment, obviously confused. “Well… then, how about saying disease is an abnormality of an organ or a system caused by germs -probably particular germs depending on the disease.”

Her face relaxed and her smile broadened. “Now we’re getting somewhere.” She leaned forward on the table. “Let’s get more specific for a moment. Let’s take tuberculosis… Anybody know the cause for TB?” She glanced around the room, determined to involve us all, apparently.

I looked up at the wrong moment, and she brushed my face with her question and pinned me to my seat with another smile. “Do you know the cause of TB…?” she said, locking eyes with me.

There was no escape. “Uhmm…” I felt embarrassed at being singled out, but the question seemed fairly straightforward. “It’s the tubercle bacterium, isn’t it?”

She sat back in her chair, and shrugged nonchalantly. “Is it?” She said, softly and with just a hint of gentle sarcasm. But her eyes were still sitting on me, and I could tell they meant no harm.

“Tubercle bacillus?” I corrected myself, remembering that people sometimes called it that.

“So…” she glanced around the table again, lifting the weight off my shoulders. “Would you all agree that TB is caused by a bacterium -a bacillus?” she added, looking at me once more. Everybody nodded.

“But don’t some healthy people have a positive skin test for it -the Mantoux test?” she continued.

We all nodded, most of us unwilling to show that we hadn’t known what the test was called.

“So, why is that?” She paused to see if any of us had an explanation, but when nobody said anything, she continued. “If the bacterium Mycobacterium tuberculosis is present…” she slowed down even more for effect. “… if some of us have it… and it causes TB… then why don’t those people have TB?” She straightened in her chair and leaned on the table with her elbows as she searched our faces for the answer.

But she was greeted by blank, albeit confused expressions around the table.

“If disease is caused by the acquisition of a bacterium, then what stops some people from acquiring the disease?”

This was new territory for us, and yet, her eyes stopped at me again. “Our defense mechanisms -the immune system…?” I suppose it wasn’t exactly a scholarly response -even in those days we’d all heard of vaccinations and antibody production.

She started nodding. “Okay, but what makes the immune system strong enough to resist?”

“VSG?” someone said, and immediately blushed because he had obviously taken a leap in the dark with the initials.

She smiled reassuringly. “BCG -Bacille Calmette-Guerin, to give it its full name?” He nodded, presumably relieved. But even in those days, there was some doubt as to its effectiveness, so she merely shrugged again. “But the person may never go for the skin test and so never know she has the bacterium…”

She stared at me again, for some reason. “Well, suppose they’re in good condition -healthy, I mean?” To tell the truth, I didn’t really know what I meant.

“But doesn’t ‘healthy’ mean free of disease? Isn’t that another tautology…?” She walked around the table with her eyes again, but this time more slowly. “So, might there be other causes of disease -apart from the infecting agent, I mean?”

I remember some of us looking at each other, as if we were beginning to understand where she was going with this.

“Where -or maybe under what conditions- do we see a lot of diseases like TB?”

I suppose I remember the seminar so well, because she kept looking at me when nobody else answered. “You mean if somebody’s poor, or living in unfortunate circumstances? Poverty…?” I managed to mumble, hoping that was what she was after.

I still remember her smile.

It was a seminal moment for me, and maybe one of the reasons why I eventually went into Medicine. But it all resurfaced when I happened upon an article in the CMAJ (Canadian Medical Association Journal) from January 22/18 with the rather long and certainly uninviting title, Effect of provincial spending on social services and health care on health outcomes in Canada: an observational longitudinal study: http://www.cmaj.ca/content/190/3/E66

Its thesis, was that spending on health care is escalating so significantly it will soon be unaffordable. The question then, was what to do about it. The study ‘used retrospective data from Canadian provincial expenditure reports, for the period 1981 to 2011, to model the effects of social and health spending (as a ratio, social/health) on potentially avoidable mortality, infant mortality and life expectancy.’ And after using various methods to analyze the figures that I didn’t even try to understand, like ‘linear regressions, accounting for provincial fixed effects and time, and controlling for confounding variables at the provincial level.’ decided that ‘Population-level health outcomes could benefit from a reallocation of government dollars from health to social spending […].’ Or, as they worded it more succinctly in their concluding paragraph: ‘The results of our study suggest that spending on social services can improve health. Social policy changes at the margins, where it is possible to affect population health outcomes by reallocating spending in a way that has no effect on the overall government budget.’

It made me wonder, though, why, if I learned the same thing many years ago, did it still need investigation? Were we so wrong back then? So naïve…?








What is the Merit of Originality?

‘I am not young enough to know everything,’ as Oscar Wilde once said, and maybe the rest of us aren’t either. It is often an unquestioned assumption that New trumps Old, that innovation usually leads to improvement, and that by standing on the shoulders of giants, the view is necessarily better. Clearer.

But there is wisdom in both the long as well as the panoramic views. Neither changing  your shoes nor altering your hat, really improves the safety of a voyage -nor does it address the original goal of a safe arrival of everybody on board. Appearing modern, seeming prepared, only helps if it helps –a leak is still a leak, especially if there are only lifeboats for a few…

Let me explain. I happened upon an article in the journal Nature that chronicled the introduction of a new, and highly accurate method of diagnosing TB through genetic analysis.  https://www.nature.com/news/improved-diagnostics-fail-to-halt-the-rise-of-tuberculosis-1.23000?WT ‘The World Health Organization (WHO), promptly endorsed the test, called GeneXpert, and promoted its roll-out around the globe to replace a microscope-based test that missed half of all cases.’ It sounded like a perfect technological fix for a disease that has so far avoided effective control. ‘Some 10.4 million people were infected with TB last year, according to a WHO report published on 30 October [2016?]. More than half of the cases occurred in China, India, Indonesia, Pakistan and the Philippines. The infection, which causes coughing, weight loss and chest pain, often goes undiagnosed for months or years, spurring transmission.’

Unfortunately, ‘[…] the high hopes have since crashed as rates of tuberculosis rates have not fallen dramatically, and nations are now looking to address the problems that cause so many TB cases to be missed and the difficulties in treating those who are diagnosed. […] The tale is a familiar one in global health care: a solution that seems extraordinarily promising in the lab or clinical trials falters when deployed in the struggling health-care systems of developing and middle-income countries. “What GeneXpert has taught us in TB is that inserting one new tool into a system that isn’t working overall is not going to by itself be a game changer. We need more investment in health systems,” says Erica Lessem, deputy executive director at the Treatment Action Group, an activist organization in New York City.’

But I mean, just think about it for a minute. ‘The machines cost $17,000 each and require constant electricity and air-conditioning — infrastructure that is not widely available in the TB clinics of countries with a high incidence of the disease, requiring the machines to be placed in central facilities.’ Sure, various groups agreed to subsidize the tests in 2012, but: ‘each cost $16.86 (the price fell to $9.98), compared with a few dollars for a microscope TB test.’ So which test would you choose if you were a government strapped for cash to provide for healthcare for a broad spectrum of other equally pressing needs?

‘Even countries that fully embraced GeneXpert are not seeing the returns they had hoped for. After a countrywide roll-out begun in 2011, the test is available for all suspected TB cases in South Africa. But a randomized clinical trial conducted in 2015 during the roll-out found that people diagnosed using GeneXpert were just as likely to die from TB as those diagnosed at labs still using the microscope test.’ That seems counterintuitive to say the least.

So what might be happening? ‘Churchyard [a physician specializing in TB at the Aurum Institute in Johannesburg, South Africa] suspects that doctors have been giving people with TB-like symptoms drugs, even if their microscope test was negative or missing, and that this helps to explain why his team found no benefit from implementing the GeneXpert test. Others have speculated that, by being involved in a clinical trial, patients in both arms of the trial received better care than they would otherwise have done, obfuscating any differences between the groups.’

‘Even with accurate tests, cases are still being missed. Results from the GeneXpert tests take just as long to deliver as microscope tests, and many people never return to the clinic to get their results and drugs; those who begin antibiotics often do not complete the regimen.’ Clearly, technology alone, without an adequate infrastructure to support it –without a properly funded and administered health care system- is not sufficient.

And it’s simply not enough to have even a well-funded health system that benefits just those who can afford it, leaving the rest of the population to fend for itself, and only seeking help when they can no longer cope –often when it is too late. Health care is a right, not a privilege –no matter what those in power would have us believe.

I’m certainly not arguing that improving technology is not part of the solution, but sometimes I wonder if it is merely putting new clothes on a beggar. Handing out flowers in a slum.

Let’s face it, real Health Care is more than a sign on a door, more than a few people in white coats. It is a kind of national empathy. A recognition that even the poorest among us, have something valuable to contribute; that even those who have strayed from society’s chosen path, are who any of us might be, but in different clothes.

The myth of Baucis and Philemon tugs at my memory: They were an old married couple living in a small village in Anatolia (part of Asian Turkey nowadays) who, unlike everyone else in the town, welcomed two peasants at their door who were seeking refuge for the night. The couple, of course, were unaware that they were actually welcoming two gods, Zeus and Hermes, disguised as humans. A common enough trope, perhaps, but an instructive one, I think -one that transcends virtually all cultures, and borders: the idea of helping others without any expectation of reward. It is not an exchange -a transaction- so much as an action. Agape, in fact.

Health care is like that. Or should be… It’s not about the glittering display in the shop window –there to impress the passersby- it’s about the people in the shop.














Once Upon a Time

Once upon a time, rumour had it that we were at the top of our game –nothing else came close. Well, maybe chimpanzees, but come on –they don’t even have a decent language, so how would we know? Anyway, we had no real competitors, and –just in case- we wrote the rules and we were the judges. Until now, that is.

It seems that the pigeon cartel has moved in on mammograms and apparently there is a push to read pathology slides as well: http://www.bbc.com/news/science-environment-34878151  Now I don’t want to come across as a Speciest, or suggest that I  wouldn’t welcome a family of them living down the street or anything, but it seems to me that we have draw the line somewhere. Jobs are going to be lost; an industry is in jeopardy. I mean, why would we train people for years and go to the expense of kitting them out in those long white coats that need constant laundering when it would be so much easier to head downtown and pull a couple of pigeons out the park? So what if they shed their feathers? Do we ever have enough pillows? And diseases they might carry? Show me a pathologist who is sterile and I’ll show you a hologram. And besides, you don’t have to put the pigeon on anybody’s breast, do you? They are experts once-removed –twice removed if you kept the cages in another room altogether. Mind you, the cooing sounds would help to allay the anxiety over the anticipated and legendary pain of pressing a perfectly good breast into an X-ray sandwich so compromises may evolve.

Now, I can foresee some difficulties in training the birds to use the standard-issue microscopes, though. Some thought will have to go into new designs for the eye-pieces, I suspect. Oh, and wing-activated focussing devices, too. For years we’ve been selfishly designing stuff for fingers and spectacle-wearing eyes straddling long and often itchy noses; it’s long since time to start thinking beaks and feathers.

But utilizing pigeons may just be the first tentative step in revolutionizing medicine –farming it out, as it were. The article also whispers about glimpses of giant African pouched rats detecting tuberculosis –something to do with stuff they keep in those pouches, I’ll bet. In breathless anticipation of a bespectacled, stethoscope-wielding animal with huge teeth and accompanied by the characteristic snaky tail, I was relieved that Google only displayed the nice ones you could feed peanuts to -the cute ones that nobody would mind crawling over her chest looking for little bits of TB. And maybe with a few modifications they could be induced to do mammography kinds of quests and check for cancer while they’re in the neighbourhood. Maybe, if they caught on as pets, we’d have a lot less disease to worry about. Oh sure, there’d be other stuff –fleas, for example, and maybe plague- but everything’s a trade-off isn’t it? We could train people in turn to learn to balance risks. Decide what’s really important to them or their families. I mean, don’t we already do this with sports and their attendant injuries? You have to admit that a lot more of us suffer from concussions than die from the Black Death nowadays. And then there’s the whole panoply of traffic –related issues. Uhmm, did I already mention war?

No, we have to look further afield than we have to date: new answers; new questions, even. I don’t know… I suppose it’s only a dream, but I’ve always felt we would all be better off using what’s around us, rather than destroying it. Joining the web of life, not tearing it down. We are Nature, for goodness sakes.

Who knows, this refreshing outlook might spawn new and exciting industries… I didn’t actually mean to use the word ‘spawn’. We haven’t yet enlisted salmon in our quest for laboratory help, although their legendary ability to see underwater might be a real boon to public health infrastructures –in waste treatment and the like. But don’t hold your breath; it’s coming. We’ve barely even splashed the surface!