Bad Samaritans?

I suspect this is an incredibly naïve, not to mention unpopular, opinion, but I suppose in these times of plague, I should be grateful we have borders -fences that keep them out, walls that keep us safe. But I’m not. I’ve always mistrusted borders: I’ve always been suspicious of boundaries that artificialize the denizens of one region -that privilege residents as opposed to non-residents, friends versus strangers, our needs compared to theirs.

Call me unworldly, but what makes me special, and you not so? It seems to me the italics I have used to mark differences, are as arbitrary as the differences they mark. We are all the same, and deserve the same consideration.

That said, we seem to be stuck with countries determined only to look after their own -even with the global crisis in which we find ourselves in these special, but frightening times. In a desperate attempt at historical recidivism, we are attempting a re-balkanization of the world.

But what is a country, anyway? And does it have a special providence -or provenance, for that matter? I happened upon an interesting essay by Charles Crawford, who once served as the UK Ambassador to Sarajevo and Belgrade discussing much the same thing: https://aeon.co/essays/who-gets-to-say-what-counts-as-a-country

As he writes -‘There are only two questions in politics: who decides? and who decides who decides? … Who gets to say what is or is not a country? For most of human history, nation states as we now recognise them did not exist. Territories were controlled by powerful local people, who in turn pledged allegiance to distant authorities, favouring whichever one their circumstances suited. In Europe, the tensions in this system eventually led to the Thirty Years’ War which… ended in 1648 with a thorough revision of the relationship between land, people and power. The resulting set of treaties, known as the Peace of Westphalia, introduced two novel ideas: sovereignty and territorial integrity. Kings and queens had ‘their’ people and associated territory; beyond their own borders, they should not meddle.’

Voila, the modern idea of states, with loyalties only to themselves. But embedded in the concept were at least two principles -two problems: ‘The first is self-determination: the idea that an identified ‘people’ has the right to run its own affairs within its own state. The other is territorial integrity: the notion that the borders of an existing state should be difficult to change.’ But borders soon spawned customs and attitudes that were different from those on the other side –theirs were different from ours, so they must be different from us. An oversimplification, to be sure, but nonetheless a helpful guide, perhaps.

Borders can change, of course, but not easily, and often not without considerable turmoil. Think of ‘the separation of Bangladesh from Pakistan in 1971 [which] claimed up to a million lives… Ambiguous ceasefires can drag on indefinitely. Taiwan and its 23 million inhabitants live in a curious twilight zone of international law, recognised by only 22 smaller countries and the Vatican.’ Examples of each, abound.

And not all borders were established to reconcile linguistic, ethnic, or religious differences. There are many examples, but perhaps the most egregious borders in modern times were those largely arbitrary ones in the Middle East drawn by two aristocrats Mark Sykes from Britain, and Francois Georges-Picot from France in 1916. As Wikipedia describes: ‘it was a secret agreement between Britain and France with assent from the Russian Empire and Italy, to define their mutually agreed spheres of influence and control in an eventual partition of the Ottoman Empire.’

A famous quotation that encapsulates the attitude was that of Sykes: ‘At a meeting in Downing Street, Mark Sykes pointed to a map and told the prime minister: “I should like to draw a line from the “e” in Acre to the last “k” in Kirkuk.”’-a straight line, more or less.

Crawford’s essay was intended to explain the continuing tensions in the Balkans, but it raises a pertinent question for these times -namely, ‘Should nations stay within their historical boundaries, or change as their populations do?’ Or, put another way, should boundaries remain impermeable to needs outside what I would term their arbitrary limits?

With the current pandemic, there are, no doubt, many reasons that could be offered for being selective at borders: family-first ones, by and large. We need to close our borders to support our own economy, feed our own people; in the midst of a global epidemic, it is not the time to sacrifice our own needs by offering altruism to others. Actually, it seems to me that the underlying belief is that migration -legal or otherwise- is a large contributor to the spread of the infection. But once a communicable virus is in the country, its own citizens also become vectors -and they far outnumber the number of refugees or migrants.

Rather than being focussed on borders and exclusion, efforts would likely be more intelligently spent on things like temporary isolation of any who may have been in areas where the epidemic may have been less controlled, and enforced social separation (social-distancing) of everybody else. Consistent, and frequently publicized advice and updates about new developments to educate the public -all the public- is key to managing fear. And epidemics -they have a habit of evolving rapidly.

And testing, testing, testing. Unless and until, we know who might have the infection and be a risk to others, we are essentially blinkered. It’s not the strangers among us who pose the risk, it’s those who are infected and either have no symptoms or who are at the earliest stages of an infection that has not yet had time to declare itself.

The World Health Organization (and others) have pointed out that travel restrictions not only divert resources from the containment effort, they also have human costs. ‘Travel measures that significantly interfere with international traffic may only be justified at the beginning of an outbreak, as they may allow countries to gain time, even if only a few days, to rapidly implement effective preparedness measures. Such restrictions must be based on a careful risk assessment, be proportionate to the public health risk, be short in duration, and be reconsidered regularly as the situation evolves. Travel bans to affected areas or denial of entry to passengers coming from affected areas are usually not effective in preventing the importation of cases but may have a significant economic and social impact.’ And, as all of us realize -and expect- by now: ‘Travellers returning from affected areas should self-monitor for symptoms for 14 days and follow national protocols of receiving countries.’ Amen.

Turning away migrants often has some desired political effects, however: diverting attention away from the receiving country’s possible lack of preparedness and foresight. It’s seldom about the Science and more about Nationalism -further stoking fears of the other.

I think that at the moment, we are forgetting, as was immortalized in that ancient Persian adage that, This, too, will pass. The pandemic will exhaust itself, and likely soon become both amenable to a vaccine and other medical therapy. And those affected will not soon forget -nor will those denied entry in their time of need. As our economies rebuild in its wake, we -and they- will need all the allies we can muster. Best to be remembered as a friend who helped, than someone who turned their back.

We really are all in this together. As one of my favourite poets, Kahlil Gibran writes, ‘You often say,I would give, but only to the deserving.” The trees in your orchard say not so… They give that they may live, for to withhold is to perish.’

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

When Thou Liest Howling

There are some things we just don’t want to acknowledge aren’t there? Some things that we would rather not hear, not so much because we don’t think they’re important, but because they embarrass us… Or maybe offend us. Sexually transmitted diseases are prime examples.

For some reason, many of us find them difficult to talk about. Admittedly they require rather special venues, and the very subject casts long shadows on the interlocutors no matter how discreetly it is introduced. Rather than appearing as an intimate trust issue, the very fact of its being raised in the first place tends to arouse suspicion -accusations by proxy.

At first, I wondered if this attitude might be a generational thing. I was raised in an era when the most feared unintended consequence of premarital sex (as we called it then), was assumed to be pregnancy; VD -another time-specific term for sexually-acquired disease- was confined to clearly recognizable and therefore potentially avoidable people. This naïveté, of course, didn’t prepare us for the inevitable consequences of our wide-eyed ignorance and even nowadays, those of us still around could yet be dragged, aged and surprised, into the vortex as I outlined in an essay elsewhere:  https://musingsonretirementblog.com/2016/10/16/too-good-to-be-true/

The initial solace of antibiotic treatment also proved too good to be true. Throughout history, sexually transmitted infections were a scourge –the wages of sin as they were considered then. But with the advent of effective treatments, those debts were forgotten –although clearly not forgiven.

Syphilis, gonorrhea, and the more recently characterized chlamydia exacted a terrible toll on fertility and long term health, but until recently, all were fairly amenable to antibiotic therapy –albeit a necessarily changing one. Gonorrhea, however, seems to be particularly adept at developing resistance to the various antibiotics thrown at it.

There are various mechanisms by which a bacterium can become antibiotic-resistant but a common and easily appreciated reason is inadequate initial treatment. Even if an antibiotic is effective, there will usually be some bacteria that are less sensitive to it for whatever reason, and hence require longer antibiotic exposure for it to affect them. People tend to continue treatment only until they feel well –in other words, until the number of bacteria infecting them has fallen below whatever level was required to cause the symptoms. Unfortunately, the few bacteria that remain, are the less sensitive ones that weren’t so easily killed off at the beginning.

Physical barriers to the acquisition of sexually transmitted infections –condoms, for example- are certainly helpful, but men don’t tend to wear them with oral sex, the World Health Organization (WHO) has warned:  http://www.bbc.com/news/health-40520125  This has led to an increasing problem with throat infections according to the BBC News article. ‘Gonorrhoea can infect the genitals, rectum and throat, but it is the last of these that is most concerning health officials.

‘Dr Wi [from the WHO] said antibiotics could lead to bacteria in the back of the throat, including relatives of gonorrhoea, developing resistance. She said: “When you use antibiotics to treat infections like a normal sore throat, this mixes with the Neisseria species in your throat and this results in resistance.” Thrusting gonorrhoea bacteria into this environment through oral sex can lead to super-gonorrhoea.’

The problem is that a throat infection with gonorrhea may be relatively asymptomatic and hence more likely to be inadvertently transmitted to someone else. And ‘It’s hard to say if more people around the world are having more oral sex than they used to, as there isn’t much reliable global data available. Data from the UK and US show it’s very common, and has been for years, including among teenagers.

‘The UK’s first National Survey of Sexual Attitudes and Lifestyles, carried out in 1990-1991, found 69.7% of men and 65.6% of women had given oral sex to, or received it from, a partner of the opposite sex in the previous year. By the time of the second survey during 1999-2001, this had increased to 77.9% for men and 76.8% for women, but hasn’t changed much since.

‘A national survey in the US, meanwhile, has found about two-thirds of 15-24 year olds have ever had oral sex. Dr Mark Lawton from the British Association for Sexual Health and HIV said people with gonorrhoea in the throat would be unlikely to realise it and thus be more likely to pass it on via oral sex.’

And apparently there are only ‘three drug candidates in the entire drug [development] pipeline and no guarantee any will make it out.

‘Prof Richard Stabler, from the London School of Hygiene & Tropical Medicine, said: “Ever since the introduction of penicillin, hailed as a reliable and quick cure, gonorrhoea has developed resistance to all therapeutic antibiotics. In the past 15 years therapy has had to change three times following increasing rates of resistance worldwide. We are now at a point where we are using the drugs of last resort, but there are worrying signs as treatment failure due to resistant strains has been documented.”’

So, we’ve got a potentially untreatable, possibly asymptomatic, and very definitely prevalent infection out there, and a societal reluctance to talk about it… Perhaps it’s time for another approach. Fortunately there is an active search for a gonorrhea vaccine –and a serendipitous observation may have suggested a possible route –although, in retrospect, it seemed an obvious place to start. http://www.bbc.com/news/health-40555702

‘The vaccine, originally developed to stop an outbreak of meningitis B, was given to about a million adolescents in New Zealand between 2004 and 2006. Researchers at the University of Auckland analysed data from sexual health clinics and found gonorrhoea cases had fallen 31% in those vaccinated.

‘The bacterium that causes meningitis, Neisseria meningitidis, is a very close relative of the species that causes gonorrhoea – Neisseria gonorrhoeae. It appears the Men B jab was giving “cross-protection” against gonorrhea.’ This is very early in the work, however, and it seemed only to be effective in a third of those vaccinated. But it is certainly encouraging.

Be that as it may, however, I can’t help but worry that if there is development of an effective vaccine against gonorrhea, it will once again fool us into forgetting about the other diseases potentially transmissible by oral sex, including viruses such as hepatitis, herpes, and HPV (for which, thank god, there is also an effective vaccine), not to mention the bacterially-caused ones like syphilis, chlamydia, and many others that don’t make for salacious headlines.

But I’m not advocating for the formation of a Temperance League to combat a practice that is likely as old as humanity, nor do I have any religious or ideological objections to its persistence in our society, but I do believe that the Past informs the Future. I think that it would be prudent to ensure that all participants –newcomers to the field, as well as those who have already passed through and are merely nibbling at memories- have a working knowledge of those risks that should not be placed, as Shakespeare put it, on the windy side of care

I just wonder if those who are entrusted with sexual education nowadays would put it so beautifully.

 

 

 

 

 

 

 

 

 

 

 

 

http://www.bbc.com/news/health-40555702

 

 

Violence Against Women

According to a recent meta-analysis by the World Health Organization, one in three women worldwide are subject to intimate partner violence (IPV) http://www.sciencemag.org/content/340/6140/1527.short . And it’s not just a third world problem either, as we Canadians with our often parochial outlook would no doubt like to believe. True, some countries seem to be over-represented: ‘East Asia having the lowest incidence, at 16.30% (range, 8.9% – 23.7%), and Central Sub-Saharan Africa having the highest incidence, at 65.64% (range, 53.6% – 77.71)’, but we in Canada are certainly not immune. http://www.huffingtonpost.ca/kirsty-duncan-/harper-womens-rights_b_4435285.html

Recognizing this, there has been a move to screen women for IPV in hopes of decreasing the violence or improving the outcomes for the victims. However, in a review published in the May 13 edition of the British Medical Journal, the lead author, Dr. Lorna O’Doherty from the University of Melbourne ‘Did not detect a decrease in rates of violence in women’s lives as a result of screening nor did it find improved mental and physical health outcomes for women.’ http://bit.ly/1m6Vskr

I have to admit that I had hoped that screening would have had more of an effect than is reported, but maybe on closer examination there are readily identifiable reasons for this. The whole issue seems to involve a complex algorithm with a lot of contextual conditions that have to be considered. First of all, the woman may not yet be ready to admit abuse is taking place; she may not actually see it as ‘abuse’ and so is unlikely to report it as such, even if asked. Or, perhaps she has thought about it, but isn’t yet ready to address or admit the issue –especially to others because of the stigma. There are phases through which she needs to progress in accepting and addressing the abuse. And yet, even if she is ready, her ability to admit it to someone else is going to be predicated on several factors -the WHO report again (and I quote an article in Medscape for the summary):

The report points out that certain healthcare settings (eg, antenatal clinics and HIV screening clinics) offer good opportunities to spot problems and intervene.

However, to be effective in such situations, the recommendations say, certain minimum standards need to be in place. Those include that:

  • providers need to be trained on how to ask about violence,
  • standard operating procedures need to be in place,
  • consultations need to take place in private settings,
  • confidentiality needs to be guaranteed,
  • referral arrangements need to established and maintained, and
  • providers need to be properly equipped to handle the physical and mental consequences of sexual assault.

This sounds reasonable; our obstetrical delivery unit provides universal IPV screening, but I am disappointed with the finding in that study published in the British Medical Journal that even so, the mental and physical outcomes for those women were not improved. And although we are probably missing the vast majority of women who suffer from abuse (and in some cases men as well -but more likely detected in a different venue), one would still like to hope that for those we have found, discovering the problem would be a step towards its solution.

But I think that public recognition of the problem is an equally important, if preliminary step. I sometimes wonder if we inadvertently stigmatize IPV because we, as a society, simply do not acknowledge it. It is something we’d rather not think about, or if we do, we do so judgementally. So, despite various professionals attempting to detect it and thereby (it was hoped) ameliorate the consequences, the victims remain reluctant to admit it is even happening. They, like the rest of us, see it as shameful and perhaps reflecting on their own choices, their own self-worth…

I’m reminded of our Canadian disgrace: the seeming indifference to the disappearance and violence against our Aboriginal women. There is, of course, lip service acknowledgement by the government that there might be a problem, but a rather indignant assurance that they are taking steps to resolve the issue seems to be all they have to offer. One could be forgiven for wondering whether they simply didn’t want any more public attention drawn to the problem.  http://www.huffingtonpost.ca/2013/09/19/canada-un-aboriginal-women_n_3952425.html

I see the problem of violence against women differently. I think that the more it is publicized, the more it will be recognized, and the more will be society’s demand that the hitherto secret norm of violence will be seen to be inappropriate –no, not inappropriate, wrong. Think of the changing (I’d like to say changed but I suspect it would be premature) attitude to drinking and driving. As a society, we are realizing it is something to be condemned, not tolerated. Something that can be, and should be, discussed in the open. Something that is no longer acceptable…

It is possible to alter behaviour we have always viewed as undesirable, yet secretly condoned by our unwillingness to confront it. We need to acknowledge and tackle it as a society –and we need confront it often, publically, rationally, doggedly. I am reminded of something Lucretius wrote: The drops of rain make a hole in the stone, not by violence, but by oft falling.