Global Mental Health

Hi Folks,

We viewed several film clips following Pamela's lecture yesterday on global mental health.

Source: http://liberia-humanitarian.blogspot.com/

The first two were #4 and #6 from a series about the work of Médecins Sans Frontières (Doctors Without Borders) on confronting mental stress and trauma in Hebron, the Occupied Palestinian Territories.  

The second was a photo essay by Robin Hammond, a New Zealand photo journalist, about his work in documenting the problem of mental illness neglect in East Africa.

Finally, we viewed a positive story about efforts by the Carter Center to train mental health nurses in war-torn Liberia, as seen in the beautifully filmed documentary "Still We Rise."

I am adding these two links which update the work of Hammond and the Carter Center, as well.  

Victims of the Liberian civil war given hope

Meantime, Pamela stressed during her presentation that depression is a major cause of morbidity world wide, in the absence of war or natural disaster, with the greatest frequency occurring in the U.S.  This TEDxMet talk by Andrew Solomon, "Depression, the secret we share",  offers a vivid description of the debilitating effects of this disease for someone who has never suffered the atrocities in Hebron, South Sudan, or Liberia.  A similar story is told in this moving article by Scott Stossel, an editor at the Atlantic Monthly, about his lifelong struggle with anxiety.

Lastly, Pamela referenced the following studies regarding the allocation of mental health resources vis-a-vis the need in low-resource settings:

• WHO Mental Health Gap Action Program http://www.who.int/mental_health/mhgap/en/ 
• Lund et al. "Poverty and mental disorders: breaking the cycle in low-income and middle-income countries," Lancet 2011,Volume 378, Issue 9801, 22–28 October 2011, Pages 1502–1514.
• Moon et al. "The Global Health System: Lessons for a Stronger Institutional Framework," PLoS Med 2010, 7(1): e1000193. doi:10.1371/journal.pmed.1000193 

I hope you find these films thought provoking and consider how the mental health challenges faced in areas of conflict and low resources can be addressed through evidence-based research.

Take care, Jim

What Do Cows and Vaccines Have in Common? It's All in the Name

Hello Everyone,

As we learned this week from Roger's talk, rotavirus-caused diarrhea can be prevented in some children through vaccination.  So what is vaccination, anyway?  In the 18th century, English medic Dr. Edward Jenner noted that milk maids were typically unblemished with facial scars when smallpox affected the population where the milk maids lived and worked.  Jenner's observation was that milk maids would become infected with cowpox, a mild disease acquired while touching the infected udders of milk cows. Hence, the well-known adulation "she has the complexion of a milk maid."

Smallpox victim

Jenner deduced that cowpox infection conferred immunity in the milk maids to the much more disfiguring and deadly (30% fatality rate) smallpox or "variola" infection.  Thus, in the late 1790s, Jenner began a program of "vaccination" (a term derived from the Latin "vacca" for cow) using the pustules of cowpox (now known to contain vaccinia virus), creating the first effective and safe inoculation against deadly smallpox.  

However, it took some 50 years before this technique of deliberately infecting someone with the milder vaccinia virus was accepted by suspicious health practitioners steeped in traditional beliefs and mysticism.

Previously, in the 1700s "variolation" was the technique of choice, whereby dried scabs from smallpox victims were ground into a powder that was blown into the nose of those uninfected.  This did indeed confer immunity to smallpox, but up to 2-3% of "variolated" individuals died as a result. Thus, "vaccination" was the much safer and effective alternative to "variolation," as described in this short TED-Ed talk.

Ali Maow Maalina

The last naturally-occurring case of smallpox in the world was contracted in October, 1977 by Ali Maow Maalina,  a young man in Merka Town, Somalia.  Ali survived his smallpox infection and went on to dedicate himself to eradicating polio until his death last year, as reported on NPR.  In 1980 the World Health Organization certified that smallpox was eradicated from Earth.

The NIH National Library of Medicine offers an excellent historical review of the smallpox eradication campaign of the 1960s and 70s.

However, smallpox is the only disease affecting humans for which such an accomplishment has been successfully achieved, though feverish efforts are currently underway to eradicate poliomyelitis, whose champion is the Gates Foundation, and dracunculiasis, whose champion is the Carter Center.  Global eradication programs in the past have also targeted hookworm, malaria, yaws, and yellow fever, but without success.

Nonetheless, since the days of Jenner, vaccination has been tremendously successful in preventing the morbidity and mortality caused by many infectious diseases (see this fascinating vaccines timeline), and reduces associated disability, economic loss, and poverty, as described in this 2008 review article in the WHO Bulletin. 

Source: CDC, MMWR, 5 Apr 2014

Yet, like many public health successes, once a problem is controlled it is no longer seen and is therefore not perceived to be a problem by some.  Public complacency and even disbelief arise, particularly in developed countries where some advocate against vaccination.  The result is outbreaks of vaccine-preventable measles, mumps, and pertussis, for example, and associated medical/hospitalization costs and disability, e.g., mumps in adolescent and young adult men may cause sterility. 

Qs:  What are the key influences that cause someone to get themselves or their child vaccinated?  What are the barriers to vaccination acceptance?  Should vaccines be subsidized by governments, so that everyone, everywhere could be fully immunized at no or low cost on schedule?  Should people be free to choose to NOT be vaccinated?  What are the risks associated with this freedom of choice?

Take care and see you next week,

Jim

"Sex, Lies, and Cigarettes"

Hello Everyone,

I've assembled a few links that I think you'll find informative, particularly on tobacco, following Michele's lecture this week on cancer and tobacco use.

First, this photo of the tobacco CEOs swearing to tell the truth before Congress was taken during a hearing lead by Congressman Waxman (D-Calif) on April 14, 1994 (20 yrs ago next week) on the dangers of tobacco. They swore that tobacco was "not addictive," knowing all the while their research showed it was, based on internal tobacco company memos dating to the 1960s.  Michele pointed me to this fascinating document published by WHO in 2008 that chronicles the tobacco companies' public relations efforts, beginning in the late-1990s,  to "re-invent" their corporate image, even admitting publicly, e.g., Phillip Morris, that nicotine is the addictive agent in tobacco.

The hearings came about thanks to an insider whistle blower, Jeffery Wigand, a former Vice President for Research and Development for Brown & Williamson Tobacco Corporation who learned early on in his career that the tobacco industry was manipulating nicotine levels in tobacco products to make them more addictive. Russell Crowe portrays Wigand in the Oscar nominated film "The Insider."

Second, the Waxman hearings fundamentally changed the way the US viewed cigarettes and tobacco use, eventually leading to the landmark settlement agreement of $368.5 billion between the tobacco industry and the state attorneys general.  These funds led to the creation of an archive of tobacco industry documents (revealed during trial discovery) and organizations like the American Legacy Foundation.  

Third, while the tobacco industry has been stymied in the US where tobacco use rates are declining (< 20% of Americans smoke), the industry is full steam ahead in the developing world, as described vividly in this 41 minute Vanguard documentary "Sex, Lies, and Cigarettes" which we watched after Michele's lecture.  

For example, in China less than 2% of women smoke, compared with nearly 53% of men.  For the tobacco industry, this means 98% of Chinese women are potential smokers. The challenge, from a marketing perspective, is how to convince young Chinese women that smoking is not for prostitutes (a longstanding cultural association) but for the modern Chinese woman.   Check out these cigarette ads to see how the industry conveyed this image to the 1960s woman, which is parodied in the film "Thank You for Smoking" about the tobacco lobby.  

Regarding electronic nicotine delivery devices (ENDs) or "e-cigarettes," unlike tobacco cigarettes, these products are not regulated by the FDA, as there is no health claim made by the manufacturers.  One argument in favor of e-cigarettes is that they are a reasonable alternative for smokers who want to quit smoking, much like other nicotine replacement products, such as gum or patches (which are regulated by the FDA because the manufacturer makes a health claim about the product).  Arguments against e-cigarettes are that the manufacturers, many of which are multinational tobacco industries, like Phillip Morris (aka Altria), British American Tobacco, and R.J. Reynolds, are marketing e-cigarettes towards youth, just like tobacco cigarettes (glamorous, sporty, youthful, sexy, etc.) with the intent that the youthful user will become addicted to nicotine (which is as addictive as cocaine) and switch to tobacco or use both.  A win-win for the tobacco industry, it seems.

Lastly, on cancer and environmental exposure, Sir Percival Pott studied and reported in 1775 on "chimney sweep's cancer" or "soot wart."  This was an occupational hazard (later identified as squamous cell carcinoma) of the scrotum in young boys who cleaned the soot and creosote from fireplace chimneys in England.  A dose-response relationship is demonstrated here, in that boys starting as early as age 6 would be exposed to soot that was not washed off for months at a time, allowing prolonged exposure to the carcinogens in soot to accumulate in the ridges of the scrotal skin, leading to a "soot wart," invasion of the testes, and eventually up the spermatic cord to the abdomen.

Eventually, England and other countries banned the use of child labor for this task (but not necessarily others, like weaving, servants, etc. until the 20th century.)

Qs for thought: If you look at tobacco companies' websites, it is clear that they now admit that nicotine is addictive and say people should quit smoking.  If this is true, why are they still in business?  What was the net profit of, say, Phillip Morris, last year?  Hint: not in the millions.  What about profits from e-cigarettes?  Does money speak to power in our democracy, thus obviating any potential for change?

Regarding environmental exposures and cancer, is more regulation of carcinogens likely to keep us safe from developing, say, lung cancer from radon (remember my earlier blog post on this element)?  What is the balance between imposed regulation and personal choice?  If so, how is this balance defined scientifically?

Hope you find this discussion informative.

Jim

ACT-UP! The HIV and TB Pandemics

HIV-1 (in green) budding from cultured lymphocyte; Source: CDC

Hi Everyone,

I'm glad to see that you all enjoyed Peter's lecture this week.  He really knows his stuff on HIV and TB! 

Regarding the former, "And the Band Played On" is an excellent book (1987) by the late Randy Shilts (and 1993 HBO film starring Matthew Modine and Alan Alda) that chronicles the early days of the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) epidemic and the social, political, and science issues confronting the world when so little was understood about the nature of this infectious disease.  More recently is "How to Survive a Plague," the Academy Award

Brian Fitzgibbon and Jim Herrington, Peace Corps Senegal, 1980

Nominee for Best Documentary about "two coalitions—ACT UP and TAG (Treatment Action Group)—whose activism and innovation turned AIDS from a death sentence into a manageable condition."  Unfortunately, the tide was not turned soon enough to save my good friend and Peace Corps colleague, Brian Fitzgibbon, who died of AIDS in 1993, just before antiretroviral therapies (ARTs) became widely available.

Although AIDS is now considered a chronic disease, because drug therapy is affordable and works, the prevention of new cases (incidence) is challenging, given the preventive choices in most low-income countries are still the ABCs = abstinence, be faithful, and condoms, with an  additional "C" for men = male circumcision.   Further, the "Vaginal and Oral Interventions to Control the Epidemic" or VOICE Trial was hoped to provide an antimicrobial vaginal gel and oral tablets that would prevent HIV infection.  Unfortunately, the trial was stopped because trial participants were not actually taking the oral or gel products, even though they self-reported adherence when asked by research managers.  This is not unlike what is termed social desirability bias in research, where participants tell the researchers one thing, while actually behaving in a manner discordant to their verbal statements.

TB prevention campaign poster from the 1920s

Tuberculosis, the second disease Peter discussed during his lecture, is a much more worrisome infection than HIV, given roughly 1/3 of the world's population is infected with the mycobacterium that causes TB and because it it spread by the respiratory route of exposure. A single sneeze can release up to 40,000 aerosol droplets 0.5 to 5.0 µm in diameter.  Sal Khan of Khan Academy fame, gives a clear, short description of the symptoms of and mechanisms of exposure to TB.

Prior to the advent of modern antibiotics, as shown in this health film from the UK, TB was treated in sanatoriums which offered collapsed lung therapy, isolation to prevent the spread of the disease, fresh air, sunshine, and rest.  Modern drugs now permit successful treatment of TB, sans sanatorium.  However, the patient must be adherent to the treatment regimen and not quit therapy early.   If not, multi-drug resistant tuberculosis (MDR-TB) results, which is much more costly and difficult to treat, but not impossible, as described in this short film, narrated by actor Brad Pitt, about Partners In Health's successful efforts in Lima, Peru.   

Cover that cough in your elbow and wash your hands with soap and water after sneezing!

Jim

Proportion of MDR-TB among new TB cases, 1994-2012; Source: WHO http://www.who.int/tb/challenges/mdr/en/