The Adventure of the Cure That Wasn’t

Published June 16, 2014 | Share your thoughts
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The Remedy: Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis (2014)
Thomas Goetz
320 pages

*Originally published in Speaking of Medicine (PLOS).

Marzieh Ghiasi and Madhukar Pai from McGill University & McGill International TB Centre, Montreal, review “The Remedy” by Thomas Goetz

No image is more iconic of the Victorian age than that of a detective with a deerstalker cap, pipe, and magnifying glass roaming the dark streets of London in search of criminals and murderers. Hidden in plain sight, the real killers of the nineteenth century were infectious diseases such as tuberculosis, responsible for as many as a quarter of all deaths in that era.

In The Remedy (2014) science journalist Thomas Goetz recounts the stories of Robert Koch, the founder of modern bacteriology, and Arthur Conan Doyle, the physician-author of the Sherlock Holmes series. In two narratives that run in parallel and eventually intersect, Goetz introduces a cast of pioneering medical detectives, from Koch’s scientific rival Louise Pasteur, to Conan Doyle’s inspiration for Sherlock Holmes, Joseph Bell. We follow a search for causative agents, preventive vaccines, and remedies for some of the deadliest infections in the Victorian era. Goetz describes how the principles of evidence-based science and systematic experimentation guided these ground-breaking discoveries, and how overlooking these principles led to setbacks.

Robert Koch, Louis Pasteur and other microbiologists made a cast of pioneering medical detectives.  A mural at The Ohio State University Social Administration Building. Source: The Short North Gazette.

Robert Koch, Louise Pasteur and other microbiologists made a cast of pioneering medical detectives, illustrated in a mural at The Ohio State University. Source: The Short North Gazette.

The Remedy begins by tracking Robert Koch working as a town doctor in Germany. Limited by resources, but moved by his experience tending the wounded in the Franco-Prussian war, he investigated the causative agents of infections. Secluded from the continental scientific community, he developed tools and methods to study bacteria which we still use, from the white mouse lab to culture media. He also developed a set of postulates, a step-wise checklist for demonstrating that a disease is caused by an organism. These real as well as thinking tools allowed him to find and track the life course of the causative agent for anthrax—Bacillus anthracis, an irrefutable proof for the then-nascent germ theory.

The strength of the book is Goetz’s page-turning account of one of science’s greatest rivalries, between Koch and the French scientist Louise Pasteur who was gaining fame for his work on vaccinations for anthrax and rabies, microbial fermentation and pasteurization. Goetz masterfully weaves primary sources, including letters and conference notes, to describe a race driven by a clash of egos, nationalism, and ambition. This competition ended in a breakthrough for Koch, who became the first to identify the infectious agent for tuberculosis— Mycobacterium tuberculosis. According to Goetz, Koch’s ambitions went further as he sought to find a cure for tuberculosis.

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Permanent linkMarzieh Ghiasi

The neglected diseases of poverty

Published May 11, 2014 | Share your thoughts
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*Originally published in The Upstream Journal.

The last week of April is World Immunization Week, promoting vaccines as powerful tools for protecting people against some of the most deadly diseases. However, there are no effective vaccines for many of what are called “Neglected Tropical Diseases” – NTDs. And where there are few vaccines and treatments available, people remain trapped in a cycle of poverty and disease.

NTDs include seventeen parasitic, bacterial and viral infections that infect more than a billion people across the world. They include diseases such as leprosy, lymphatic filariasis, leishmaniasis, Chagas disease, dengue and sleeping sickness.

Despite the name ‘tropical’ the NTDs thrive far beyond the tropics and represent a great health burden worldwide. These preventable “diseases of poverty” primarily affect the world’s poorest people and can cause severe lifelong disabilities such as blindness, deformities, and debilitation. However, the devastating impact of these diseases is often overshadowed by the “big three” – HIV, tuberculosis and malaria – leaving them neglected in discussions of global health, investment, and research.

Velayuthan pillai (Age 69), a tailor. Elephantiasis turned his life into misery by taking away both his legs. Having lost his legs and job, he returned back to his home town and joined as a guard for a temple for the pay of (Rupess 800) 17.60$ per month. With the help of this little income he's struggling to make both ends in life along with his wife." Photo by Rajvinoth Jothineelakandan.

Velayuthan pillai (Age 69), a tailor. Elephantiasis turned his life into misery by taking away both his legs. Having lost his legs and job, he returned back to his home town and joined as a guard for a temple for the pay of (Rupess 800) 17.60$ per month. With the help of this little income he’s struggling to make both ends in life along with his wife.” Photo by Rajvinoth Jothineelakandan.

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  • Nov 13, 2013 » The curtain
    Hercule_PoirotFor the past 25 years, David Suchet has brought Agatha Christie’s Hercule Poirot to life. It’s a thrilling but subdued show that I’ve enjoyed watching no matter where in the world, and as it draws to a close I must bid adieu!
    “It is the brain, the little grey cells on which one must rely. The senses mislead. One must seek the truth within — not without.” – Agatha Christie (Poirot Investigates, 1924)
    # #
  • Survivors: Age and isolation

    Published November 10, 2013 | Share your thoughts
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    One of the great things about living in downtown Montreal is I always pass by at least a dozen galleries on the way home, and one of these is FOFA Gallery at Concordia University. Earlier this week, I decided to take a look at some of the new work being showcased as part of the annual exhibition of the university’s Fine Arts undergraduates. Most of the work was interesting, but nothing really stood out to me until I saw the photo series ‘Survivors‘ by Yulia Grebneva and frankly — they stopped me, then moved me– emotionally and intellectually.

    YG Survivors Concordia*Click on photo to see original photograph & here to see full photo series

    Once I’d taken a close look at the series I read about the piece from the writer Greg Mattigetz. Here’s an excerpt:

    Survivors is a photographic series that reflects experiences of both the solitude and disregard, as well as steadfastness and persistence of elderly women living in urban environments… This series is based on Yulia Grebneva’s observation that these elderly women are lonely and forgotten within the context of the city. By removing the figures from the cityscape and placing them into harsh landscapes, the artist calls attention to how these women experience everyday city life by trying to keep up with the fast-paced and sprawling nature of the urban sphere.”

    Two years ago I did a project asking whether there were any social risk factors that put elderly people living in cities at risk of death during heat waves. One of the factors that I identified in literature was social isolation. In the 2003 heat wave in Paris, which I was using as a case-study, the social isolation of elderly during heat waves was associated with a sixfold increase in the risk of death. This was not an issue that I had thought about before, and learning about the extent of it genuinely surprised me.

    Since then, I’ve been paying more attention and every so often will read a story or a paper that mentions the same phenomenon. For example, a story in the BBC earlier this year described that “A study of 6,500 UK men and women aged over 52 found that being isolated from family and friends was linked with a 26% higher death risk over seven years.” The research accounted for other confounding factors and found that “after adjusting for factors such as underlying health conditions, only social isolation remained important.”

    In every discussion of public health, the issue of aging populations in developing countries invariably comes up. This issues is often framed as a “demographic time-bomb” that will send the health-care costs in Canada and other countries (the UK, Ireland, China, Russia… ) out of orbit, an apocalyptic image has been well-disputed. Nevertheless, the fact is populations are aging, and as described in this Canadian Medical Association piece “Health promotion/prevention… can contribute to offsetting the impact of the aging population on the health care system.”

    But what exactly is prevention in this context? I was reading a story earlier this year about climbing suicide rates among elderly here in Canada, and I found some of the comments unsettling. There was some discussion on how people are living longer than years before, often coping with severe illness in their final years, and should have the choice to depart their way. That’s a discussion worth having. But at the same time, we should acknowledge that we’ve created environments where growing old and requiring care is seen as a burden on families and society, rather than an obligation as it was in the past, and the life of elderly, their wisdom and their experience has become devalued.

    What elderly populations face today are what most of us will eventually face, should we be lucky to live for so long. The seriousness of these issues really hit me when I volunteered for a short period in a geriatric care facility where I saw a lovely woman of about seventy-five years break down into tears at the loss of her autonomy, because she had been told she couldn’t go home for Christmas. Or an elderly gentleman relay his deep worry that he was a burden to his children who visited him once or twice a week. We are slowly beginning to take depression, loneliness, isolation, and vulnerability seriously in youth. But when it comes to the elderly, these psychological and social issues treated as inevitable parts of aging– and the public health discussions become about how can we can best manage the physical symptoms of aging, spending the least money. I think that’s a shortsighted and callous approach. Aging may be difficult, but it doesn’t have to be undignified suffering.

    In a world where extended familial ties are waning, it is increasingly important for all of us to look after each other, and treat each life with respect. I think that providing support for home care and caregivers, supporting social programs that promote caring and cohesion (such as the Yellow Door here in Montreal), ensuring that there is good infrustructure that doesn’t inhibit mobility (i.e. Montreal’s winter street ice-rinks) may all help alleviate loneliness and isolation among our elderly –with positive health ramifications– and preserve that dignity so beautifully captured in Grebneva’s photo series.

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    Permanent linkMarzieh Ghiasi
  • Oct 18, 2013 » Hofstadter’s Law
    I learn this at the end of every project, and forget it starting the next project. Hofstadters Law
    Hofstadter’s Law: It always takes longer than you expect, even when you take into account Hofstadter’s Law.
    Source: Sean Li #
  • Ecological public health

    Published October 12, 2013 | Share your thoughts
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    Ecological public health: the 21st century’s big idea? (2012) by Tim Lang and Geof Rayner is a superb essay in the BMJ I read today and thought I’d share here. Three things really make it worth a read. First, it really lays out the necessity of better models for understanding public health issues and implementing public health policies. Particularly, the authors identify the “diminution of perspective” as an issue plaguing modern approaches to public health. Essentially, there is so much focus on technocratic solutions and approaches at the personal scale, that we are in a sense losing sight of the big picture and the larger context in which people’s health is embedded. Second, the article identifies the different approaches to public health clearly and beautifully, as you can see in this table. They discuss each of these approaches and their historical context in detail.

    Click for larger view

    Five Models of Public Health (Click for larger view)

    Third, the article makes a compelling case for adopting ecological approaches to public health in the 21st century. The ecological model of public health is described as an integration of historical approaches to public health (i.e. sanitary environmental approaches) and modern approaches to public health (i.e. techno-economic). In the paragraph quoted below they really lay out the benefits of the ecological public health model (accompanied by a shoutout to Darwin/Wallace):

    A strength of the ecological public health model is that it draws upon and integrates parts of the other models). Secondly, it articulates modern thinking about complexity and system dynamics, addressing, for example, questions of non-linearity, variations in scale, feedback, and other emergent qualities of nature, biology, and human behaviour. In the UK, we see some of such thinking in the government chief scientist’s Foresight programme. Thirdly, ecological public health seeks to build knowledge as a continual intellectual engagement. This means more than just evidence, and includes the open pursuit of social values, highlighting the role of interest groups, and debate across society not just within restricted scientific circles. Think Darwin and Wallace, Beveridge or Roosevelt: big thinking about the nature of life, good societies, order and change. Fourthly, it incorporates an evolutionary perspective, from matters like nutritional mismatch to questions of biological feedback. Fifthly, this is an overtly interdisciplinary and multi-actor model. It celebrates that public health requires action on multiple fronts and embraces the argument familiar in the 19th century that public health action requires a public health movement.

    Great, brief article. Definitely worth a read.

    Cited

    Lang T, & Rayner G (2012). Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof Rayner. BMJ (Clinical research ed.), 345 PMID: 22915666

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    Permanent linkMarzieh Ghiasi
  • Sep 28, 2013 » Emerging shadows
    Tim Noble and Sue Webster Tim Noble & Sue Webster‘s shadow sculptures emerge from jumbled statues of discarded wood. #
  • Physician at the Frontier: Development of Public Healthcare in Saskatchewan, Canada from 1915 to 1965

    Published September 28, 2013 | Share your thoughts
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    On July 1st, 1962 two-thirds of physicians in the Saskatchewan locked their practices, commencing a strike against the Province’s newly enacted Medical Care Insurance Act. The debate about whether public healthcare would meet the needs of populations extends back into the beginning of the last century. These protests culminated after five decades of changing medical practice and legislation in the province. The debate has been shaped by three stakeholders, the government, and the public and healthcare professionals. The position of these stakeholders has changed over time, depending on broader socio-political and economic trends.

    In this paper I examine evidence of physician attitudes towards increasing public and government involvement in their profession between 1915 and 1965. I find that physicians initially responded positively to public and state intervention, but increasingly became hostile towards such intervention, with hostilities culminating in the strike. I argue that this drastic shift in attitude was shaped by three underlying factors: (1) concerns about adequate compensation, (2) concerns about professional autonomy, and (3) increasing professionalization of physicians. I will examine how each of these factors related to broader socio-political and economic trends and associated health care legislation in Saskatchewan. In the first part, I will look at legislation concerning municipal doctors and hospitals between 1915 and 1930. Then, I will examine depression-era medical schemes as well as schemes developed during and in the response to the Second World War. Finally I will discuss the development of universal healthcare in the province between 1947 and 1962. Under each of these arrangements, I will look at funding, provision and delivery of medical services, and the response of the medical profession.

    medicareprotestcanadaProtesting the implementation of medicare, July 11, 1962. Saskatchewan Archives Board. Image source.

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    Permanent linkMarzieh Ghiasi
  • Aug 19, 2013 » Still life coming alive
    Alexa Meade Instead of capturing and constraining a slice of life on a still canvas, Alexa Meade breathes life into canvases and sets them free in a perpetually moving world. #
  • DRM and rights in a digital world

    Published August 14, 2013 | 2 responses so far
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    A couple of days ago I was listening to an older edition of Science Weekly, particularly a lecture by Cory Doctorow. I found the lecture to be a truly thought-provoking look at digitization of the world and its implications. Doctorow’s focus was on DRM (Digital Rights Management) in the narrow scope, but broadly dealt with our rights and freedoms in an increasingly digital world. He made a lot of interesting points, I’d like to go over some parts of the lecture which I found very interesting.

    When it came to DRM, I have to be frank– I never really understood the controversy in some technology quarters. It always made sense to me that any company or artist worth their salt would try to do their best to prevent, or at least discourage, pirating. However, Doctorow framed the issue from a completely different perspective, and related DRM to the broader issues of a person’s rights and freedoms to control their life in the digital world. At the beginning of the lecture Doctorow began by describe our world as a digital one, where everything we do and everything we are is encased in a computer.

    “We have computers on our desks, and we have computers in our pockets. We have computers we insert in our bodies, and we have computers into which we insert our bodies. And they have the power to liberate us, or enslave us. When computers don’t tell us what they’re doing, they expose us to horrible risks.”

    As a lay person, I’d wondered what was the worst that could happen: You can’t copy that DVD or game you bought? An inconvenience for sure, but not a full-scale tragedy. Doctorow gave several examples of the risks and some real-life worst-case scenarios. One particularly compelling example was the Sony BMG copy protection rootkit scandal in which Sony essentially installed two pieces of software via their CDs to prevent copying by interfering with the operating system interface. The programs were designed to not be detected by the computer at all, and prevent recognition of software with a certain extension (rootkits). Now, of course, this was very quickly exploited by virus-developers etc. to help install other nefarious programs. The popular narrative often places the blame on the virus-makers, blackhat hackers, etc. But Doctorow’s metaphor provided a wonderful counterpoint to this: the viruses, trojans etc. were like opportunistic infections taking advantage a gaping open wound. A wound caused by Sony effectively committing a covert assault on the digital extension of millions of individuals, all in order to enforce their DRM.

    According to Doctorow, there have been other examples of this kind of behaviour. He described a scandal involving seven companies involved in hire purchase laptop business. Providing these laptops on installment plans, the companies felt they needed to reduce risk of loss. Hence they essentially began monitoring users, interacting with their webcams etc. all under the guide of ensuring their property would not be lost, without any outward indication that the computer was being monitored. After a legal battle, the companies were told by the government that they could continue to “monitor”, so long as their users consented to it. That is, as long as it was in the fine print.

    “[Consumer Union] reckoned that it would take 27 hours a day to review all the user agreements that you interact with in a day… and they all come down to the same thing, by being dumb enough to be a customer of this firm, you agree that they’re allowed to come over to your house and punch you in the mouth… so none of us read them… before you click the agree button, one thing you’re sure of, is you don’t agree.”

    The comedian Eddie Izzard actually has a fantastic bit on terms and conditions which I think would be quite fitting here.

    “They’ve made us liars… No one has read the terms and conditions. No one in the world. No one. Even the lawyers who wrote it wrote it like this. It could say anything in there.”

    Eddie-Izzard-no-one-reads-contracts

    Indeed when it comes to terms and conditions the user who makes the choice not to read the contract or skim over the contract is to blame. Right? But does reading the fine print even make a difference when (a) a user don’t understand what it says (b) a user no choice but to agree with it and hope for the best. In getting a mortgage, making a large purchase etc. we take our contracts to lawyers who’ve been trained to read these things. But is it realistic to expect people to do the same when purchasing a toaster? Most of us have an assumption of trust and goodwill, or at least, a hope that our toaster won’t start broadcasting our eating habits to the world.

    For instance, when I purchased my tablet I had a host of apps I wanted to install to make the tablet actually useful. However, all of these apps wanted a range of strange permissions. It perplexed me as to why a calculator wanted permission to access my “fine (GPS) location”, phone calls “read phone state and identity”, personal information “read contact data”. It wasn’t one or two obscure apps that asked for these permissions, almost all of them asked for permissions that seemed to be completely unrelated to their purpose. Of course, I consulted various websites, and the advice was generally “use common sense”, and “when you come across something you don’t understand, usually a bit of deductive reasoning can figure out why an app needs to do something.” But what if I can’t figure it out? What if I draw the wrong conclusion? Do I need to do this for every single app? What if the app isn’t trust-worthy? What if I don’t want my calculator to have access to my camera? It became a matter of installing an app and hoping for the best, or not installing any apps at all and not taking advantage of my purchase.

    We all have the choice to not use a tablet or a smartphone, or not even a computer. We can become luddites and hide in caves. But we live in a world where everything is going digital. In the words of Doctorow “We have computers we insert in our bodies, and we have computers into which we insert our bodies.” But increasingly we are living in a world, people don’t know what is happening to their computers. They may as well be black-boxes. According to Doctorow, we’re also increasingly living a world where legislation, pushed in part by DRM-supporters, hinders or even criminalizes those who know from informing people about what is happening to their computers and other electronics. Even with the best of intentions in mind—we’re all becoming more and more vulnerable.

    By the end of the lecture Doctorow did not really propose a ‘solution’ or a way to navigate into the future. However, I think his point was not really for us– the users– to understand the nitty-gritty parts of DRM. Rather, for us to keep in mind the broad ramifications when smaller debates and legislation involving digital technology come up. For this reason, whether one doesn’t agree or isn’t sure what to think– I think listening to Doctorow’s lecture is worth the time.

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    Permanent linkMarzieh Ghiasi