Medicor 2014 #3 by Medicor MF Magazine

medicor medicinska fรถreningen i stockholm

16 The 5:2 Diet with Kerstin Brismar

2014 #3

20 SEK

32 The Ebola Epidemic in West Africa

A SPACE ODYSSEY Christer Fuglesang and how our bodies function in microgravity

Prelude

A New Perspective AS A NEW ISSUE IS SENT TO THE PRESS, WE HAVE A SHORT MO-

As always, we are aiming high with this issue, maybe higher than ever before as you can see on the cover. Not only did we have the pleasure of interviewing Sweden’s first and only astronaut, Christer Fuglesang but we also have articles covering the recent Ebola outbreak in western Africa with a complete overview of the outbreak, including interviews from the scene. MSF:s Johan von Schreeb and UK citizen Rupert Day, who has been living in Sierra Leone for four years, tell their sides of the story on the battle to contain the deadly epidemic. Moreover, we had the opportunity of interviewing Anders Nordström, former general of SIDA and current Swedish ambassador of Global Health. Of course, we have plenty of other fantastic articles covering everything from depression to Health Care in Danger. Don’t miss them! A lot of the interviews we get for the magazine could not have been accomplished without some very helpful people that should not be forgotten. So we wish to extend a great thanks to Anders Arner and Cecilia Lövdahl who kindly invited us to be a part of the SPS2014 conference here at KI. As I’m running out of space I would like to end this, my first editorial letter, by saying that Medicor is constantly developing and improving and I’m really excited to see how far we can take it. There are many new faces for this term and definitely a great deal of new perspectives and ideas. Hopefully, even more of you want to join us because without you there wouldn’t be any Medicor. So what are you waiting for? Come tell your story.

Sincerely, Robert de Meijere Editor-in-Chief

Cover photo by Martin Kjellberg for Medicor 2

Photo by Jingcheng Zhao for Medicor

ment of peace before we start working on the next one. Sometimes, I think that we are too busy with always looking forward, always wanting to improve that we don’t take the time to really reflect on what we have accomplished. The more I think about it, the more I realize how proud I am of all the people working with this magazine. Most of us don’t have any training, all we have is our passion for writing, photography and graphic design. We come from different parts of KI, have different experiences and are in different phases of our lives. Yet we all come together in creating this truly amazing magazine I now have the pleasure of being Editor-in-chief of.

Medicor Magasin Grundad 2006. Sjunde årgången. Utges av Medincinska Föreningen i Stockholm ISSN: 1653-9796 Ansvarig utgivare: Robert de Meijere Tryck och reproduktion: Åtta45, Solna Adress: Medicinska Föreningen i Stockholm Nobels Väg 10, Box 250, 171 77, Stockholm Utgivningsplan 2014: nr 1: mars, nr 2: maj, nr 3: oktober, nr 4: december. Kontakta Medicor: chefredaktor@medicor.nu www.medicinskaforeningen.se Frilansmaterial: Medicor förbehåller sig rätten att redigera inkommet material och ansvarar inte för icke beställda texter eller bilder, samt tryckfel. Upphovsman svarar för, genom Medicor publicerat, signerat frilansmaterial; denna(e)s åsikter representerar nödvändigtvis inte Medicors eller Medicinska Föreningens.

Overture COVER STORY

KAROLINSKA

GLOBAL FOCUS

A UNIVERSITY FOR DIVERSITY? Ett öppet brev till Karolinska Institutets rektor Anders Hamsten

Richard Ssegonja discuss Vitamin D deficiency.

“MY WORKPLACE IS THE WHOLE GLOBE” Florian Schober interviews the organisers of Global Leadership 2014.

HEALTH INNOVATION ON THE RIGHT TRACK Jens Magnusson on how a group of young people are addressing challenges in healthcare.

24 “I SAW AN AD, APPLIED AND WAS LUCKY ENOUGH TO GET THE JOB.”

SWEDISH FOREIGN AID Sergio Scro Petualang interviewed Global Health ambassador, Anders Nordström on today’s role, challenges and future issues.

An inspiring interview with Christer Fuglesang & Dag Linnarsson.

FEATURES

A CONTROVERSIAL JOURNEY TO THE CENTRE OF THE BRAIN

HEALTH CARE IN DANGER

INSIGHT

Nicolas Guyon on the quest to understand the brain.

SUCCESSES AND FAILURES OVER TIME Sergio Scro Petualang analyse the development of neglected tropical diseases.

A SPACE ODYSSEY

SCIENCE

THE NUTRITIONAL DEFICIENCY WE MAY BE UNAWARE OF

ARCHITECTURE’S EFFECT ON HEALTH

PER RENSTRÖM Medicor’s new segment on medical careers featuring an interview by Filippa Grönqvist

Haroon Bayani tells us about the importance of a pleasant environment.

UNRAVELING THE 5:2 DIET Kim Franson talks to Kerstin Brismar about the trending diet.

CULTURE

Douglas McBride on the link between depression and creativity.

THE EBOLA EPIDEMIC IN WEST AFRICA A complete coverage of the facts, numbers, present challenges and predictions. In which direction is the Ebola epidemic going?

CREATIVITY AND DEPRESSION

THE ELEPHANT Some comic relief by Mikael Plymoth

medicor Robert de Meijere • Editor-in-Chief | Oskar Swartling • Associate Editor | Andrey Pyko • Creative Director Ibrahim Rayyes • Proofreader General | Vladimir Choi • Executive Editor | Sergio Scro Petualang • Editor of Global Focus | Yasmine Djoumi • Producer Janne Andersson • Senior Advisor | Amanda Kaba Liljeberg • Editor of Campus | Iskra Pollak Dorocic • Editor of Science | Poya Livälven • Editor of Culture Filippa Grönqvist, Furat Al-Murani, Kim Franson, Florian Schober • Reporters | Martin Kjellberg, David Humphreys • Photographers Nicolas Guyon, Yasmine Djoumi, Haroon Bayani, Veronika Kremer, Jens Magnusson, Richard Ssegonja, Douglas McBride • Writers Fergal Horgan, Halima Hassan • Proofreaders | Xinming Wang, Mikael Plymoth, Lukas McBride, Jakub Lewicki • Illustrators

Aperture Violence against health care personnel increases, globally. This photo shows a doctor who is going to evaluate if a patient is to be evacuated from war-torn Misrata, Libya. How can we as future humanitarian workers fulfil our medical code if we are threatened to be killed if we do our job? Read more on page 40. PHOTO BY: ÂŠ ICRC / A. LIOHN / V-P-LY-E-00129

Smörgosbord

14.5 billion litres

Irn-Bru, the shockingly orange soft drink “made from girders” is the biggest selling soft drink in Scotland. First produced in 1901 in Falkirk, “Scotland’s other national drink” is sold at a rate of 12 cans (330ml) every second, in Scotland alone. One 330ml can of Irn-Bru contains 34.7g of sugar - higher than the WHO’s recommended daily intake. Over 14.5 billion litres of soft drinks are consumed in the United

Kingdom annually. The flavour of Irn-Bru has been described as that of bubblegum, wet sheep fleece, barley sugar and plastic. It is unclear whether consumption of Irn-Bru is linked to voting preferences.

per second

“

It’s all the other presidents that are strange” José Mujica - Uruguays president, also known as “the poorest president in the world”.

Kenya

M-Pesa(-money in swahili): Launched in 2007 in Kenya and Tanzania, this innovative initiative now extends to many countries in the world. M-Pesa allows users with an ID card to deposit, withdraw, and transfer money easily with a mobile device. The initiative quickly captured a huge market share for cash transfers, and grew to 17 million subscribers by December 2011 in Kenya alone. The growth of the service has forced formal banking institutions to take note of the new venture. In December 2008, a group of banks reportedly lobbied the Kenyan finance minister to audit M-Pesa.

Sweden By eating on average 17kg of candy a year, Swedes are said to have the highest per capita consumption of candy in the world. Whether this is the result of eating ”lördagsgodis“ during weekdays or just a logical consequence of all food stores in Sweden usually having a whole wall lined with “smågodis“ - we don’t know. But what we do know is that the World Health Organi-

zation is dropping its sugar intake recommendations from 10% to 5% of the daily calorie intake. Some health experts even call for a further cut to no more than 3%. For an adult of normal body mass index, 5% is equivalent to around 6 teaspoons of sugar or a small handful of “godis“ per day.

17kg per year

150 million Bangladesh is 115 times smaller than Russia in terms of surface area. Yet, their populations are nearly equivalent (156 vs 150 million).

China Although the country with the highest phone usage is China, Hong Kong wins gold when it comes to the number of phones in use compared to the size of the population, with an average of 2.37 phones per person as of June 2014.

2.37 phones per person

Australia Philippines 258 selfie-takers per 100,000 people is the highest number of selfie-takers per capita in the world and can be found in Makati City, Philippines, according to a Time.com article in March 2014. They downloaded Instagram photos with location data and tagged “selfie” in two five-day periods in February and May 2014. They ranked cities around the world with at least 250,000 inhabitants according to the “number of

selfies taken within 5 miles divided by the population of that city”. Three Swedish cities made it to the top 100: Malmo (47th) with 50 selfie-takers per 100,000 people, Stockholm (56) with 45 selfie-takers per 100,000 inhabitants and Gothenburg (64) with 39 selfie-takers per 100,000 inhabitants.

According to the United Nations 2014 World Drug Report, Australia has the highest proportion of ecstasy consumers in the world. It also ranked high for the use of opioids like codeine and morphine. Only the United States showed an even higher proportion. Seemingly Dr. House is not the only American with a taste for the contents of small orange vials.

Student Commentary

A University for Diversity? Ett öppet brev från Queerolinska till Karolinska Institutets rektor Anders Hamsten. FÖRST AV ALLT VILL VI PÅ QUEEROLINSKA

tacka er i Karolinska Institutets ledning för er samverkan och ert stöd under Pridefestivalen. Där visade vi att vi har ambitionen att vara ett University for diversity. Vi upplever dock att mycket kan bli bättre på KI; dels önskar vi en modernare utbildning med HBTQ*- och genusmedvetenhet, dels vill vi belysa problematiken kring dagens utbyten till Uganda. En av vårdpersonalens största utmaningar är att kunna bemöta våra patienter på ett värdigt och professionellt sätt. Då är det viktigt att vara förberedd inför patientmöten med bl.a. transpersoner. Den kompetensen får vi inte idag genom utbildningen. Dessutom upplever många studenter att föreläsningarna är genomsyrade av ett könsnormativt tankesätt som inte överensstämmer med den värld vi lever i idag. Detta är ett problem dels för att det hindrar oss i våra framtida arbeten, dels för att det är kränkande och exkluderande för oss HBTQ-studenter. Låt oss ej glömma att utbildningen här färgar tankesättet för oss studenter som följer oss hela vägen in på klinik och i mötet med patienter. Vi är många som följt utvecklingen i Uganda där det tidigare i år beslutades att införa livstids fängelsestraff för

homosexualitet. Trots att lagen upphävdes av byråkratiska skäl i augusti, blev den målande för hur komprimerade HBTQ-personers rättigheter är i Uganda. Lagstiftningen var en legitimisering av ett redan existerande förtryck, då HBTQ-personer sedan länge varit utsatta för kränkningar, förföljelser och mord. Idag har vi på KI fortsatta utbyten med Makerere University i Uganda trots att detta har ifrågasatts ända upp i Utbildningsstyrelsen. Utan Queerolinskas eller någon annan HBTQ-organisations inblandning valde ni i KIs ledning att trots allt uppmana programstyrelserna till att fortsätta med utbyten till Makerere University; detta under tiden lagen ännu implementerades. Vi är djupt missnöjda över er hantering av denna fråga. Det kan vara livshotande att som HBTQ-person befinna sig i Uganda, trots försök till att vara diskret. Är tanken från KI:s sida att även HBTQ-personer ska få ta del av dessa utbyten? Kan de studenter som åker till Uganda föra en dialog kring dessa ämnen på plats utan att riskera sin säkerhet? Varje utbytesstudent är oundvikligen även en representant för Karolinska Institutet och de värderingar - medicinska och sociala - som KI väljer att förmedla. KI bör, i egenskap av ett av världens ledande medicinska universitet, vara en tydlig förebild i dessa frågor. Det

bör därför föras en dialog med Makerere University angående såväl studenters säkerhet där under utbyten, som deras inhemska HBTQ-patienters säkerhet. Inför framtiden önskar vi att ni är öppna för att lyssna på våra åsikter när ni tar beslut om frågor som berör oss. Vi i Queerolinska är gladeligen med och diskuterar fram en genus- och HBTQmedveten utbildningsplan för KI. Då kan vi på riktigt bli ett University for diversity. Tacksamma för svar, Queerolinskas Styrelse - Medicinska Föreningens HBTQ-förening *HBTQ-personer: Homosexuella, bisexuella, trans- och queerpersoner.

Svar från rektor Anders Hamsten DE FRÅGOR SOM QUEEROLINSKA tar upp är mycket viktiga för Karolinska Institutet. Självklart är vår ambition att KI:s utbildningar ska ligga rätt i tiden och i högre grad än nu genomsyras av HBTQ- och genusmedvetenhet. Vad som behöver ändras, och hur det ska göras, kan jag inte svara på nu. Men jag kommer att ta upp frågan om hur vi ska gå vidare i vårt arbete med dessa frågor på nästa möte med KI:s ledningsgrupp, där ordföranden och vice ordföranden i Medicinska Föreningen ingår. Vi behöver också diskutera frågan med rådet för lika villkor. Jag ber därför att få återkomma i denna fråga. Karolinska Institutet har sedan mer än 15 år haft ett mycket aktivt samarbete med Makerere University i Uganda med utbyte av studenter, lärare och forskare samt en gemensam forskarutbildning. Samarbetet finansieras till stor del av bidrag från Sida. Vad gäller antigaylagarna i Uganda så tar Karolinska Institutet naturligtvis avstånd från dem. Vi tror dock att vi genom 8

samarbete hellre än isolering kan påverka opinionen och kunskapen i Uganda, liksom i många andra länder där vi har samarbeten inom forskning och utbildning Vi följer regeringens exempel i deras reaktion till lagstiftningen i Uganda. De Sida-medel som gick till stöd till den politiska utvecklingen har frysts, medan Sida-medel till akademisk verksamhet är orörda. Idag är det över 80 länder som har lagar som förbjuder homosexualitet. Ett exempel är Singapore, där KI har flera samarbeten. I samband med att Internationella strategigruppen tar fram nya etiska principer för internationella samarbeten så behöver vi diskutera hur vi på bästa sätt kan sörja för studenter och medarbetares säkerhet under utbyten och hur Karolinska Institutet på bästa sätt kan verka för lika villkor. Jag ser att rådet för lika villkor och representanter för studenterna är viktiga parter i denna fortsatta dialog.

Anders Hamsten, rektor

KAROLINSKA

“

My working place is the whole globe

By Florian Schober The organisers of “Global Leadership 2014”: Sandra, Martina, Tove, Josefine, Wintana and Stefania

THE STAGE OF AULA MEDICA IS BATHED

in red light, a white spot on the speaker’s desk. The dapper setting fits perfectly to the first speaker of the evening. Åsa Hedin, ranked as one of the 125 most powerful women in Sweden in 2013, is Executive Vice President of an international medical engineering company that employs more than 3000 people. “My working place is the whole globe”, is her key message and, at the same time, an essence of this event. Its title is “Global Leadership 2014 – Mastering a Multicultural Setting” with a distinct focus on women in decision-making positions. On this particular evening, three female leaders tell about their experiences towards their current careers in an international setting. With that, they can easily inspire an audience that fills about half of Aula Medica, most of them female students. This is not surprising with regard to the life-shaping questions that we have to answer in our young careers. But looking around, one can realise that the event does not only attract women – about 30% are men. “Women can be inspirational for both females and males”, says Stefania Basogianni, one of the organisers of “Global Leadership”. Together with her five colleagues, she is campus ambassador of an organisation with the bulky name “Harvard Undergraduate Women in Business”, short

HUWIB. The initiative was originally found at Harvard University in 2000. The idea of inspiring young women to develop their leadership skills was so attractive that it developed into the largest undergraduate business organization on Harvard campus. Soon, other people across the globe got interested. The first KI students applied about two years ago to be HUWIB ambassadors. With that as a starting point, the new KI ambassadors organised three events in Stockholm, cumulating in the recent exceptional conglomerate of inspiring talks, a workshop and a networking session with representative of companies and organizations. The incredible amount of work that the six student ambassadors invested into this event is obvious throughout the evening. The first plans were drawn about one year before the happening. Finding speakers, organising the room, the volunteers, recruiting sponsors. That is why it is most likely that not the people in the audience, but the organisers themselves had the biggest learning outcome. Having put all these efforts into a few hours, one would expect nervousness on the day of the event. But the two moderators guide the audience professionally through the program. The first three speakers highlight the complications of the current world that we all face in our daily lives. E-mails are crashing upon us

and trends are faster than ever before. It becomes increasingly harder to focus. Though, as programme director Tanja Tomson points out, focus is the key to success. One of those phrases that are impossible to fulfil? One step towards “editing out noise”, as Tanja puts it, are profound listening skills. Without listening, one gets lost in a setting that requires effective group work – which most of us deal with. A strong link to the final talk: How do we deal with a multicultural setting? According to Anne Stenbom, leadership consultant, listening paired with cultural openness and knowledge can counteract failure of international groups. It is inspiration, not definite guidelines what Global Leadership offers the audience. Now is the time for the listeners to work with these ideas. The organisers will continue thinking, too. They will travel to Harvard University, USA, in mid October, to get to meet other HUWIB campus ambassadors from all over the world. And to hopefully come back to Stockholm with new ideas for new events. Thank you for a great event, Stefania Basogianni, Martina Jonczyk, Josefine Klein, Tove Sundquist, Sandra Weisse and Wintana Woldemariam.

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KAROLINSKA

Health innovation on the right track How a group of young people are addressing challenges in healthcare By Jens Magnusson THIS SUMMER, 16 TALENTED YOUNG

people from Sweden, the Netherlands and the UK gathered in Stockholm for a few intensive days. Their goal: to create innovative solutions to healthcare challenges – in 99 hours. They had come to work with The Think Train, an initiative aiming to tackle health-related problems in creative ways. “Healthcare is a field where our knowledge improves rapidly but where systems within organizations are sometimes resistant to change,” says LisaMarie Larisch, public health student and one of the Think Train’s founders. Similar to “health hackathons” organized by students at some American universities, the Think Train addresses healthcare challenges by bringing together inventive young minds and putting them to work on defined projects for a short time – only 99 hours per project. “Many people think that healthcare innovation has to take forever, but here we’re stimulating innovation in a very short time”, explains Larisch. Many problems facing today’s healthcare are complex, and their solutions require collaboration between many disciplines. “That’s why our 16 Talents represent such a broad range of skill-sets, from medical students to web designers.”

...people mistakenly equate gender medicine with women’s health... In Stockholm, Talents joined Karolina Kublickiene, head of the Centre for Gender Medicine at Karolinska Institutet. “Many people mistakenly equate gender medicine with women’s health, when in fact male aspects are just as important. We want to promote a correct view of sex and gender in science and education,” says Kublickiene, who worked 10

Photo: Gustav Solberger

closely with the Talents during their 99 hours in Stockholm. “And I was incredibly happy with what they were able to achieve. Wow!” Among other things, the Talents built a web site (www.genderedreactions.com) where users can easily explore sex differences in drugs’ side effects, using data recently released by the American Food and Drug Administration (FDA). “We’re some of the first people to make use of these data like this; it’s really a very powerful tool”, says Larisch. And the response to the website has been very positive; even the FDA itself has promoted it in its tweets. The Talents also traveled to Amsterdam where, as one of their projects, they developed an app with which autistic children can use selfies to recognize and express their emotions – often a source of

... the next step is the world misunderstandings in the daily lives of some of these children. Working across national and professional borders has been a guiding idea for the Think Train creators since the start. “But after this pilot project in Europe, the next step is the world”, smiles Larisch. “We want to work with new organizations, involve more, motivated Talents and make the Think Train method sustainable.” Expect, therefore, to see more health innovations from the Think Train in the future. “The achievements of young, skilled and motivated people is really what drives sustainable change in the world.”

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KAROLINSKA

By Yasmine Djoumi I CLIMBED UP THE UNFORGIVINGLY

narrow stairs to utskottsvåningen at Medicinska föreningen and was met by the new Flix ensemble sitting around a homecooked meal preparing for what is to come. This fall’s spex production can be summed up by the word’s ‘Titanic meets Inception’. The ambiance in the room is bubbly and homely. As soon as the, manditory, presentations are over, it is time for business and a few ground rules are put forth. The spex can seem as a flamboyant and quirky group (which they are), but you soon realize they take what they do seriously. While the actors have a break, I seize the oppertunity to talk to the directors. ”Spex is an interactive form of theatre. Every show is different as the audi-

ence have a great power over the cast, if you are unhappy with the preformance of an actor you can ask them to do their line in a different way or do it again, it is very exciting and spontanous”, says David Thalén, Jonathan Szeps and Arman Valadkhani, directors of this year’s production. ”The spex is a sanctuary for us science students in need to express our creative side. There is no need for experience wether you want to stand on or off stage. And it is an excelent way to make new friends.” They were very careful to point out that spex is not only the cast. The ensemble do not count up to a third of the production. There are people creating the set, making costumes, make-up and much more. What you see on stage is only the tip of the iceberg. This fall’s spex will premiere on the

17th of November and run until the 20th at Improvisation och Co. Hagagatan 48 near Odenplan. Information about sales will be posted on campus and on the Flix website.

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17 th of November 20 t h of November Improvisation och Co. Hagagatan 48 More info:

www.flixspex.se

Fiction becomes Science

The 15th anniversary of the science conference Nov2k By Veronika Kremer “NOV2K – FUTURE OF SCIENCE AND

Medicine” is a multidisciplinary scientific symposium like no other, breaking with existing conference traditions and creating an all-round experience. Organized by graduate students from Karolinska Institutet and Stockholm University, Nov2k has been successful in attracting excellent speakers such as Miguel Nicolelis, Polly Matzinger and Samuel Weiss, as well as a great and engaged audience. Who would have thought that a local conference, started in 1998 on the initiative of PhD students at KI Huddinge and since 2010 with the support from Konstfack students, would over the years take such an exciting turn and become a leading conference on the future of science? This November, Nov2k celebrates its 15th anniversary. With the theme “Science fiction”, the conference pays tribute

to scientific innovations that may have previously been regarded as science fiction but which today have the potential to impact society tremendously and shift scientific paradigms. Participants can look forward to meeting fantastic scientists like Mark Post who cultures beef from muscle cells to make burgers, Ruth Ley, explorer of host genetics and the microbiome in the human gut and DNA origami maker Björn Högberg, just to name a few. The talks will be embedded in an engaging program, including an interactive workshop, a poster slam with live voting in addition to a conventional poster session, an exhibition on the future theme; in short, Nov2k will again strive to make the conference an unforgettable experience. Prior to the conference, participants are given the chance to get creative and take part in the Nov2k competition that will involve de-

signing a lab tool of the future. The winner will get the chance to print out his/ her tool on a 3D printer! The event will end with a spectacular gala dinner at Färgfabriken, a location that in itself represents a link between the past and the future. So get ready for two days full of excitement and inspiration! Nov2K will take place on November 20th-21st at Novum, Huddinge. The registration is now open on www.nov2k.com. Join Nov2k on Facebook and Twitter to stay updated.

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12TH NOVEMBER AULA MEDICA, SOLNA

Career Fair Organizers:

Exhibitors and Sponsors:

SCIENCE

Science snippets By Iskra Pollak Dorocic

CHASING COMETS Ten years ago the EU launched a space probe named Rosetta, with the ambition of making it the first spacecraft to orbit and land on a comet. Rosetta finally reached Comet 67P/Churyumov-Gerasimenko this past August, no easy feat considering the spacecraft must match the speed of the comet and ride alongside it, something never accomplished before. Not only that, the orbiter is equipped with a robotic lander which will attempt to land on the comet in November of this year, providing the first opportunity to study a comet up close. The landing of Rosetta is the most ambitious comet study ever attempted: scientists know that comets contain organic molecules that are building blocks of DNA and RNA. By studying them they hope to understand more about the formation of the universe, planets, stars and perhaps even life itself. (European Space Agency - www.esa.int) DIFFICULTY OF BEING ALONE It’s surprisingly difficult and maybe even unpleasant to sit alone with our thoughts without anything to distract us. This is what researchers at the University of Virginia recently discovered when they asked study participants to sit in a quiet room and let their mind wander for 15 minutes. About half of the participants afterward said they found the experience unpleasant. Even more surprisingly, given the choice to sit idly or distract themselves with painful electric shocks, many participants opted to shock themselves (men much more than women). No wonder everyone is constantly glued to their smartphones during any quiet moment, at least they don’t shock us. (Wilson et al, Science, July 2014) TOWARD CLINICAL TRIAL TRANSPARENCY The European Medicines Agency (EMA) has decided to publish clinical-trial reports on any drug that becomes approved in the European Union, making it the first major drug regulatory agency to take such a step. The industry has long been criticized for the lack of transparency in the process of testing medications and this step would open the field to noncommercial testing and comparison of trials. Due to privacy concerns, no data that can be traced to individual patients will be released. (Nature News, 13 June 2014)

Image credit: DLR German Aerospace Center (Flickr)

Image credit: Taki Steve (Flickr)

Image credit: Marshall Astor (Flickr)

GOOGLEING HEALTH Google has been dabbling in health-related research for a while, in particular as part of its research-intensive Google X division. A new project, dubbed the Baseline study, aims to define what it means to be healthy. It will start by sequencing the genomes of 175 volunteers and identifying expression of biochemicals, proteins and genetic mutations and correlate it with sickness and health. In addition to donating biological samples, the participants will wear medical tracking devices to monitor their well-being. Eventually the study will encompass thousands of subjects and make use of Google’s huge computer power to analyze the massive amounts of data acquired. The goal is to discover new biomarkers and try to detect diseases such as cancer and heart attacks earlier than is currently possible. (Science Magazine News, 28 July 2014) LANGUAGE GENE INVOLVED IN COGNITIVE FLEXIBILITY The ability to speak and use language is one of the defining characteristics of humans. The discovery of the FOXP2 gene, linked to a speech disorder, made it possible to study language in a genetic context. Interestingly, it’s been shown that this gene differs in only two base pairs between humans and chimpanzees. More recently, scientists have inserted FOXP2 into a mouse brain to study it in more detail. When testing mice engineered to have the human FOX2P gene, compared to those without, scientists at MIT saw the FOXP2 mice were better at quickly switching from conscious mode of learning to a repetitive or more automatic mode – suggestive an increased cognitive flexibility. (Schreiweis et al, PNAS, August 2014) IG NOBEL WINNERS ANNOUNCED The satirical and completely unrelated counterpart of the Nobel Prize, the Ig Nobel, announced this year’s winners during the September 18th ceremony at Harvard University’s Sanders Theatre. Several actual Nobel laureates handed out the prizes to this year’s winners, which included the physics prize for measuring the amount of friction between a shoe and a banana skin and between a banana skin and the floor, and the neuroscience prize for trying to understand what happens in the brains of people who see the face of Jesus in a piece of toast. (Ig Nobel - www.improbable.com/ig) 13

SCIENCE

A Controversial Journey to the Centre of the Brain By Nicolas Guyon

Illustration by Xinming Wang

IT IS AN EXCITING TIME TO BE STUDY-

ing the brain. In the last one hundred years, we have acquired a deeper understanding of how its 100 billion neurons are born, grow, and connect. But as the discovery of DNA changed the larger field of biology, giving a physical structure to how building blocks of life are encrypted, neuroscience is waiting for a similar breakthrough. How are thoughts encoded and how do they emerge from the neuronal circuitry of our brains? Which laws govern the way neurons are connected and the dynamics of their interactions? How are these translated into our intricate mental processes?

ter to the European Commission, these skeptical scientists expressed their concern about the current course of the Human Brain Project and are calling for the close examination of both the scientific policy and management of the HBP.

One of the authors of the contestation letter, Zachary Mainen, a neuroscientist at the Champalimaud Center for the Unknown in Lisbon, is not only concerned about the transparency behind the administration of the project but also its feasibility. “It’s like a moonshot, but before we knew how to build an airplane,” he said to the New York Times. “We can’t simulate the 302 neurons in a nematode brain. It’s a bit premature to simulate the 100 billion neurons in a human brain”, he added, in reference to the mapping of the C. elegans nervous system back in 1986, which has not yet been able to give us information about how the nematode behaves.

In a quest to answer these kinds of questions, as well as to develop more high-tech tools to study the brain, the European Commission has given an unprecedented 1 billion euros to the Human Brain Project (HBP). This collaborative project, that spans over one hundred neuroscience and technology groups across the world, aims to build a largescale computer simulation of the entire brain using data collected from experimental studies. Both the United States (with the BRAIN initiative) and China have since followed suit, with their own highly funded neuroscience initiatives focused on brain mapping and neurological diseases. More recently, the HBP has been the subject of controversy as some of the scientists involved in the program are concerned that this type of research is diverting funding from more realistic studies, towards a kind of highly unrealistic Utopian dream. In an Open Let14

stead focus solely on the computer modeling. “Numerical simulations and ‘big data’ are essential in modern science, but they do not alone yield understanding. Building a massive database to feed simulations without corrective loops between hypotheses and experimental tests seems, at best, a waste of time and money”, wrote Yves Frégnac and Gilles Laurent, two eminent European neuroscientists, in an article published in Nature about the change of focus of the HBP.

They are worried about the decision to stop funding the experimental neuroscience part of the project, which had the task to collect data from non-humanprimates, rodents and humans and in-

One thing is certain, the director of the project, Henry Markram, will have the task of making the program more open and to show that it can, like a Jules Verne novel, leave the realm of science fiction and make it to the Moon.

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SCIENCE

Photo: William Cho (flickr)

Architecture’s effect on Health By Haroon Bayani THESE DAYS IN MOST STOCKHOLM SUB-

urbs one can find blocks after blocks of grey buildings surrounded by a few trees and a lot of concrete. These buildings are simplistic, with their plain grey colour melting into the environment on cloudy days. The windows of these buildings are rather miniscule and permeate little light. The ceilings are also low, creating the feeling of being in a small cubic box. On the other hand, there are the grander buildings of the inner city. These are dramatically different, with large and grand windows and with an adjacent view of greeneries or other similar apartments of varying colours. Imagine the same apartment with big and spacious rooms and with an endless ceiling. Lastly, imagine the room being ornate with 19th century décor. Which of these two types of apartments are optimal for us humans? That is what the comparatively new scientific field of neuro-architecture is trying to figure out.

it is of great importance to be in an environment that we find pleasant. As most of us spend on average about 90% of our time indoors, it is of great importance to be in an environment that we find pleasant. If we, on the other hand, spend our time in a setting

which we find confining, it will affect our brain. The main research group in the field, Academy of Neuroscience and Architecture (ANA), consisting of neuroscientists and architects, has shown that certain types of space may stimulate growth of new neurons. Therefore, those living in a dull and dreary environment may be affected by certain psychological effects, compared to those living in more stimulating environments. One of the scientists in ANA even claims that “Architects could even design environments expressly to foster research breakthroughs”. Although there is still much more to uncover, the scientists are optimistic. In the future, they believe that by using colour, lightning and layout, scientists, along with architects, can find ideal designs for different workplaces, e.g. schools, hospitals. Some of the ideas of neuro-architecture have already been implemented. In hospitals it is possible that the construction of a well-designed environment will reduce a patient’s stay and may even play a part in the treatment of, for instance, memory loss and stimulation of brain activity. These principles of construction will most likely turn out to be group sp cific, where children’s needs will differ from the adults’. In general, the feeling of being lost, hesitant and having navigational difficulties causes great stress, especially for children. Hospitals can be

improved with clear planning, such as simple circulation instead of long corridors, clear landmarks instead of signs consisting of strange combinations of numbers and letters, and colour references and symbols. Furthermore, environmental enrichment of nature must not be forgotten. Those workplaces that have a planned green area have seen an increase in productivity, although it is not clear whether such changes will have long-term effects. Although neuro-architecture may be a relatively new field of science, there are great discoveries to be made. Though on the surface, neuroscience and architecture seem like two disparate subjects, neuroscience is as revolutionary for architecture as physics and the introduction of steel buildings once was. If these discoveries yield results in educating architects on how buildings should be built, the minds and brains of millions of people can be affected. Hopefully making us all a tiny bit happier.

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SCIENCE

Unraveling the 5:2 Diet An interview with professor Kerstin Brismar Story by Kim Franson HAVE YOU HEARD OF THE 5:2 DIET?

You’d probably answer “yes”, right? The 5:2 diet is the latest and most popular method of losing weight and has been the talk of the town for about two years now. Eat just five hundred kcal per day for two days a week and whatever you like during the remaining five weekdays! The claims are that you will look slim and healthy, be more alert at work, live longer, just to name a few. It may seem like a nobrainer. But as is often the case with diet fads, there is a huge discrepancy between the claims proponents make and what the science actually say. Skeptics claim there is little evidence to conclude that the 5:2 diet really works as advertised but maybe that’s about to change? The research of the renowned professor Kerstin Brismar at the Karolinska Institute aims to prevent diabetes and its complications. “A healthy diet is a critical part of preventing diabetes, and we’ve been doing studies on different types of diet recommendations during the last five years”, Brismar says. I recently had the honor of chatting with Brismar to hopefully straighten out a thing or two. “I was a medical student here ‘round 1968 – It was a wild era, full of philosophical and political discussions in which I was often engaged until 4 in the mornings”, replies scientist Kerstin Brismar when asked about how she first got involved with the Karolinska Institute. A scarf worn around professor Brismar’s head sort of like a bandana gives a hip feel to this otherwise normal looking 68-yearold – and as soon as she starts talking about the early years, her exhilarated face and eyes give me a flash of how “wild” she indeed must have looked as a young determined medical student about fifty years ago. As we sit down in the office by her lab right next to New Karolinska Solna, I learn that the young Miss Kerstin was engaged in several of the societies and committees of Medicinska Föreningen. “We ran our own restaurant back then, of which I was chairman, as well as being caretaker of “Solvik”, the sports cabin of Medicinska Föreningen.” 16

“As I’ve been involved in research here ever since medical school, I never really left the Karolinska Institute,” says Brismar, who first specialized in gynecology and then endocrinology. She advanced from one position to another and finally became professor in 1998, a position that she still holds. However, due to the harsh policy of Sofia-hemmet, of not allowing anyone over sixty-seven years of age to continue their clinical work, Brismar was recently shut off for being “too old”. “Though, the flipside of it all is that I have all the more time to do science now”, cheers Brismar, “After all, I have a huge lab and numerous PhD’s to attend to”. As the National Board of Health and Welfare has traditionally told us to eat lots of carbohydrates and only low quantities of fat, Professor Brismar wanted to investigate how these recommendations affect our bodies. She goes on saying: “I wanted to compare the conventional high carb low fat diet with a bunch of other diets such as high fat low carb-, high dietary fiber- and high protein diets.” The subjects in the studies were given the different diets in the quite cozy restaurant right next to Brismar’s lab rather than inside the actual lab itself. Tests were performed before and after to see how the meals would affect blood sugar, blood fats, inflammation and oxidative

“It was a wild era, full of philosophical and political discussions” stress, all of which are important markers for cardiovascular disease. “We want to know how our demand for insulin is affected by what we eat and contrary to what one might think, there actually aren’t that many studies performed yet that specifically examines this topic.” When the study is completed, hopefully before the end of the year, Brismar and her team hope that their results can be used to give better advice to people about

Kerstin Brismar in the laboratory. Photo: Mattias Ahlm

what diet is most healthy. “As of today, we frankly don’t know what people should eat, or not eat, to stay healthy”. In another study by Brismar, the subjects ate “neo-nordic food”. “By neo-nordic food”, explains Brismar, “we mean a special Nordic version of the well-known Mediterranean diet, appreciated around the world for its prophylactic properties regarding cardiovascular disease.” So instead of the Mediterranean fruit, common Nordic fruits such as apples, pears, raspberries and blueberries were used. Likewise, as far as vegetables and rootcrops were concerned – only the common Nordic varieties made it on the menu. Moreover, they used canola oil instead of olive oil, hazelnut instead of almond and so on. The study showed, quite conclusively that “Neo-Nordic food”, just like its Mediterranean counterpart, protects against diabetes, cardiovascular disease and cancer. Since Brismar’s area of expertise includes insulin-like growth factors, IGFs, she was called in to be the expert commentator on Swedish national TV when science journalist Michael Mosley’s BBC-documentary was shown last year. “The documentary about the ‘5:2 diet’ really caught

my attention and I wanted to take a closer scientific look at this new method”, Kerstin Brismar says. “Up until now, only a handful studies on the 5:2 diet have been published.” Kerstin goes on to explain that we generally eat too much these days – caloric intake has increased a lot since the eighties among children as well as adults. Whereas the average caloric intake in the USA was about 1800 kcal per day in the eighties – the corresponding value today is about 2400 kcal. That’s a huge increase. We also don’t do as much exercise now as we did then. “Look at today’s meal-sizes”, says professor Brismar, “everything’s larger, larger drinks, larger burgers, larger plates. Try buying just one hotdog today and the vendor would assume you’re buying it for a child and not an adult – that wasn’t the case thirty years ago.” This great change in eating behavior, explains Brismar, makes us put on a lot of extra weight, especially when we reach middle age – but even kids become overweight nowadays. “It’s a zero-sum game – what we put in, we must use, or our body will store it as fat.” Although this equation may seem simple, it’s not that easy for people to wrap their heads around

it in their everyday lives. For example, research has shown that labeling meals with their corresponding calorie-content has little to no effect on what meals people choose in restaurants. Perhaps we should instead be enlightening people on how much they’d have to exercise to burn those very calories.

“It’s a zero-sum game – what we put in, we must use...” “However”, says Kerstin, “I wanted to know how this 5:2 diet would work on different groups of people – who would follow through and who wouldn’t.” She also wanted to know what the typical personality traits were in those who could stick to the diet, if there are differences between men and women, differences between diabetics and non-diabetics etc. Brismar goes on to explain that we must have the answer to these questions to be able to give advice to people. And so, she started the 5:2 diet study in December last year. Says Brismar: “We will have a total of one hundred participants in this study – at present there are sixty subjects, ten

new ones each month”. So far, the results look very promising according to Kerstin. It seems like the 5:2 diet is an easy enough protocol to stick to. Whereas many people find it very hard to eat just 1700 kcal per day, every day, (which is a normal weight loss protocol) eating 500 kcal per day, 2 days a week is more convenient. “The data suggests that it doesn’t really matter how you decrease your overall caloric intake, the positive effects on the body’s biochemistry are still the same. You get increased insulin sensitivity, less abdominal obesity, decreased inflammation, better IGF-values, etc. However, the 5:2 diet appears to be the easiest diet for people to stick to over time, and that’s a huge plus.” Aside from a lower overall caloric intake, there may also be other upsides to the 5:2 intermittent fasting diet – it could have a positive effect on our cells’ ability to repair themselves. The implication of which would be that intermittent fasting, as in the 5:2 diet, would reduce the risk for somatic mutations to propagate, hence lower the risk of developing cancer. “It is not yet clear if this works in humans”, Kerstin Brismar says, “but that will indeed be the topic for my next study.”

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GLOBAL FOCUS

Image credit: Bradley Stemke (flickr)

The nutritional deficiency we may be unaware of: A Problem Not Exclusively in Children By Richard Ssegonja

Vitamin D deficiency is often mistaken as a problem exclusively in children. However, adults are at risk too and can suffer from serious consequences. This affects their overall performance/productivity and thus eventually impinges on national development. Globally, vitamin D deficiency is considered one of the most common nutritional deficiency that usually goes unnoticed because of the subtle manner in which it tends to present itself in a clinical context, combined with the insufficient health literacy among those affected. Vitamin D is a fat-soluble vitamin that is essentially obtained from exposure to the ultraviolet B radiations from the sun and dietary sources such as oily fish, eggs, fortified milk as well as fruits. Serum levels to consider are: >50nmol/l as normal, 2550 nmol/l as insufficient and <25nmol/l deficient. The people at risk of deficiency are strict vegetarians, young children, pregnant women and immigrants due to variations in latitude, duration of exposure to the sun, style of clothing and dietary habits that are mainly influenced by culture. 18

Vitamin D deficiency causes rickets in children, osteomalacia in adults and calcium derangements. It is thought to be

Globally, vitamin D deficiency is considered one of the most common nutritional deficiency that usually goes unnoticed a risk factor for autism, depressive disorders, chronic obstructive pulmonary diseases, cancers, pre-eclampsia, osteoarthritis, diabetes mellitus, hypertension, tuberculosis and respiratory infections. Furthermore, Sudanese and Somali children in Sweden have a high prevalence of autism, compared to their counterparts in Africa. The foreign-born Swedish community call it: Swedish sickness. However, the link to vitamin D deficiency needs further research. Further studies carried out in Norway, the UK and Denmark show a great deal of vitamin D deficiency in the immigrant population as compared to the native

population. The immigrants considered in the studies were from Africa, Asia and the Middle East. An additional study from Sweden showed severe vitamin D deficiency in pregnant women of Somali descent. Therefore, the foreign-born Swedish community should be prioritized as a vulnerable group. Vitamin D deficiency can be prevented. The most common ways to prevent it include: fortification of foods, education and use of supplements. The Swedish government has programs in place to address this issue, although these might need to be scaled up to achieve the intended goal. Nevertheless, there is a need to conduct studies to assess the level of health literacy concerning the issue, in the Swedish population. Such studies could, for example, be conducted in schools or healthcare centre settings through questionnaires and comparisons. The outcome of such action could result in an improvement of health and health literacy.

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GLOBAL FOCUS

37 people died of cannabis overdose – or did they? The monetary and health effects of cannabis By Haroon Bayani

ON THE SECOND OF JANUARY, AN ARTI-

cle was published on the satirical news blog ‘The Daily Currant’. It claimed that on the first day of cannabis´ legalization in Colorado, 37 people died by overdose. Subsequently, the article was spread on the entertainment website reddit.com where it was coincidently read by the former Minister of Justice Beatrice Ask. Sadly, Ms. Ask, unaware of the fact that not everything on the Internet is quite true, linked the thread on her Facebookpage, of all places, and got mocked for it for weeks to come.

...one must not neglect the benefits of cannabis. This rather sad story clearly shows how oblivious people tend to be when it comes to cannabis. However, as will be shown, the effects of its legalization in Colorado and other US states are more complex and sometimes even unexpected. The text will mainly focus on the monetary and health outcomes of the legalization. At first sight, one might believe that the meagre tax revenue of $26.4 million collected by the state of Colorado in the first five months is the main economic benefit of the legalization. Yet that is only tip of the iceberg. When measuring economic benefits, all aspects have to be taken into account. The savings Colorado has made on fewer people being incarcerated for cannabis abuse are immense. In fact, crimes such as burglaries and robberies are on the decline compared to the prelegalization era, albeit it could be a mere correlation. What is even better, however, is the fact that the legalization has created an upswing of investment and jobs in construction and tourism. These effects, though being difficult to measure, are nonetheless all indirect profits of the legalization.

Image credit: Thierry Ehrmann (flickr)

Despite that the health effects of cannabis on the human body have been researched on for decades, there are still gaps which need to be filled. One of the main arguments opposing cannabis consumption is that studies have indicated that it may cause brain damage and in the long run increase the risk of disorders such as dementia, schizophrenia and Alzheimer’s. However, these studies have failed to determine a causal relationship between high cannabis consumption and the aforementioned disorders. Moreover, one must not neglect the benefits of cannabis. Amongst other things, cannabis can alleviate the symptoms of grave medical illnesses; people with cancer, AIDS and chronic pain have used cannabis to relieve their often unbearable pain with great success.

Furthermore, one has to accept that cannabis has been used as recreational drug millennia before it was banned. By prohibiting it, those using cannabis for recreational purposes are forced to turn to illicit channels of distribution. By keeping the drug illegal, criminals are gaining titanic sums of cash each year, money that could have gone to the state. Until then, sadly, people using it for recreational purposes and those using it in order to soothe their medical conditions have to rely on the hazardous environment of the black market instead of the safety of regulated stores.

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GLOBAL FOCUS

Image credit: Daniel Neal (flickr)

Successes and failures over time To what extent are we still neglecting neglected tropical diseases? By Sergio Scro Petualang NEGLECTED TROPICAL DISEASES (NTDS)

are a group of parasitic and bacterial diseases that cause substantial illness for more than one billion people globally. Affecting the world’s poorest people, NTDs impair physical and cognitive development, contribute to mother and child illness and death, and limit productivity in the workplace. As a result, NTDs trap the poor in a cycle of poverty and disease. The World Health Organization (WHO) provides a list of 17 NTDs: Dengue, Rabies, Blinding trachoma, Buruli ulcer, Endemic treponematoses (yaws), Leprosy (Hansen disease), Chagas disease, Human African trypanosomiasis (Sleeping sickness), Leishmaniasis, Cysticercosis, Dracunculiasis (guinea-worm disease), Echinococcosis, Foodborne trematode infections, Lymphatic filariasis, Onchocerciasis (river blindness), Schistosomiasis, and Soil transmitted Helminthiases (intestinal worms). Most NTDs have a long incubation period and the infections can easily be asymptomatic for a long period of time. NTDs kill an estimated 534,000 people worldwide every year. Individuals are often affected with more than one parasite or infection at a time and treatment cost for most NTDs mass drug administration programs is estimated at less than US$0.5 per person, per year. However, despite the low costs, far more resources are given to the “big three”: HIV/AIDS, malaria, and tuberculosis. This is due to their higher mortality and public awareness. The connection between a death and a neglected tropical disease that has been latent for a long period of time is not often realized. The World Health Organization (WHO) has produced overwhelming evidence to show that the burden caused by many of

the 17 diseases that affect more than 1 billion people worldwide can be effectively controlled and, in many cases, eliminated or even eradicated. On 14 October 2010, WHO’s DirectorGeneral, Dr. Margaret Chan, launched the first WHO report on neglected tropical diseases to demonstrate the progress achieved since 2007 with the collaboration of endemic countries and partners. The results are visible, the strategic approaches technically feasible, and the investment cost-effective. With the right medicines and services comes success. Over the past 20 years, 116 of 122 endemic countries have eliminated leprosy as a public health problem and since the introduction of multidrug therapy in 1985, 14.5 million people have been cured of the disease. WHO recommends five strategies for the prevention, control, elimination and eradication of NTDs: • Preventive chemotherapy; • Intensified disease management; • Vector and intermediate host control; • Veterinary public health at the human– animal interface; • Provision of safe water, sanitation and hygiene. However, those steps are often not in place and ignored by health ministries, NGOs and medical staff. The successes achieved in some diseases such as Leprosy equal the failures in other ones such as Chagas disease and Schistosomiasis. The latter, for instance, is a human parasitic disease that in terms of socio-economic and public health impact in tropical countries is second only to malaria. Schistosomiasis is endemic in roughly 74 countries and although while it is not a fatal disease

in most cases, it causes severe complications in around 20 million people annually. Despite the vast epidemiology of the disease, treatment of Schistosomiasis consists of an oral dose once a year and the parasite can be easily avoided by not drinking untreated fresh water from lakes and wells. Schistosomiasis is just an example, and the situation is similar for most NTDs. Affordable treatments are available, knowledge is available, and willing organizations such as the Bill and Melinda Gates Foundation have achieved impressive results in treating Schistosomiasis and Dracunculiasis. Nevertheless, the practical help is not in place. Medical staff in rural health centres are often unaware of the diseases or how to treat them. Treatments are also not always available in those centres where patients go for treatment. Factors such as the relatively low mortality rates of NTDs as well as low economical interest from pharmaceutical companies to invest in research have made the 17 NTDs some of the highest ranked diseases, in terms of global burden of disease, in most of Sub-Saharan Africa, South-East Asia and Latin America. The Bill and Melinda Gates Foundation have accomplished remarkable goals in the area of NTDs. Local Ministries of Health in affected countries and other NGOs must follow their steps in order to tackle the problem and lower the global burden of disease as much as possible.

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GLOBAL FOCUS

Swedish foreign aid: Today’s role, challenges and future issues By Sergio Scro Petualang THE SWEDISH MINISTRY OF FOREIGN

Affairs comprises numerous international and experienced staff members; Anders Nordström is one of them. Graduating as a medical doctor from Karolinska Institutet, he then undertook a number of work placements that would take him around the globe. Nordström began his career with the Red Cross in Cambodia; he then worked for SIDA and subsequently he was recruited by WHO where he worked for five years in Geneva. He is now the Swedish ambassador for Global Health within the Ministry of Foreign Affairs. In his latest job position, he acts as an active board member for two international organizations: GOBI and the Global Fund for AIDS, TB and Malaria, as well as representing Sweden in global health policy work. The global agenda and the new epidemic of non-communicable diseases (NCDs) in low and middle income countries were at the centre of the discussion. There has been an explosion in NCDs in the past decade in regions that are still struggling with weak economic growth, high levels of corruption and high illiteracy rates. Places in which there was practically no diabetes 20 years ago, are now reporting much higher disease prevalence. According to Nordström: “The Global agenda has been focusing on survival rather than prevention lately; reducing child mortality, reducing maternal mortality and lowering the burden of AIDS, TB and malaria. However, there is need to focus more on long term prevention given the epidemic of non-communicable diseases (NCDs) in low and middle income countries”. Physical activity, a healthy diet and changing the attitude of people is what is needed; however, it is the poorest people who suffer the most from NCDs. There is a trend whereby most economically disadvantaged people get a little extra cash, they will purchase a coke and a hamburger; if they get a little more they will buy cigarettes; and if they have even more, they’ll buy a car. All of these activities are unhealthy and risk factors for de22

“The Global agenda has been focusing on survival rather than prevention lately; reducing child mortality, reducing maternal mortality and lowering the burden of AIDS, TB and malaria.” veloping NCDs. The trend goes hand in hand with the economic boom in China, India, South-East Asia, Latin America and parts of Sub-Saharan Africa. Changes of attitude cannot occur without a change in society and in most low and middle income countries, this change in society is something that cannot be predicted and may take generations in order to occur. “Infrastructures are needed now more than ever in order to face the increase of NCDs”, argues Nordström. Infrastructures that are now used for treatment of HIV/AIDS, which is currently considered a chronic disease, could be used for the treatment and diagnosis of NCDs. From a development perspective, lit-

However, the situation and attitude is different in every country and varies even within countries. tle has been done so far in the field of NCDs by Sweden; however, “it is beginning to take off now,” Nordström affirms. One of the Swedish priorities in the aftermath of the Millennium Development Goals (MDGs) is to put NCDs on the global agenda. This process will take time and effort, however, it is a process that will begin soon enough. Moreover, the MDGs have achieved great success in lowering maternal mortality, increasing newborn health and lowering the burden of malaria, TB and

HIV/AIDS; however, great failures have also occurred. Whereas, for instance maternal and newborn health has greatly improved in Uganda, HIV/AIDS has also spiked up to a 7.2% national prevalence. In Zimbabwe, maternal mortality is at its highest now- five times higher than 20 years ago. According to Nordström “political leadership is the reason why in some regions MDGs have not yet been achieved”. In those regions that are dealing with ongoing conflicts, aftermath of conflicts, weak capacity and weak leadership, we understand that the MDGs are far from being reached; DRC and Somalia for instance. Nonetheless, there have been also remarkable exceptions such as Afghanistan, considering its poor security on the ground, and economy. Furthermore, where there has been strong political leadership and good management, a progress has been recorded in the achievement of the MDGs; Ethiopia is a good example of good management and good leadership. However, the situation and attitude is different in every country and varies even within countries. According to Nordström: “Botswana has not done well in lowering the rate and incidence of HIV/ AIDS considering that it is one of the most politically stable and economically developed country in Sub-Saharan Africa. They have just not addressed the issue efficiently”. Moreover, when discussing the future challenges of global health, the rise of NCDs and mental diseases are undoubtedly the future tasks that the global agenda needs to address. People are now living longer and getting richer; therefore obesity, cardiovascular diseases and diabetes are on the rise. Lastly, “Prevention and management of diseases”, he added “need to be tackled in the future by cooperation rather than just foreign aid. We have to cooperate with other countries in order to face future challenges and outbreaks”.

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GLOBAL FOCUS

Anders Nordstrรถm, Photo: Private

A SPACE ODYSSEY Story by Oskar Swartling & Robert de Meijere Photo by Martin Kjellberg

COVER STORY

“

I saw an ad, applied and was lucky enough to get the job.

“A

nd then you look at the Earth when you have a moment. That usually takes up a lot of the free time.” Christer Fuglesang, docent in particle physics and Sweden’s first astronaut, describes his time in space as an amazing experience, especially the view over Earth. He continues: “The weightlessness and the spacewalks were also really special.” After two space shuttle missions, Fuglesang spent a total of 26 days, 17 hours and 38 minutes in space, including 31 hours and 54 minutes spread over five spacewalks. For these two missions, Fuglesang trained for over 13 years, and rightly so, for being in space is physically very challenging. “A lot, if not all, of our physiological systems are affected in space. Especially by the microgravity”. There is a whole branch of medicine called Space physiology, dedicated to the study of how our body functions in space. It is a unique environment, with microgravity and high radiation that affects the human body in a way that has never been experienced before. While we strive to go further into space, many of the potential showstoppers lie within the medical field. On the question how Fuglesang became an astronaut, he laughs and says that it is a hard one to answer. “The short version is that I saw an ad, applied and was lucky enough to get the job.” And he continues: “But why did I apply? I have always been interested in space. I used to speculate a bit about how amazing it would be to go to space and that if I got the chance, I would 26

have to take it. Then suddenly I saw an ad. At that time I had no idea they even had an astronaut program in Europe.” He describes the admission process as being long and tiresome, consisting of for one thing, medical tests with over 500 parameters. Finally, he became one of five European astronauts to be sent up to space and the International Space Station, ISS. On the 10th of December 2006, the space shuttle Discovery was sent off to space, making Fuglesang the first Scandinavian leaving the Earth’s atmosphere. He would later return to space in 2009, completing his second mission. Fuglesang describes the time in space as wonderful but adds that he was lucky, from a medical perspective: “Many get sick more or less instantly, suffering from something called Space Adaptation Syndrome. I felt it in the beginning, but then I managed to focus on something else.” The syndrome,

“A lot, if not all, of our physiological systems are affected in space.” more simply space sickness, is due to the adaptation of the vestibular system to microgravity and is related to motion sickness. But space sickness is not the only difficulty the astronauts encounter. “Another problem is that many astronauts suffer from back pain in the beginning of their stay. The spine gets longer in space,

or more accurately, it is not compressed as it normally is on Earth. But the pain usually subsides after a few days.”

“At that time I had no idea they even had an astronaut program in Europe.” A third problem the human body faces in space is that the microgravity no longer pulls fluid towards the legs. Therefore, the fluid balance in the body changes. “You lose a lot of fluid that you don’t need and your face will seem plump. It is also really important that you drink before landing, otherwise you risk losing consciousness.” The astronaut’s everyday-life is planned to the minute and has been practiced over and over again. Amongst other things, they’re scheduled to sleep for eight and a half hours, work for eight and a half hours and exercise for two hours; the latter is essential for the maintenance of muscle mass. However, research and science is gaining ground, becoming increasingly important on the missions and on ISS for each day. “Now, when the ISS is starting to be completed, more and more time is spent on research. A big part of that research is being done on physiology.” Fuglesang describes the return to Earth as “tough”. He brings up the re-introduc-

COVER STORY

Photo: Robert de Meijere

tion of the Earth’s gravity and the stress it places on the body in particular. “To stand up when you are back on Earth is hard. Moreover, the sense of balance is really disturbed, especially during the

“The vision is to go further and be away for increasingly longer periods of time...” first day. Again, some get sick but I was lucky enough to avoid that.” Even though Fuglesang has no upcoming space missions, he is still very clear on the future of space exploration: “The vision is to go further and be away for increasingly longer periods of time and space physiology is an essential part of that. Except 28

for weightlessness, the other significant problem that needs to be dealt with is the radiation. It is not only about exploring space. Equally important is using our knowledge to improve life on Earth. It is usually said that a lot of what the body undergoes in a state of weightlessness is analogous to ageing and we are therefore using it to understand how ageing works. One example of that is osteoporosis. You lose bone mass in space, and we are not really sure what drives that.”

that appointed Fuglesang as Sweden’s top candidate for the recruitment of astronauts. “There are a number of difficulties. It is a slow process, where the rate of demineralisation is a few percent per

Professor Dag Linnarsson agrees with Christer Fuglesang. “The biggest remaining challenge that remains to adequately study is the degradation of the bones, i.e. the process of demineralisation.” Linnarsson is a well-known figure in space physiology, having worked with NASA, European Space Agency and having been the chairman for the Swedish committee

month, precisely on the limit that we can detect. […] In principal, you could say that the loss of calcium from bones during one month in space is equivalent to that normally lost in one year.”

“Equally important is using our knowledge to improve life on Earth”

Having started his career in space physiology in 1976, Linnarsson has been particularly interested in the effect of gravity

“

COVER STORY

The big guys are not necessary in space. You don’t have to be strong, but you have to be healthy.

on the distribution of gases and blood in the lungs and what happens in microgravity. “We know that gravity pulls down blood to the lower parts of the lungs or the posterior parts if you are lying on your back, as well as changing the dimensions of the alveoli so that they expand most at the bottom when you are inhaling.” he explains and continues: “When you take away gravity two things can happen. Either the distribution of blood and gas in the lungs is optimised, or the distribution becomes chaotic. Without gravity, how can the blood know where the gas is travelling and vice versa?” Nonetheless, Linnarsson and the researchers have had

front to see what happens. One way of understanding the effect of gravity is to see what happens when you remove it.” The knowledge of the impact of gravity is not only useful in space. Understanding the interaction between gravity and the lungs can help understanding how particles on Earth damage the lungs and where the damage accumulates. Linnarsson and Fuglesang share the confidence that research in space physiology will help people’s health here on Earth. They also share another vision: the missions will go further and the astronauts will be away for longer periods of time. For that they need a new generation of astronauts.

“One way of understanding the effect of gravity is to see what happens when you remove it.”

Everyone with the dream of one day looking down on our blue planet from a pitchdark space can take a breath of relief. “You don’t have to be extremely well-trained.”, Linnarsson says, himself being involved in the selection of the astronauts. “You don’t have to be a physiological superhuman.” The general requirements are a high academic education, high capacity of multitasking, no predisposition for kidney stones and social competence. “On the contrary, when you don’t have gravity you don’t have any need of big muscles. From that perspective, women are more efficient as astronauts since they, in general, have a lower muscle mass, lower metabolic rate and lower oxygen needs. The big guys are not necessary in space. You don’t have to be strong, but you have to be healthy.”

an advantage compared to older generations concerning an issue that could have potentially stopped space exploration in its tracks. “Ever since Gagarin’s flight in 1961, we at least knew that you’d survive.” The study of physiology in space is unique. Life has evolved with gravity and without it, every part of the human body is affected. As Linnarsson puts it: “If you want to understand how it normally affects the body, it is not enough with turning people upside-down and back to

Space has always been a mystery to mankind, inducing mixed feelings of love,

“Ever since Gagarin’s flight in 1961, we at least knew that you’d survive.” wonder and fear. But our determination to explore the unknown is immense. It is the same determination that explores the life of cells, the systems of our body and the complexity of our brain. It is the same determination that put man on the moon and wants to put one on Mars. In space, the study of physiology not only teaches us new space-related things, but also provides a better understanding of how we function on Earth. Our biggest challenges are still ahead and we are still not ready to take the next step towards our red neighbour. Asking someone who practiced for more than 13 years before his first visit to space on how prepared you generally are prior to take-off, he answers: “You are actually not”.

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...AND HOW OUR BODY FUNCTIONS IN MICROGRAVITY SPINE Feeling short? Go to space! Without gravity, the spine is free to expand, making the astronauts taller. The growth can be as much as up to 3 percent (during a six-month flight) and the effect even lasts through the first five months back on Earth.

BONES Normally, bone mass is constantly changing. Bones are continuously broken down and rebuilt in a well-balanced process. Conversely, in the presence of microgravity the rate of breakdown increases and causes bone to be constantly diminished with no recovery. It quite literally dissolves away. Some tests have shown a decrease of as much as 1-2 percent a month from specific body parts, like the pelvis. To put that in a perspective: a normal man in his fifties loses about 0,5 percent per year. That’s a remarkable amount and results in a large amount of calcium being excreted into the bloodstream, which could lead to the production of renal stones. NASA is currently working on how to best counteract the atrophy and developing exercise programs for the astronauts.

SLEEP Sleep deprivation is one of the most widespread problems among astronauts. Not only do they have to adapt to sleeping strapped to the wall, their light-dark cycles and circadian rhythms are unbalanced. This is not aided by them often arriving there overexcited and having to work in shifts and gets worse in orbit when they experience a new dawn every 90 minutes. A common way of dealing with the sleep deprivation is sleeping pills.

LUNGS The classic space suits are not only used for the looks. They are actually a sort of self-contained individual spacecraft and are generally inflated with 100 percent pure oxygen at a pressure much lower than the atmospheric. By eliminating components such as nitrogen and lowering the pressure, the space suit allows the astronaut to breathe and move comfortably. This is however not entirely uncomplicated. Before doing a spacewalk they have to “pre-breathe” in order to let their body tissues slowly outgas the nitrogen. Failure to do so will result in bubbles forming in the blood stream, known as decompression sickness.

FACE Our bodies are made up of 60 percent water, something that becomes obvious in zero gravity. Within a few moments of leaving Earth, fluid is immediately re-distributed from the legs to the upper body resulting in - what astronauts call - a “moonface”. After a while the body adapts and upon return to gravity it returns to normal.

EAR A very common effect of being weightless is nausea. The inner ear has a problem with adapting to the loss of gravity and will cause the astronaut to experience dizziness and balance problems. For that reason, they are on “anti-dizziness” medication for the whole duration of the flight.

NOSE All the fluids travelling up to the head also lead to nasal congestion. The symptoms are very much like those of the common cold and may last throughout the entire trip.

MOUTH Change in the sense of taste. Some astronauts find that their food no longer tastes good. Others discover that they like different type of foods that they wouldn’t normally eat. The reason for this is uncertain. However some theories include food degradation and simple boredom. The solution? Spicing it up!

EYE

Since the amount of fluid in the head increases in a weightless environment, the intracranial pressure rises. This might have an effect on the eyeballs, slightly affecting their shape and putting pressure on the optic nerve. This is not documented as a problem for shorter flights but could be a major issue in the future with flights to, for example, Mars.

MUSCLES HEART The re-distribution of fluid in the bloodstream also results in a decrease in plasma (water in the blood stream). To compensate for this the body sets in motion a cascade of different adaptive systems that includes regulation of blood pressure and atrophy of the heart due to it having less blood to pump. Upon return to Earth these adaptions can be dangerous for the astronauts. A weakened heart results in lower blood pressure and consequently less oxygen reaches the brain. Moreover, some experience lightheadedness and have problems standing up for more than 10 minutes without fainting. Fortunately the effects decline after a few weeks.

Our body’s muscles are dependent on gravity to be kept conditioned. Without any force to counter-act them, some muscle groups quickly start to deteriorate. The muscles needed to move around in space are not the same as those required for terrestrial locomotion. Since they’re no longer required for standing up, the muscles of the back and legs are especially affected by this. Without exercise, astronauts could lose as much as 20 percent of their entire muscle mass in under 10 days. The type of muscle fibers is also affected. Slow-twitch fibers that are no longer needed for standing up change to fast-twitch which is better optimized for heavy workloads. This might be ideal in space but becomes a problem back on Earth. To manage the complications astronauts have to exercise for two hours a day.

Photo: NASA

EBOLA

THE EBOLA EPIDEMIC IN WEST AFRICA Facts, numbers, present challenges and predictions. In which direction is the Ebola epidemic going?

Story by Iskra Pollak Dorocic & Sergio Scro Petualang Infographics by Jakub Lewicki Photo: afreecom/Idrissa SoumarĂŠ

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tâ&#x20AC;&#x2122;s impossible to not have heard of the ongoing and unprecedented Ebola epidemic in West Africa, with its steady escalation and horrifyingly high death count over the past six months. Every day there are reports of more and more people contracting the disease, with the US Centre for Disease Control predicting the

gain control of the outbreak, the rest of the world has for the most part stood idly by. Medicor spoke to several experts, as well as people in the affected region, and in the following pages takes an in-depth look at the disease - from virology to public health issues.

Healthcare workers and the family and friends in close contact with Ebola HF patients are at the highest risk...

Ebola virus disease (EVD) is one of several viral haemorrhagic fevers. The Ebola type produces a severe and often fatal disease affecting both humans and nonhuman primates (such as monkeys, gorillas, and chimpanzees). When infection occurs, symptoms usually begin abruptly. The first Ebola virus species was discovered in 1976 in what is now the Democratic Republic of the Congo, near the Ebola River. Since then, outbreaks have appeared sporadically.

number of cases could surpass 1 million by the end of the year if drastic measures are not taken. As the affected countries are scrambling, so far unsuccessfully, to 34

THE BASICS

The natural reservoir host of Ebola viruses remains unknown. However, on the basis of available evidence and the nature of similar viruses, researchers believe that the virus is animal-borne, with bats being the most likely reservoir. Four of the five subtypes occur in an animal host native to Africa. Symptoms of EVD include high fever, severe headache, muscle pain, diarrhoea, vomiting and abdominal pain. Symptoms may appear anywhere from 2 to 21 days after exposure to the virus. Someone who becomes sick with Ebola could be able to recover. However, patients who die usually have not developed a significant immune response to the virus at the time of death. When an infection does occur in humans, the virus can be spread through direct contact with a sick personâ&#x20AC;&#x2122;s blood or body fluids (urine, saliva, faeces, vomit, and semen), objects (such as needles) that

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“

Usually the industry is interested more toward money, and the money is more where there are more patients, so there is more research for HIV, malaria, tuberculosis.

Photo: EC/ECHO/Cyprien Fabre

have been contaminated with infected body fluids and infected animals. Healthcare workers and family and friends in close contact with EVD patients are thus at the highest risk of getting sick. During outbreaks of EVD, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Expo-

This is when the real problem starts. The infected cells induce a ‘cytokine storm’... sure to Ebola viruses can occur in healthcare settings if the hospital staff is not wearing appropriate protective equipment such as masks, gowns and gloves. Unfortunately, these relatively cheap basic medical materials are often not avail-

able in poor settings. Proper cleaning and disposal of instruments such as syringes is also important. If instruments are not disposable, they must be sterilized before being re-used. Without adequate sterilization of the instruments, virus transmission can continue and amplify an outbreak. No specific vaccine or medicine (e.g., antiviral drug) has been proven to be effective against Ebola.

WREAKING HAVOC IN THE BODY

What exactly makes the EVD virus so deadly? When the virus enters the body, it quickly infects various cells of the immune system, including monocytes, macrophages, and dendritic cells. These then spread via the blood to the lymph, spleen, and the liver where they infect more cells dispersing the virus throughout the

whole body. In a normal case, immune cells fight back by producing antibodies against the pathogen. However, EVD manages to evade the immune system by inactivating certain defence genes and disrupting the function of interferon, an important antiviral protein. This is when the real problem starts. The infected cells induce a ‘cytokine storm’, an exaggerated response of the immune system to a new pathogen, resulting in recruitment of more and more of the small molecules which the immune system uses for communication - the cytokines. Too many cytokines can eventually cause tissue damage, organ destruction and death. This is exactly what is seen in later stages of an EVD infection, when the strong immune response causes blood vessels to leak and result in internal and external bleeding. This haemor-

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rhage is what in most cases ultimately leads to the patient’s death.

TRACKING THE OUTBREAK

Past Ebola outbreaks have occurred since Ebola records began in 1976 in the Democratic Republic of the Congo (DRC), Gabon, South Sudan, Ivory Coast, Uganda, Republic of the Congo (ROC) and South Africa (imported). The current Ebola outbreak is occurring in Guinea, Liberia, Sierra Leone, Nigeria and DRC. How exactly did the current outbreak begin? To begin answering that question, scientists have sequenced and analysed the genomes of Ebola virus samples from 78 people who were the first ones diagnosed with the disease at a hospital in north-eastern Sierra Leone, near the borders with Liberia and Guinea. Sierra Leone’s initial outbreak of Ebola in the early summer has now been traced back to a single event – a traditional healer’s funeral at which 14 women were infected. Geneticists at the Broad Institute of M.I.T. and Harvard who sequenced the virus from blood of the patients found that all 78 had virus traceable to funeral guests, and also showed that the West African Ebola strain is different from a strain that has been circulating thousands of miles away in Central Africa since 1976. These two strains are thought to have diverged in 2004 and the West African outbreak originated in a single event in which the virus passed from an animal to a person. The DNA sequences have shed light on how much the virus is changing throughout the outbreak and will be used to improve diagnostic tests, which are currently developed for the older strain of the virus and not the current one. Eventually, the genetic information will be useful in order to develop vaccines. On

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RESEARCHING THE VIRUS

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hausted supply and production of more will take months. Time is also a factor in testing and producing a number of potential vaccines. Companies producing the vaccines still need to confront the technical challenges of boosting production. It Incubation forinEbola seems that a lackperiod of interest developing preventative measures is coming back to haunt authorities, who are now approv301 cases ing development and trials with an un144 deaths precedented speed. involving health-care workers in Guinea,has Liberia, A last desperate measure been and Sierra Leone Incubation period forthe Ebola proposed to slow down fatalities. WHO announced that blood from recovered Ebola patients should be used cases to treat the infected ones.301 This strategy has been used in several patients during 144 deaths beds ainvolving previous much smaller Ebola outbreak workers inavailable Guinea, Liberia, doctors andhealth-care nurses needed to treat inand with success. It canSierra Leone apparent an for a 1995, 70to 80-bed Ebola patient not be denied that time anywhere is of thein utmost Ebola treatment centre Liberia importance in battling the current Ebola outbreak. The longer the virus is on the loose, the more genetichealth-care mutationsworkers it is acbeds quiring, making it more likely to mutate that the WHO doctors and nurses needed available to treat into a to form that more dangerous wantsistoeven be from for a 7080-bed an Ebola patient than the current one. foreign countries Ebola treatment centre anywhere in Liberia

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The measures of isolaandusual Sierra containment Leone tion of patients have failed and the outbreak seems to be out of control. This reality has finally mobilized authorities to push for a fast-tracked development of drugs. A number of infected health beds care doctors and nurses needed available to treat workers, for the most part from outside for a 70- to 80-bed an Ebola patient of Africa, have successfully been treated Ebola treatment centre anywhere in Liberia with the experimental drug ZMapp, containing a cocktail of three monoclonal antibodies. Trials in monkeys have also workers shown a positive effect health-care of the drug. The that the WHO drug is, however, in a very limited and ex-

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tific literature between research on Ebola versus other types of pathogens, with less than 2,000 scientific papers on EVD compared to the widely-researched HIV which covers almost 300,000 publications. Aside from this scarcity of basic research, do pharmaceutical companies have incentives to invest in EVD drug development? “There is of course several aspects to consider”, says Dr. Mirazimi, “First of all, HIV is a much, much bigger health problem than EVD, in Af-

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number rica cases as well as many other parts of the of world, including Western countries. This

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lie towards money, and the profit is larger where there are more patients.” Then there are the other limitations, including the high-level biosafety laboratories. “Keep in mind that studying these viruses is very expensive as you need high-containment laboratories and the maintenance of these laboratories has a huge cost”, says Dr. Mirazimi. Only about a handful of these highest biosafety level facilities exists in Europe (including one at Folkhälsomyndigheten), while Africa has only one, located in South Africa. “So generally speaking, there is a limitation in number of these facilities, there is limitation in priority of how this disease is seen in correlation with other public health problems, Uganda and how much money the in2000-2001 dustry is interested in investing. These issues make the research on diseases like EVD really limited in comparison to other pathogens.”

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Medicor also interviewed Anneli Eriksson, a Swedish nurse and Médecins Sans Frontières (MSF) staff member. She worked in Monrovia, Liberia during August 2014 in an Ebola hospital set up by MSF. She considers the outbreak in Liberia “out of control”. Many staff members and health personnel have been infected by EVD and have subsequently died; many of the country’s hospitals and healthcare centres have been closed or perform their activities in a very limited way in order to avoid the spread of EVD within the hospital premises. Eriksson also adds that the peculiarity of the outbreak in Liberia is that no clusters or hotspots have been identified. Infected patients come from all over Monrovia and all over the country. The MSF Ebola centre in Monrovia is currently run by approximately 300 national staff members and 60 international. They have an availability of 200 beds and the centre is overcrowded. Their admission policy is

beds available to treat an Ebola patient anywhere in Liberia

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to only admit patients that have strong symptoms, and thus high viremia, with the aim of isolating the most infectious patients in order to limit the spread.

DISASTER MEDICINE

Furthermore, Medicor approached Dr. Johan von Schreeb, a disaster medicine specialist and Associate Professor at Karolinska Institutet, where he leads research and training on health response following disasters. During the last 25 years he has on a regular basis worked for MSF and World Health Organization (WHO). He recently returned from Sierra Leone where he was deployed on behalf of WHO to coordinate the foreign medical teams’ response to the Ebola outbreak. “The situation in Sierra Leone is out of control”, says also Dr. von Schreeb. He emphasizes the need of supporting the existing health staff, primarily nurses. “They need to be ensured a substantial risk allowance, have access to treatments if they are infected, in addition to an insurance package that protects their families in case of death. They are courageous and take risks, it is our duty to support them, without them this epidemic will continue to ravage”.

However, none of the pillars above mentioned are working properly in Sierra Leone, according to Dr. von Schreeb.

Zaire 1976

countries with cases

Senegal Guinea Sierra Leone Liberia Nigeria

avoiding contact with sick. Discouragingly, none of the pillars mentioned above are working properly in Sierra Leone, according to Dr. von Schreeb.

EU ON HIGH-ALERT

Beside case management, an additional four essential pillars must be in place to control EVD: epidemiologic surveillance to monitor the evolution of the epidemic, contact tracing and follow up of persons in contact with the sick, safe burials of suspected EVD deaths and finally and the most challenging, community sensitization. This means building trust and confidence with the population at risk, convincing them to follow guidelines and 38

Uganda 2000-2001

At the European level, the European Centre for Disease Control (ECDC) is facing the Ebola outbreak in a number of ways. As public health professionals, the ECDC staff is working hard on keeping the outbreak under control and protect the health of EU citizens and residents, according to the ECDC’s press department. They have produced a first Rapid Risk Assessment in March 2014 that has been updated periodically as the outbreak evolves. In an interview with them, they state that the ECDC is considering three main risks for EU/EEA: “risks for someone from the EU being infected in the affected countries; risk of importation of EVD virus into Europe and the risk of onward transmission, should it be imported”. The most obvious option to decrease the risk of importation from affected areas is to advise travellers to defer their travel to these affected countries until the outbreak is controlled there. Twenty-four

EU/EEA countries have recommended this option for their citizens of which twenty have recommended avoiding or postponing non-essential travel and four advising against all travel in the affected areas. Should any infected person enter the EU, the transmission within the EU should be prevented and controlled. To achieve this, preparatory activities are ongoing, to ensure that all Member States are well aware and prepared for this eventuality. Finally, it seems as though the rest of the world is taking notice of the severity of the outbreak and jumping into action. US president Obama announced on September 16th that the US will be sending 3,000 military troops to set up treatment centres with 1,700 beds. China and Cuba are also sending medical personnel and equipment, as are a number of other countries in smaller quantities. The last day of September also saw the first diagnosis of EVD outside of West Africa, brought by a traveller to the United States. The struggle is a race against time, as the longer the virus is on the loose, the more deaths there will be and the more difficult and expensive it will be to contain the epidemic.

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“

They didn’t believe it existed.

A Story from Inside Sierra Leone By Furat Al-Murani WHEN IT COMES TO THE MASS MEdia, media coverage of the Ebola epidemic has thus far focused on its regional, and potential global health ramifications. Medicor caught up with Rupert Day, a UK citizen who manages an international cocoa trading company based in Eastern Sierra Leone, the centre of the Ebola zone.

“Then it jumped to Liberia and Sierra Leone and there were a few headlines.” When did people notice something was happening? When it was in Guinea, there was nothing in local or international press. Then it jumped to Liberia and Sierra Leone and there were a few headlines. The first I heard about it was from Sylvia Blyden (special executive assistant to the president), who posted that she thinks there is Ebola in Kailahun, Sierra Leone, although nothing official was released. It was denied by most people, saying the government were trying to put a smear on the East because it’s opposition territory. International efforts stepped up when two American doctors in Monrovia contracted it and were flown out. People realised a symptomless person could step on a plane in Freetown and 6 hours later be in Europe. How did things change when it spread? One of the biggest problems was people. They didn’t believe it existed. I remember hearing about an ambulance heading to Koindu, Sierra Leone (where the outbreak started). Local children built a trench on the road which the ambulance drove into and smashed. It’s understandable, people from small villages have been disconnected from the government for generations, dealing with problems themselves, and suddenly the government was telling them what to do.

You were quarantined in Kenema, Sierra Leon, what was that like? It was complete and utter chaos. We had a former security guard, John-Jo, who had been working with us for 4 years. His father in law ran a dispensary, contracted Ebola and died. John-Jo denied it existed. He died 6-7 days later. The body was in the house for 3 days after he had died. He was living with 2 security guards who continued to come into work. This came up in conversation afterwards! MSF and the Red Cross are aware what they should be doing, they just aren’t able to do it. It was up to us to run around and do the contact tracing ourselves. How does it compare with the situation during the war? People think this will be worse than the war. My finance manager explained how in the war, you had an idea where the rebels were, and if and when they were coming close. You could find a place to hide. With Ebola, people have no idea what’s going on. There is a real state of confusion.

“People think this will be worse than the war.” What about financial implications for everyday people? In terms of day to day life, the places under quarantine felt the biggest price hikes; Kailahun and Kenema. People cannot enter or leave either place, but food stuffs are still allowed to come in. The thing is people don’t know what the state of emergency means, so prices went up and panic buying started. The price of basic goods like rice or chlorine tablets has shot up. The government has tried to get traders to put prices down but it’s completely unregulated. What I can’t stress enough is how fragile these economies are. The difference of a farmer selling his cocoa and not is the difference between

Rupert Day, private photo

him sending his kids to school and not. There are no savings. One bad season can be catastrophic.

Where does this leave the region for the future? I was speaking to the head of the Red Cross who said to me it will take maybe a year with an antidote, just to manage the outbreak. There is a real fear from people here that it will be like the post war days again, where a country is trying to get back on its feet but has a negative international image. In the few years I was there, with all the problems with corruption and infrastructure, there was genuine progress, and a lot of that has been put on hold. This place has had more than its fair share of knocks, it doesn’t deserve this.

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HEALTH CARE IN DANGER

Stepping up for Access to Health Care Ethical implications of violence towards medical personnel, and what students can do about it.

By Anna-Theresia Ekman* and Gustaf Drevin** *

Health Care in Danger Focal Point IFMSA-Sweden Health Care in Danger Organizing Committee IFMSA-Sweden

AS STATES FAIL OR GO TO WAR, DEEP

rips are torn through social structures. The humanitarian community will step up and replace systems such as health care. As of late, health care personnel suffer from targeted attacks as they try to fill that void. This poses grave implications for our ability to fulfil the ambitions expressed in the Universal Declaration of Human Rights (UDHR) and is a direct insult to International Humanitarian Law (IHL), as health care workers are forcibly prevented from helping those in need of treatment. Mogadishu. It is graduation day for the second (!) batch of Somali medical students to successfully complete their

medical training in twenty years. Two students stand on the back of the stage waiting to get their diplomas, at Hotel

We should be deeply worried about health care attacks becoming a new war strategy... Shamo. Even the ministers of health and education attend the commencement. Suddenly, an individual dressed in womenâ&#x20AC;&#x2122;s clothes approaches the scene. Seconds later, there is a big explosion; a ball

of dust and smoke, followed by chaos. Twenty five people are killed and over eighty are injured. Most of them are the newly graduated doctors. The students, dressed in black and golden gowns, are covered in blood whilst trying to save their friends. The professors bear testimony to the horrific consequences of violence targeted at the health care community. If you have ever taken the medical code for granted, you must continue reading. The 2009 Hotel Shamo Bombing was in itself a horrific crime, and the long-term impact on the Somali access to health care was even more dire. We should be deeply worried about health

Pakistan, 12 April 2010. An ambulance is set ablaze by angry protesters in Abbottabad, located in the North West Frontier Province.. Photo: ÂŠ Reuters / Abrar Tanoli / RTR2CQ0D

HEALTH CARE IN DANGER

Ambulances take huge risks during armed conflicts to reach and transport the wounded and can fall victim to stray bullets. Photo: COSMOS / Catalina Martin-Chico

care attacks becoming a new war strategy as warring parties attempt to invoke maximum fear and anarchy. Now, the international community steps up, with more and more research being done by institutions such as the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières.

THREATS AGAINST HEALTH CARE

As student coming from different backgrounds and studying to become different specialities, we most certainly have our differences. But if there is one thing we can all agree upon, it is this: when providing health care, we must always prioritise the need of the patient. This professional ethic, shared by all health care personnel, has its root in the horrendous war crimes committed by, among others, doctors during the Second World War. From these experiences,

Other attacks aim at the destruction of health care units... the UNDH emerged, stating the sacred right to life and health. People impartially working with improving the health of the injured and suffering should not be targeted. Although almost every state in the world has ratified the UDHR, there is a lot of truth in the words of ICRC’s Chief War Surgeon when he says that “[one] of

the first victims of war is the health care system itself.” As workers are threatened and impediments are posed in the way of their duties, the ethical ramifications are huge. Research within the field of violence against health care is relatively new, but we have good data. Earlier this year, Humanitarian Outcomes reported that 2013 was the deadliest year for humanitarian workers as 155 were killed, 171 seriously wounded and 134 kidnapped, in a total of 251 separate attacks. This marks an astonishing 66% increase from 2012. Additionally, during the first eight months of 2014, we have seen more deadly attacks against health care staff than in the whole of 2012. Given the instability within many parts of the world, an increase might have been expected. The problem, however, is that an increasing trend has now been observed over a longer period of time. Back in 1996, six ICRC personnel were assassinated in their beds by masked men in Novye Atagi, Chechnya, sparking the ICRC’s withdrawal from the region. 20 people in an aid vehicle convoy were killed in Somalia in 2000, while ten men and women working for a Christian aid agency were killed by the Taliban in Afghanistan in 2010. If you do an internet search for attacks on health care workers, you will find hundreds and hundreds of similar cases. First responders (ambulance personnel, emergency staff, and drivers) and national staff are in the front lines of these

attacks. 87% are directed against health care personnel working in their own countries. It is also worth noting that

...even in noncombat zones, health care personnel are prevented from following their professional ethic... while only 8% of field workers are expatriates (i.e. field staff not coming from the country in which they are working), a whole 13% of attacks are directed at expatriates. Ransoms and invoking fear of foreign involvement in conflicts are the main driving forces behind these attacks. Attacks on health care facilities are another side of the same coin. Deliberately targeting hospitals and medical care facilities can be used as a method for military parties to gain advantages by depriving opponents of medical care. Other attacks aim at the destruction of health care units that are believed to have given support to one party in a conflict or housing belligerents. Moreover, these types of attacks can be used as means to invoke maximum fear or suppress civilian resistance. The looting of drugs, as well as medical equipment, further diminishes the possibilities for health care personnel to provide the needed care. Additionally, we need to speak up for access to health care; itself a part of the 41

HEALTH CARE IN DANGER

“

One of the first victims of war is the health care system itself. Marco Baldan, Red Cross Chief War Surgeon.

Human Right to Health. There are even more impediments hampering this right, such as checkpoints and road closures where the military can halt an ambulance for hours or prevent people from reaching medical facilities.

THREATS AGAINST HEALTH CARE IN EUROPE

Up until now, we have only mentioned violence towards health care personnel operating in armed conflicts. The reality is that, even in non-combat zones, health care personnel are prevented from following their professional ethic and fulfilling the Human Right to Health. In Europe, the financial crisis has substantially diminished the economical means given to health care systems. Parties and other groups that do not acknowledge the inherent dignity and the equal and inalienable rights within all humans are gaining support and have even made their way into the very core of European politic; the European Parliament. Through the internal disturbances in Ukraine, it has become evident that peace is not as stable as we might think. In order to assure access to health care in times of conflicts and other emergencies, it is absolutely crucial that we are able to fulfil our obligations in times of peace. Even in Sweden, health care personnel have been having difficulties reaching injured during internal disturbances. During the riots in Malmö on the 23rd of August 2014, the police was unable to guarantee ambulances safe passage. This

lead to health care personnel organizing themselves outside of the official system to provide care at the subsequent demonstration that took place in Stockholm. Ambulance staff has been voicing concerns

...wounding 1101, and seeing the kidnapping of 166 humanitarian workers. over the increased threats they meet in their work. At the same time, health care personnel in the emergency wards are being trained in self-defence in Stockholm. Nevertheless, an unsafe environment isn’t only a problem directly related to violence. Economic strategies overthrow the medical code, posing big obstacles to the provision of equal treatments for everyone. When unreasonable restraints are put on the health care system, it is always the most vulnerable groups that are at the greatest risk; among others we can recognise individuals with chronic illnesses and people with disabilities as the most exposed.

SOLUTIONS

Fortunately, there are those who oppose this violence. The International Committee of the Red Cross (ICRC) initiated the advocacy-awareness campaign Health Care in Danger (HCiD). The HCiD project launched the first ever study on the properties of violence against health care in 2011, presenting data from 16 coun-

tries over a period of 32 months. Over the whole period, there were 655 violent events, killing 727 staff, wounding 1101, and seeing the kidnapping of 166 humanitarian workers. HCiD works with warring parties, states, NGOs, and influential members of the civil society to create a “community of concern” for the immense issue of attacks against the health care sector. By advocating for these questions, the ICRC influences decision-makers to improve working conditions on the ground for health care workers all over the world. The World Health Organization is currently addressing the issue by documenting the problem in order to propose solutions, affirm the right to health in such settings and advocate for the protection of health care workers and facilities. In Sweden, the work laid down by Vård för Papperslösa, Röda Korset and Rosengrenska Stiftelsen have made immense contributions to access to health care for undocumented migrants. Initiatives such as Vårdvrålet and Läkarupproret take a clear stand towards a patientcentered health care, where professional ethic will be a leading word for health.

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Photo: Robert de Meijere

SPS Stockholm 2014: From Polar fish to Kv7 channel activity By Oskar Swartling

SCIENTISTS FROM DIFFERENT FIELDS

and from all around the world gather from time to time, joyfully discussing and questioning their colleagues’ work. This summer, the Scandinavian Physiological Society (SPS), invited physiologists to Karolinska Institutet for a program with a vast spectrum of topics. Ranging from the cardio-respiratory physiology in Polar fish to sleep regulations in humans, from high renal interstitial hydrostatic pressure in the giraffe to the understanding of human taste, this symposium offered something for everyone. Founded in 1925, SPS’ main objective has been to spread the interest in physiology in its member countries, through promoting research and education. Much is done through their journal, Acta Physiologica. The journal is one of the world’s oldest physiological journals, founded in 1889 as Skandinavisches Archiv für Physiologie. With annual or bi-annual meetings and symposia, SPS gather not only the Scandinavian physiological community but also researchers and students ranging from Brazil to Japan. The congress consists of a number of oral presentations, guided tours of the poster presentations and invited lectures. The intellectual and scientific ambient attracts cutting-edge

researchers and companies, permitting an ideal situation for scientific stimulus that tries to move the old field of physiology forward. This year’s meeting took place in Stockholm, a 3-day-event at Karolinska Institutet with the opening in Aula Medica. Throughout the symposium, physiologists presented their ideas, research and findings to a curious audience. Although the topics differed greatly, the lectures were organised under categories. For instance, one category, “Physiology in the extreme”, covered the extreme situation Polar fish live in and how their habitat affects their cardio-respiratory system as well as how the cardio-respiratory response of snakes is an effect of their high catabolic rates. For another category, “Pain physiology”, lectures were given on research trying to understand chronic pain and how acute pain becomes chronic. One of the funnier categories included “New Adventures in the Vascular Wall”, no doubt attracting a lot of interested and adventurous scientists. The symposium was not only for its Scandinavian members. With partners in Brazil, Japan, Italy and China, this Scandinavian meeting had an international

touch, giving it an extra dimension of international collaboration. Aside from the science-filled days, SPS offered a social program after-hours. The Stockholm City Council invited all of the participants to the City Hall, with a dinner in the Golden Hall, famous for hosting the Nobel banquet. As compulsory when visiting Stockholm, a visit to the Vasa Museum was found in the program, including a gala dinner. The SPS symposium in Stockholm was a wonderful event in many ways. Presenting interesting and in-depth lectures on every topic under the sun, creating a forum for scientists in the same field and giving the visitors a rare chance to see the city, the meeting is a must for researchers and students in physiology. With an extreme mix of physiological topics, everyone is going to find something they want to spend days after days trying to understand. If renal protection in the giraffe or the role of G-protein beta gamma subunits on Kv7 channel activity isn’t your thing, other topics definitely will be. How about motor control and microcircuits or long-term physiological adaption in the auditory system?

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INSIGHT Starting with this issue Medicor is implementing a new feature called Medical Career with the purpose to shine light on some of the different occupations and branches within the medical field. Each edition will feature an interview with a selected person and a presentation of his or hers specific area of specialization. The intention is to inspire and to give students some insight into some lesser known career paths and specialties.

Per Renström

Orthopedic Surgeon, Professor of Sports Medicine and member of the Medical Commission of the IOC. By Filippa Grönqvist SPORTS MEDICINE IS A CROSS- AND MUL-

tidisciplinary competence and a part of medical science. It is a specialty that prevents and treats injuries related to sports and general physical activity. Physiology, orthopedics, traumatology, general practice and psychology are some of the disciplines included in sports medicine. Today, sports medicine is considered a specialty in countries such as Canada, USA, France and Netherlands but not in Sweden, although the SFAIM (Svensk Förening För Fysisk Aktivitet och Idrottsmedicin) is working hard to establish it as such. Per Renström, one of our most famous Emeritus Professors at Karolinska Institutet, is a world-renowned researcher who has tried to develop the area of international sports medicine. He started his career in Gothenburg as a sports-interested medical student determined to combine work and interest. Professor Renström emphasized the importance of never giving up. “You have to fight for your beliefs. There are no 44

shortcuts”. Sports medicine didn’t exist as a specialty when he graduated from medical school 1972. However, due to his specialization in orthopedic surgery, Professor Renström managed to work with sports medicine-related injuries anyway.

“You have to fight for your beliefs. There are no shortcuts” He states that his two biggest commitments in life, except for his wife and four children, have been his membership in the International Olympic Committee (IOC) (where he has been a member for 24 years) and tennis. Since the 1990s, Professor Renström has attended almost every Olympic game as the doctor responsible for the well-being of the participants. “I was 18 years old when I watched the first Olympics on television and I decided that I wanted to participate. I quickly realized that I wouldn’t succeed as an elite athlete so I became an IOC doctor instead” Ren-

ström said, and laughed. Furthermore, he has been working on the ATP World Tour as well as the ITF for nearly his whole life. For many years he was the medical director of the Davis-Cup team and traveled with the top Swedish tennis athletes. Professor Renström concedes that being a team doctor is a special opportunity that allows you to follow the athletes from pain and injury to top performance. Professor Renström has, of course, also been a scientific researcher in the area of sports medicine. He has published approximately 200 articles and 17 books. His most famous book, authored with Lars Peterson, “Injuries in Sport” is a world-wide bestseller and has been translated into 13 languages. For 10 years, he lived with his family in USA, Vermont where he had a full professorship in the field of orthopedic surgery and sports medicine. He also the opportunity to develop a method of arthroscopy. In 1997, he was offered a job as professor for the section of sports medicine at Karolinska Institutet where he supervised 17 Ph.D. students.

INSIGHT

In 2009, Professor Renström was elected as a member of the AOSSM Hall of Fame (American Orthopaedic Society for Sports Medicine). Being inducted into the Hall of Fame is one of the highest honors given to a society member. Professor Renström explained that for many years, orthopedic surgery and physiology have been the two dominating disciplines in sports medicine but have now been overtaken by other disciplines. These include prevention of sports-related brain- and cardiovascular injuries. He then went on emphasizing the importance of turning sports medicine into a medical specialty in order to improve the treatments of patients suffering from these types of injuries. He recommended that students get involved early on in their educations by volunteering as assistant doctors for long-distance races or for the local football teams. Professor Renström also mentioned the importance of collaboration between professions in sports medicine since physiotherapists and nurses have even more important roles to play in the treatment of patients in these disciplines. The humble Professor Renström continuously emphasizes the importance of his wife in both his life and successful career. Moreover, he encourages all young doctors to consider working within the subfield of sports medicine as it’s stimulating as well as exciting. Finally, he stresses the importance of hard work and dedication over short-cuts for quick fame. He strongly believes that continued good education and participation in research will together develop sports medicine as a specialty sometime in the future and will need students from all corners of medicine ready to become pioneers.

Photo: David Humphreys

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’09 Hall of Fame of the AOSSM ’07 Professor Emeritus ’97 Professor of Exercise Medicine, Karolinska Institutet ’77 Published “Injuries in Sport” ’77 Specialist in Orthopaedic Surgery

’88 Professor of Orthopaedic Surgery and Exercise Medicine, University of Vermont, USA ’72 Graduating Medical School

CULTURE

Creativity and depression Is there a link between them?

By Douglas McBride

has found that there not only is a higher prevalence of bipolar disorder among creative professions, but that authors, musicians etc. also have a higher prevalence of diagnosed bipolar disorders amongst close relative. This could mean that the healthy relatives, with similar characteristics as the ones diagnosed with bipolar disorder, are more likely to have creative professions which could indicate that certain genes play a role in both creativity and depression.

THERE HAS LONG BEEN A LINK BETWEEN

creativity and depression. Pain and sorrow seem to be an inexhaustible source of inspiration for poetry, love songs and novels. Famous artists such as Vincent van Gogh, Kurt Cobain and, recently, Robin Williams all suffered from depression and ultimately chose to take their own lives. Is all this just a coincidence or is there an actual link between creativity and depression? Depression is one of the most common mental illnesses and a widespread issue in today’s society. An estimated 5% of the entire global population suffer from depression and the number of patients diagnosed is continuously rising. Depression can show itself in a variety of different forms including dysthymia, bipolar disorder and psychotic depression.

...depression and affects as much as 7% of the adult population in the United States. The most common type is called major depression and affects as much as 7% of the adult population in the United States. Some symptoms of depression include extreme sadness, lack of energy, changes in eating or sleeping habits and thoughts of death and suicide. To get an official diagnosis the symptoms must last at least two weeks. Some patients suffer only from one episode of major depression, however the condition tends to return throughout the patient’s life. But has creativity got anything to do with it? Well, obviously not all creative people suffer from depression and neither is every depressed person a creative genius. However, there are notable statistical differences between creative professions, for example authors, musicians, actors etc., compared to the general population when it comes to diagnoses for depres46

Illustration by Lucas McBride

sion and other mental illnesses. Among creative professions there is a clear overrepresentation of bipolar disorder and authors are almost twice as likely to commit suicide as the average person. Although the link between depression and creativity is recognized, the underlying mechanics are still unclear. One reason for the high prevalence of depression could be the nature of the creative professions. A lot of artists have a productionbased income, meaning that their financial situation is directly affected by how well they produce. This may lead to performance anxiety, stress and depression. This, in addition with the high rates of alcoholism and substance abuse among artists, could explain why there is a link. However, recent studies suggest that the link has to do with genetics. Research

Interestingly, enough studies have found changes in the thalamus when testing divergent thinking that are similar to, however not as significant, those found in people with psychotic disorders. Changes in the thalamus could affect the brain’s ability to filter out nonvital information, which could lead to more divergent thinking. One of the ways of testing creativity is to give the person two minutes to list as many uses as possible for an everyday item, such as a paperclip. If a person’s thalamus would filter out fewer thoughts, one could theoretically come up with more ways to use the paperclip compared to someone with a normally functioning filtration. This could mean that someone diagnosed with bipolar disorder is better at divergent thinking, i.e. more creative than the normal person. The overrepresentation of bipolar disorder in creative professions is clear and can therefore be seen as evidence of the connection between the two. But contrary to popular belief, it is not necessarily that creative people are more likely to be depressed, but rather that the people suffering from depression tend to be more creative.

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CULTURE

The Elephant By Mikael Plymoth

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