Oxford Medical School Gazette Issue 63(3) by Oxford Medical School Gazette

OMSG 63 (3)

OMSG 63 3

WWW.OMSG-ONLINE.COM

Cover FINAL.indd 1

GLOBALISM

BLOOD MONEY 4

THE WAY WE TREAT 19

SPIN DOCTORING 8

THE SECOND STRUGGLE 20

BATTLE SCARS 10

ONLINE LEARNING 30 26/03/2014 10:59

CROSSWORD 63(3)

GLOBALISM 1

9 10

14 OXFORD MEDICAL SCHOOL GAZETTE COMMITTEE Editors: Joshua Luck, Barnabas Gilbert Sub-editors: Stuart Mires, Laura Munglani, Nicholas Aveyard, Kevin Cheng, Bing Tseu, Nicola Kelly, Kiruthika Ananthan, Amrit Gosal, Giles Neal, Alex Barry, Lauren Passby, Suzanne Harrogate Peer Review editor: Thomas Hine Book Review editor: Edward Chesney Design Lead 63 (1), (2) & (3): Rosalie Brooman-White Design: Hannah Thompson, Giles Neal, Lara Hibbs Design team: Alix Brazier, Simone Paulson, Richard Sykes, Dariush Micallef Patron: Professor Sir John Bell, Regius Professor of Medicine Honorary Treasurer: Mr Stephen Kennedy Senior Members: Dr Tim Lancaster, Dr Peggy Frith, Dr Sue Burge and Dr Vanessa Venning OMA Liaison: Dr Peggy Frith Alumni Officer: Jayne Todd Accounts Officer: Christine Lees-Baxter Development Officer: Maria Mahmood Fundraising Officer: James Kennedy Oxford Medical School Gazette (OMSG) is the oldest medical school journal in the world. OMSG is produced by the students of Oxford University Medical School for the enjoyment of students, doctors, alumni, academics and any other interested readers. OMSG may not reflect the views of Oxford University Medical School. The views of our writers do not necessarily reflect the views of the Gazette staff. The Gazette is a not-for-profit publication and relies on the generosity of advertisers and its readers to subsidise production. If you are able to contribute in any way, all donations, either financial or in kind, are gratefully received. SUBMITTING ARTICLES TO THE GAZETTE The Gazette welcomes submissions from students, alumni, clinicians, other health professionals and members of Oxford University academic staff. Articles do not need to have been specifically written for the Gazette. The Editors reserve the right to reject, alter or amend any copy received, following discussion with the author. If you would be interested in contributing please contact the Editors at editors@omsg-online.com. SUBSCRIBING TO THE GAZETTE To subscribe directly to the Oxford Medical School Gazette please contact the Editors by email at editors@omsg-online.com or by post at the address below. ACKNOWLEDGEMENTS The Editors would like to thank the members of the senior committee, Jayne Todd, Karen O’Brien and the Medical School Office Staff for their hard work and helpful input. Particular thanks to Robin Roberts-Gant from the Medical Informatics Unit who has, as ever, given tremendous support in producing this issue of the OMSG. ILLUSTRATION AND PHOTOGRAPHY Many of the images used in OMSG are produced by members of the medical school and we thank all those involved in the modelling, photography, and illustration of this issue. Images without specific acknowledgement are outside copyright and freely available. COMMUNICATION Oxford Medical School Gazette, Medical Sciences Office, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU.

17 20

23 24

DOWN 1 Physiologist is a short ballerina and a small meringue dessert (6) 2 Run with ball whilst salivating (7) 3 Confused Rudolphs without are poorer (7) 4 Angry ex (5) 5 Crazy – tin fire is neater! (7) 6 The state of France (1’4) 7 Risk acne eruption without this (8) 10 Beetle injects subcutaneously before chasing Saudi (6) 14 Start married and put in order? Rubbish! (6) 15 Job’s company and Mr Baracus marry for this drink (5,3) 18 I hope Ray is in the musical play (5) 19 Chained oddly, mammal could make ‘gegs’ (7) 21 Longer limb aids brisk movement (7) 22 City not to run from (7) 23 Man behind a brave new world of sodium channels (6) 25 To wear for exercise (5)

ACROSS 1 Emergency department in underwear – they are so particular! (7) 4 Wicked things (7) 8 Covered by glen (6) 9 Matching paper (8) 11 Company makes writing fluid (3) 12 Pain in the bum - the nerve! (7) 13 Fear of tail of biggest mistake (6) 14 Sailor looks to mine rare oddities without energy (7) 16 Of the Muslim God (1,2) 17 Saying: Dog wearing lead (7) 20 Shelter mad Neal too (4-2) 24 Finish the unusual cheese, suckers! (7) 26 Leg turns to jelly (3) 27 Shed one for the myelofibrosis cell (4,4) 28 Painful gasps – continue CPR (6) 29 Snake stops road surface (7) 30 Odd geek or loon guy studies rocks (7) Crossword created by Ed Warren, a fifth year medical student at St John’s College

PRODUCTION Medical Informatics Unit, NDCLS, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU. Telephone +44 (0)1865 222746 COPYRIGHT NOTICE © 2014 The editors of Oxford Medical School Gazette (OMSG) and the contributors to OMSG. All rights reserved. The contents of this publication may not be reproduced in whole or in part without the express prior written permission of the editors.

Cover FINAL.indd 2

26/03/2014 10:59

2014 63:3

Blood money

Sarah Billingsley explores whether cutting the cost of manufacturing surgical equipment leads to the exploitation of vulnerable people

The doctors’ social media revolution

Marco Narajos asks whether the digital age can improve medical services

Ann Tivey discusses the coverage of medicine in the media

Battle scars

One of your “five-a-day”

The Medicines Patent Pool

Nicola Kelly examines the legitimacy of the Vietnam War Claudia Snudden explores the future of edible vaccines

Movin Abeywickrema outlines four reasons why pharmaceutical companies should join

In defence of ignorance

Ben Jacobs argues the case for keeping patients in the dark about rare side effects

Online learning

A perfect opportunity

Should society trust the medical profession?

Lydia Yarlott and Rosalie Brooman-White recount their experiences of Obstetrics and Gynaecology in Botswana

Georgina Newman considers the potential of cervical cancer screening in SubSaharan Africa

Face the music

International health electives: who benefits?

Dr Brian Phillips explores the neurological and therapeutic effects of music

Clinical trials abroad

What does ‘growth’ mean to a doctor?

3365

Bringing the world to the bedside

Curcumin: more than just a spice?

Great medical discoveries

Peter Johnstone assesses whether the outsourcing of clinical trials is a step too far

Zohaib Arain’s winning entry for the inaugural OMSG Schools Essay Competition

The second struggle

David Henckert explores how asylum seekers in detention are denied adequate healthcare in 21st century Britain

Howell Fu reports how educational media can become a force for good

Cian Wade investigates this pressing question

The way we treat

Nicholas Black investigates the proposed therapeutic effects of this well-known condiment

Dr Roger Bodley explores the use of speed dating as a learning resource for medical students

Kate Milne considers whether ‘altruistic’ electives in developing countries may be doing more harm than good

Dr Alexander Finlayson describes how MedicineAfrica is tackling key challenges in global health; Abbie Taylor reports

Meet the medics

Spin doctoring

Mad world

Robotics – a revolution?

Book reviews

Peer Review

Crossword

Emma Pencheon provides a global view on mental health Amrit Gosal critiques the use of robotic surgery in Urology and beyond

An exhibition at the Bodleian Library, Oxford, 22 Nov 2013 – 18 May 2014

47 2014 63:3

63-3 FINAL.indd 1

28/03/2014 11:21

A Note from Design Welcome to the third and final Gazette of this year. We hope you agree that OMSG design has progressed over the year to culminate in the issue you see before you. We hope you enjoy our last hurrah. If you have any queries, or would like to get involved, do not hesitate to get in touch with the new team at: design@omsgonline.com - Rosalie Brooman-White, Giles Neal, Hannah Thompson & Lara Hibbs design@omsg-online.com

63-3 FINAL.indd 2

2014 63:3

28/03/2014 11:21

63(3) EDITORIAL

The world around us is changing at a pace that few of us could ever have imagined. Within medicine – indeed within all aspects of human endeavour – national borders are being replaced by a collaborative, trans-national agenda. While technological progress continues to pervade every aspect of society, the potential for good remains uncapped. To us, this marks an exhilarating prospect. Welcome to Globalism. The social media revolution has transformed the way that medicine is packaged, marketed and accessed in all corners of the globe. A sensitive response from health care professionals is needed, as Marco Narajos highlights. And should our browsing (read: procrastinating) take us anywhere near the preposterous headlines of the Daily Mail and others, we wouldn’t be the first in medical circles to chastise their clumsy, inchoate handling of new research. Thankfully Ann Tivey takes a more temperate approach in her critique of the world of spin. Elsewhere, despite compelling evidence for improved population health outcomes, the deficit of attention paid to mental health disorders across much of the developing world remains a concern. Emma Pencheon explores this unresolved issue in Sierra Leone, Haiti and China. It is not inconceivable that Oxford’s very own medical students have encountered such problems whilst on elective, but have felt powerless to help. Kate Milne provides an essential reminder of the ethical dilemmas underpinning international medical placements; she stresses how, during the interregnum between frustrated student and terrified junior doctor, we must beware the dangers of practising without safe supervision. Of course, this is far easier said than done, as is vividly depicted in Lydia Yarlott and Rosalie Brooman-White’s account of an obstetrics placement in Botswana.

This issue also seeks to examine whether we could (or indeed should) use the notion of ‘change’ as proxy for ‘progress’. Perhaps, argues Claudia Snudden in her thoughtful exploration of the future of edible vaccines; or perhaps not, as Amrit Gosal contends in her piece on robotic surgery. Howell Fu poses the same question as he reflects on the rising popularity of Massive Online Open Courses, or MOOCs. Does the YouTube era herald a bright new dawn in the way medical teaching is delivered, or are we witnessing a step in the wrong direction? We are delighted, as ever, to include contributions from alumni too. While Dr Roger Bodley reimagines speed dating as a valuable learning resource, Dr Brian Phillips returns with a playful review of the medical perks of music. It is with a tinge of sadness that we pen this, our final Editorial. What a year it has been for the Gazette. We were thrilled to launch our inaugural Schools Essay Competition, for which you will find Zohaib Arain’s quite brilliant winning entry enclosed. Special thanks must go to Maria Mahmood, our Development Officer, for her efforts here. We were also delighted to be shortlisted for The Guardian newspaper’s ‘Student Publication of the Year’ award, the first time a medical publication of any kind has been recognised! And as we began the year with a quote from an old great, so too shall a few ancient words lay close to our last. Hippocrates’ assertion that “Whenever a doctor cannot do good, he must be kept from doing harm” certainly rings true for us. The Gazette has kept us from trouble for a little over a year and it is with some mournfulness that we must hand over the reins to our magnificently talented successors, Amrit Gosal and Nicola Kelly. We wish them the very best of luck.

The departing OMSG Editors, Joshua Luck and Barnabas Gilbert

editors@omsg-online.com | www.omsg-online.com

2014 63:3

63-3 FINAL.indd 3

28/03/2014 11:21

IMAGE/ROSALIE BROOMAN-WHITE

63-3 FINAL.indd 4

The National Health Service is a multi-billion pound business. Since its inception in July 1945, the primary aim has been to provide free and unbiased healthcare for the British people. However, with seismic economic changes and enormous pressure to deal with increasing numbers of patients on a tighter budget, the business face of the NHS is becoming ever more apparent. Like all organisations under pressure, the NHS must find a way of cutting costs, and on a massive scale. It comes as no surprise, then, that medical supplies for the UK are commonly imported from foreign manufacturers. The NHS spends ÂŁ30 billion on procurement of medical supplies annually [1] and in order to stretch its finite budget, supplies are often procured from abroad. Yet recent investigations into NHS equipment sources revealed a dark side to this supply chain.

destined for the NHS [1, 2]. Searches of the premises and conversations with the factory workers revealed a lack of welfare provision, corporate negligence and systematic health and safety failures. The workers complained of working long hours for meagre pay. Worryingly, there was also evidence of child labour, with children as young as seven toiling for hours in scorching metal forges [3]. Similar situations were seen at a Malaysian latex glove manufacturer; workers told investigators how a lack of safe guidelines meant that excruciating scalds and burns were commonplace. Employees at a plant in Mexico reported very similar tales of neglect and injury [1]. Swedcom, a Swedish body that looked at the manufacture of products for their own healthcare system, revealed the same issues in the sourcing of uniforms from India â&#x20AC;&#x201C; again, child labour and exploitation were common themes [4]. The picture painted by these studies is a sadly familiar one; in order to supply cheap health to the rich West, we exploit the foreign poor.

In 2006, Bhutta et al. carried out an extensive investigation into the working conditions of manufacturing employees in Sialkot, a deprived town in northern Pakistan. The factories here produce surgical equipment for Western health services, with 1 in 10 products

The reasons behind exporting trade are many and varied, but it all boils down to the pressures of a global economy. In the UK, it is too expensive to manufacture the products we need on such a scale; raw materials, land, factories, employment, wages and a variety

2014 63:3

28/03/2014 11:22

of other essentials combine to make domestic equipment manufacture largely unfeasible. In Pakistan and Malaysia, the price of each constituent part of the process is hugely reduced – i.e. manufacturing is cheap. However, a significant portion of such cost cutting results in a poorer quality of life for local employees. Poverty and lack of education narrow down work opportunities, leaving families vulnerable to ill treatment and abuse. Yet there is no easy solution; the issues involved are rather more complex than they might at first appear. An obvious answer would be to either improve working standards or stop importing supplies from manufacturers in places like Sialkot. But such sweeping reform might manifest in negative results for the dependent communities. If manufacturers are forced to improve working conditions, increase pay and stop using cheap child labour then the cost of production necessarily increases. This makes manufacture more expensive for foreign investors, encouraging them to look elsewhere. If factories are subsequently put out of business, then already poverty stricken locals may be denied even a basic wage. Perhaps the vicious cycle can only be broken by education – a vehicle capable of lifting even the most desperate populations out of the need for menial jobs. But we might better focus our attention on our own role in the global market: Pakistani suppliers complain that pressure to drive down prices from Western consumers like the NHS leads to their use of child labour and substandard working environments [2]. Since the original report’s publication in 2006, the NHS has introduced new strategies to improve ethical procurement.

2014 63:3

63-3 FINAL.indd 5

The first guidelines on ethical sourcing of medical supplies made available to NHS trusts were set out by the NHS Purchasing and Supply Agency (PSA) in 2008. In a document entitled ‘Ethical Procurement of Health’, these recommendations aimed to ensure all goods bought for and used by the NHS were sourced properly [5]. It remained, however, at the discretion of individual NHS trusts to implement them; no penalties would be enforced for failing to do so, leading Parliament to criticise the initiative as “feeble” [2]. The PSA was disbanded in 2010 but the early good work continued; the BMA joined with the Ethical Trading Initiative to produce the Ethical Procurement of Health Workbook, giving NHS trusts a framework to help develop principled labour management [6]. Dr. M. Bhutta recently hosted the CleanMed Europe 2013 conference in Oxford, where sustainable medical equipment manufacturing and the issues surrounding it were discussed at length [7]. Since the initial investigations, NHS trusts have become increasingly aware of the problems encountered in overseas equipment sourcing. Many hospitals have implemented radical changes to their procurement of resources; the Welsh Health Supplies body, for example, ruled that any contracts valued over £25,000 must undergo a full health risk assessment (including a scrutiny of labour standards throughout the supply chain) [8]. The NHS is making progress but we still have a long way to go. Full references available at: www.omsg-online.com

Sarah Billingsley is a fourth year medical student at Somerville College

28/03/2014 11:22

Home

Connect

Discover

The Doctors’ Social Media Revolution @MarcoNarajos Can the digital age improve medical services?

1046 TWEETS

308

FOLLOWING

2975

FOLLOWERS

The digital age of medicine is here to stay, heralded first by patient record systems, then medical education software and, more recently, symptom checker apps. Social media is increasingly a part of this trend, with many branches of the NHS disseminating information through various online channels. These interfaces might seem innocuous – a constituent part of public health, even – but is there a danger of social media subverting the interaction between patients and doctors? Social media is a method of communicating and interacting online, predominantly through networks that allow sharing of content to a wide audience. Websites include Facebook, Twitter, LinkedIn and YouTube. Medicine, as a profession, is primarily concerned with people, and as social media enables a connection to be made with many thousands simultaneously, it can seem like an attractive tool. But amidst fears of breaking confidentiality and disrupting the doctor-patient relationship, the GMC recently published a guideline on ‘Doctors’ use of social media’ last year. In it, the GMC describes the risks encountered in the use of social media, such as overstepping professional boundaries and breaking patient confidentiality.

IMAGE/LARA HIBBS

Indeed, these concerns are not unsubstantiated. Take the case of the gynaecologist Dr. Patrick Muffley, who shared sexually explicit messages with a patient through Facebook, a clear violation of the fiduciary relationship between a doctor and a patient [1]. The case epitomises the blurred lines between a physician’s public and private life.

63-3 FINAL.indd 6

Another case of questionable Facebook use is that of The Medical Registrar, a page with a following of over 55,000 people. A group of eight anonymous doctors contribute by posting light-hearted, often sardonic, remarks, venting their frustrations about working in the NHS. The anonymity allows The Medical Registrar to say what it likes, seemingly without repercussion. However, one of the GMC’s social media guidelines is that “if you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name” as the public may interpret the author’s opinions as that of the medical profession as a whole. In an article in the Student BMJ, the authors of The Medical Registrar discussed their relief at the GMC’s reassurance that the guidelines were what they were – guidelines – and that the GMC were not laying down a law; The Medical Registrar lives on, still incensed by the NHS and the government [2]. There are, however, more health-centred uses for social media. The NHS has Facebook and Twitter pages encouraging public health (including NHS Smokefree and NHS Choices) as well as pages that encourage blood and organ donation. In this way, no patients are involved, but the public is informed. As a public health initiative, these sites reach a vast audience – the NHS Smokefree page has visits from over 200,000 people. Similarly, on Twitter, there are groups that regularly discuss issues like the provision of dementia care. Other doctors post about health in a personal capacity, like TV doctor and sexual health campaigner Dr. Christian Jessen, whereas others

Social Media is changing the way we interact with people 2014 63:3

28/03/2014 11:22

As a public health initiative, these sites reach a vast audience discuss government health policies. Even more encouraging is seeing doctors, nurses and other healthcare professionals forming networks to facilitate patients’ access to information about health. Patients are not the only ones who can benefit from social media. Medical students regularly tap into blogs, forums, Facebook groups, and even YouTube to supplement their medical education. Social media also promotes the rapid dissemination of information – online resources such as academic journals and instructional videos on clinical procedures are becoming increasingly invaluable. There are, however, similar fitness to practise concerns for medical students. Many may have incriminating photographs or videos of unprofessional behaviour. Some may have controversial or indecent posts, perhaps from their school years. But does this compromise their fitness to practise? Is there a distinction between being a student and a doctor? And to what extent is a medical student held to the same professional standards? The BMA says in its own guidelines that “Doctors and medical students should be conscious of their online image and how it may impact on their professional standing.” In the same 2011 publication, the BMA discussed the suspension of a group of doctors and nurses who indulged in ‘planking’ – an internet phenomenon that involves taking a photo of yourself lying face down in an unusual, public place before posting it online. The group ‘planked’ on resuscitation trolleys, ward floors and even an ambulance helipad, contravening hospital regulations. But whether it is the act of following an internet craze or that it was done in a hospital environment is a pertinent question. If medical students, or indeed doctors, did the same thing outside of work hours and outside the clinic, would this amount to unprofessional behaviour? I personally do not think so, especially if no patients are able to see the photos and if patient care is unaffected. I do, however, recognise the BMA’s concerns. Social media sites (despite improving privacy settings) are, by their very nature, social. A Full references available at: www.omsg-online.com

Marco Narajos is a first year medical student at Christ Church

2014 63:3

63-3 FINAL.indd 7

post that may seem private can easily be made public, deliberately or accidentally, and patients’ access to personal information may be harmful to a relationship built on trust. Whilst these issues may seem like a slippery slope, other considerations about the value of social media are less easily delineated by negative and positive outcomes. From a patient’s point of view, human interaction may be crucial. Medicine is intrinsically a profession that works with people, but social media can change the nature of that interaction. To a great extent, the physical presence of a doctor is important in a consultation; however, perhaps less so when the role of the physician is to simply provide advice. As part of the GMC’s Duties of a Doctor, doctors are told to “work in partnership with patients” and to “protect and promote the health of patients and the public.” Social media may be able to help in this regard – for example by connecting doctors or trained healthcare professionals with chronically ill patients requiring long-term management. Their ideas can be dispensed from afar, not necessarily requiring direct human contact. Online groups dedicated towards management could supplement the treatment of patients with chronic pain, obesity, and depression. And while social media will not be able to fully replace or substitute seeing a medical professional, it may prove to be complementary to current medical services – not least in that it should decrease the need for face-to-face visits. Social media is changing the way we communicate and interact with people. Whether this is overwhelmingly favourable remains unclear, but there is one thing of which we can be sure: that it is important to nurture the positive aspects of social media whilst mitigating against its myriad risks. Patient confidentiality and professionalism must not be compromised in the pursuit of so-called progress. Ultimately, time will determine the place of social media in medical services – I, for one, look forward to a future in which medical services are improved by a helpful dose of social media.

A post that may seem private can easily be made public, deliberately or accidentally

28/03/2014 11:22

Scandal in the clinical school Page 5

JOSH AND BARNEY

5th year’s not what it’s cracked up to be...

Where are they now and what’s next after a year in charge Page 34 of the OMSG

SPIN DOCTORING

Newspaper for medical students

Volume 63, No. 3 © XX 2014 PRINT EDITION

Medicine in the Media By Ann Tivey

Every day the newspapers contain a plethora of health related stories, be it something which causes cancer, cures cancer, or the gene for jet lag. But how reliable a source of information is medical journalism? It is estimated that 90% of the public get information on developments in medicine and healthcare from the mainstream

The OMSG reviews the portrayal of

Page 2

Medicine in News

media [1]. In addition to being able to critique primary literature, should medical students be taught how to decode the Daily Mail headlines?

Ann Tivey

How accurately is medical research portrayed in the media? A 2012 study found that 51% of news stories reporting on randomised controlled

What techniques are used to spin stories? • • • • • • •

Ignoring safety data which may limit the clinical utility of a treatment Reporting positive but not statistically significant results Reporting results from inappropriate subgroups for whom the treatment would not apply Reporting outcomes the trial was not designed to assess which arose incidentally Studies in mice/in vitro being over-extrapolated Reporting relative rather than absolute risks Stating that ‘gene for X disease’ has been discovered when condition is multifactorial and polygenic, gene may only

8 63-3 FINAL.indd 8

• • • •

play small role in disease aetiology Basing articles on conference abstracts when research is at preliminary stages and has not been properly scrutinised by peer review Over optimistic timelines – for in vitro research to progress through clinical trials can take well over 10 years. Reporting success/cure in preliminary Phase 1 clinical trials which are normally very small studies focused on safety and without control groups. Quoting proxy outcomes (i.e fall in BP doesn’t equate to reduce heart attacks)

2014 63:3 28/03/2014 11:22

trials (seen as the gold standard in judging a treatment’s efficacy) were subject to ‘spin’[2]. This study also highlighted that this spin can arise at all levels; 41% of abstracts and 46% of press releases from the research institute were found to contain an element of spin. An example of this is a headline from the Daily Express; ‘Cure for deafness found’[3]. This claim was based on the development of an in vitro method to induce differentiation of mouse embryonic and induced pluripotent stem cells into mechanosensitive ear hair cells [4]. However, hair cell damage is only one of several causes of hearing loss, and the study was far from translating such research into a clinical ‘cure’. The Express’ assertion that a ‘cure for deafness’ had been discovered is therefore an example of ‘spin’. Do health articles in the mainstream media convey the information patients need to make informed decisions? Garry Schwitzer, working for HealthNewsReview.org, analysed over 500 articles and found that 33% quantified harms, and only 28% quantified benefits, in absolute rather than relative terms [5]. The latter can give rise to attention grabbing figures such ‘a 50% higher risk’ without putting it in the context of very low initial risk. Only 38% explained how the treatment compared to existing alternative options.

Why does the misrepresentation of medical research in the media matter? Reporting of medical research in the mainstream media can be invaluable in educating patients about potentially beneficial treatments, as well as raising awareness of certain health risks. However, inaccurate reporting can cause unnecessary concern for patients if these risk factors are exaggerated. More importantly, over-optimistic reporting can encourage patients to spend large sums of money in hopes of a miracle cure. Stem cells are notorious example of this due to the great potential they offer for tissue replacement therapies. For example an early phase I/II trial, containing no control group and carried out only in patients with relapsing remitting MS, was reported by the Sun with the headline ‘Stem Jab cures MS’ [6,7]. The Clarke’s daughter Dakota was born with septo-optic dysplasia which left her almost blind and suffering from a balance disorder. Having read positive testimonials on the internet, the Clarke’s launched a campaign to raise the £20,000 (plus travel costs) needed to take Dakota to the Beike clinic in China. Here she received six injections of stem cells over the course of a month.

Worryingly, 46% stories did not look beyond the news release for independent validation or to explore conflicts of interest in the information they were presenting. If journalists cannot be relied on to perform an investigative role Her family were convinced that they saw an into the validity of a source, how are patients improvement in Dakota’s sight; however inmeant to get to the truth? dependent testing found no improvement. Yet the The Mirror ran with the headline; ‘Stem cell miracle gives gift of sight to toddler Dakota Clarke’[8]. Several other newspapers reported that Dakota was able to see Full references available at: for the first time, potentially influencing www.omsg-online.com others who were similarly desperate for a miracle cure [9]. Ann Tivey is a third year medical student at Magdalen College

Is current teaching sufficient? Medical students are taught how to critically analyse primary research, but portrayal of research in academic literature will inevitably differ from that in the mainstream media. Doctors can play a crucial role in interpreting the former whilst explaining what the latter may have omitted or exaggerated for their patients. Explaining spin is a skill in itself. Whilst it may seem obvious that in vitro

2014 63:3 63-3 FINAL.indd 9

As of yet there is no reliable evidence that these therapies work. Even if the mainstream media do not directly claim they are effective, in exaggerating the potential of preliminary research they lend plausibility to the clinics offering such therapies. research in a mouse model will not translate to a cure with the next couple of years, this needs to be expressed to patients with clarity and without being dismissive. In addition, the relationship between the medical profession and the media needs to change to improve the quality of reporting. It needs to be recognised that emotive stories will carry more impact, and utilise this effectively in communicating health stories to the public. Doctors shouldn’t be afraid of media coverage but should work to ensure more weight is given to peer-reviewed studies published in respected academic journals

Conversely, if the misreporting of medicine in the media can cause patients to reject treatment suffering and deaths can result. The MMR vaccine is the most infamous recent example of this. A flawed paper by Andrew Wakefield claimed a link between autism and MMR [10,11]. For several years MMR dominated medical news, with peak coverage in 2002 consisting of over 1257 news stories on the subject. However, less than a third of broadsheet reports in 2002 referred to the evidence demonstrating that the MMR vaccine is safe, and 80% of the coverage was by generalist rather than scientific reporters [12]. There is evidence that declining MMR uptake can be attributed to the negative media coverage. The South Wales Evening Post (SWEP) ran a concerted campaign about the dangers of the MMR vaccination from 1997 (before Wakefield had even published). A BMJ report found that MMR vaccine uptake declined by 13.6% in the distribution area of the SWEP, and by 2.4% in the rest of Wales, for the quarter July-September 1998 compared with the previous year [13]. On a national level, between 1998 and 2008 there were 15 measles-related deaths reported to the Health Protection Agency in England and Wales [1]. The MMR scandal represents not only a problem of news coverage reporting, but also of the medical profession as a whole. Doctors were inadequately explaining the safety of the vaccine and the dangers of not vaccinating, with a 2006 study finding that 52.5% parents felt that doctors were too dismissive of the risks of MMR vaccination [14]. The mainstream media might be the initial source of information for the majority of the public, but consulting with their doctor is still likely to play a significant role. Accordingly, doctors should be aware of topical stories in mainstream media. They need to be equipped to recognise how stories may misrepresent the research they discuss, and crucially they need to effectively explain this to patients.

rather than unpublished claims. There is a close link between the mainstream media and a patient’s understanding of certain aspects of their care. I believe it is of sufficient importance to warrant more formal training in how to respond to concerns raised by media coverage. In an ideal world the reporting of medical research would be accurate, factual and put into a wider context. Unfortunately this is not always the case and doctors have a responsibility to bridge the gap between what the headlines claim and what the research actually shows.

9 28/03/2014 11:22

Nicola Kelly discusses the legacy of the Vietnam War Though many of the effects of the Vietnam War are being rapidly confined to Year 7 classrooms and history books, the consequences of the conflict live on in the millions of people suffering from exposure to Agent Orange, a chemical defoliant. Between 1962 and 1971, an estimated 50 to 72 million litres were dumped on the Vietnamese countryside during Operation Ranch Hand [1, 2]. The range of herbicidal formulations, supplied by big pharmaceutical companies, including Dow and Monsanto, were named after the coloured bands marking their storage barrels: Purple, Pink, Green, White and - most infamously - Orange [3]. These defoliants were highly toxic to both plants and people; and two thirds were also contaminated with dioxin [3], a known human carcinogen [4]. Whilst the jungle was sprayed with the ostensible aim of uncovering Viet Cong troops and their tunnels, it is more shocking, perhaps, that other missions specifically targeted crops. This operation, known as Farmgate, forced starving rural populations into towns, where they could be more easily controlled. Analysis of US Airforce data, as part of a study published by Stellman and colleagues in Nature, suggests that up to 4.8 million people were living in rural hamlets directly below the flight paths of defoliant missions [5]. Yet, by the end of the war, all responsibility lay with the Republic of Vietnam. US troops on the flights wore civilian clothes; American planes were branded with Southern Vietnamese army insignia; and a single native Vietnamese would release the chemicals [5].

A dangerous legacy Although a booming tourist industry means that many of us are likely to visit Vietnam, foreigners are often unaware of the continuing environmental devastation caused by the widespread use of defoliants during the war. Dioxin is a highly stable compound – potentially dangerous for up to a century. It runs off the land and into the water supply, the food chain, the fatty tissues of animals and, ultimately, the local people [2].

box 1

63-3 FINAL.indd 10

box 2

American Veterans are able to claim compensation if they develop any of the many diseases associated with exposure (see Boxes 1 & 2). The US government has, however, failed to acknowledge responsibility for any harm caused to Vietnamese nationals. The Victims of Agent Orange Relief Act was assigned to a congressional committee on 26th June 2013 and is still awaiting review. The “govtrack” website [7], which documents all pending US legislation, gives the bill a 2% chance of getting past committee. Nevertheless, in recent years some funding has been made available to support decontamination of dioxin “hotspots”, including Da Nang International Airport (where the estimated soil content is 300-400 times greater than permitted levels). The problem seems to be that, too frequently, the money given is just a fraction of the total needed, leading many to suggest that US aid has come “too little… very late” [2, 6].

2014 63:3

28/03/2014 11:22

IMAGE/LARA HIBBS

A “Do You Dare to Dream” competition run by Danone, where she worked in 2006, led her Evidence is also acThe US government has failed to to wonder whether she could improve the cumulating to suggest lives of those living in the orphanage acknowledge responsibility for any that detoxification that was so nearly her childhood home. may be just the start. It harm caused to Vietnamese nationals She entered, and won. Establishing the is becoming clear that Agent VVN, she has since returned to Vietnam Orange affects not only the chilevery year to visit GoVap. Her volunteers are dren, but also the grandchildren, of encouraged to spend their time not with the healthy those exposed. A growing body of research babies in the newborns’ room, but on the terminal suggests that epigenetic mechanisms underlie wards. Whilst medical partnerships have facilitated lifethe trans-generational increase in congenisaving operations on at least 10 children born with hydrotal defects and developmental abnormalicephalus, Kim emphasises the value of basic physiotherapy, ties seen. Animal studies provide strong mobilisation and interaction with the terminally bedridden evidence to support this hypothesis; children. In contrast to many volunteering opportunities, many have shown that exposure causes siminone of the VVN volunteers pay money for their experilar birth defects in rodent models. For example, ence and must organise their accommodation, transport, Manikkam et al. demonstrated epigenetic abnormaliinsurance and leisure activities independently. Unsurties in the unexposed progeny of female rats exposed to a prisingly, many do raise money for the organisation non-toxic dose of Agent Orange during gestation. Crucially, - this goes towards medical equipment and employthese ‘non-toxic’ exposures were also associated with histoing local Vietnamese physiotherapists [9]. pathological abnormalities and developmental changes in the unexposed F3 generation [8]. The VVN is expanding fast and Kim’s enthusiasm is infectious. I am hugely glad that I The authors suggest that the accumulation of dioxin in the fatty tistrusted her with my visit to Vietnam sues of humans (where it has a ten-year half-life) means that women although, as with many volunteerwho became pregnant up to 20 years later could have unwittingly passed ing projects, it is hard to quantify on the effects of dioxin to future generations. However, if gamete cells are the amount of “good” done. permanently altered at the time of exposure, it is plausible that the ova of any However, the VVN has alwoman exposed after puberty may carry pathological patterns of epigenetic ready gone global and a conchange. Differential demethylation patterns in germline DNA would mean that stant stream of volunteers the legacy of dioxin could not be erased simply by soil decontamination, howarrives from the USA, ever thorough the clean up. Australia, Canada, the UK and Ireland every year. Getting hands-on Perhaps, then, the real benefit of volunteering This time last year I met Kim Nguyen Brown, a British-Vietnamese businessin Vietnam is through woman and founder of the Vietnam Volunteer Network (VVN) - a non-profit raising awareness; the organisation that sends medical volunteers to a number of sites within Vietnam. continuing impact She helped me to organise a volunteering placement at an orphanage located of the conflict on the on the outskirts of Ho Chi Minh City; here, I saw the devastating effects of health and wellbeing of Agent Orange first hand. The orphanage was where Kim spent the first the Vietnamese populafew weeks of her life until, at only 2 months old, she was thrust The legacy of dioxin tion looks rather more into the arms of an American pilot during the April 1975 evaccannot be erased lasting. uation of Saigon. She was then flown to the UK via Hong by soil decontamination Kong, to be greeted by her adoptive parents. Full references available at: www.omsg-online.com

Nicola Kelly is a fourth year medical student at The Queen’s College

2014 63:3

63-3 FINAL.indd 11

28/03/2014 11:22

CLAUDIA SNUDDEN explores the future of edible vaccines

One of your “five-a-day” 12

63-3 FINAL.indd 12

“We must make this the decade of vaccines”. Speaking at the World Economic Forum four years ago, Bill and Melinda Gates pledged $10 billion in a call to increase research, development and delivery of lifesaving vaccines to the world’s poorest countries by 2020 [1]. Immunisation is undeniably one of the most cost-effective health investments, preventing an estimated two to three million deaths a year [2]. Though traditionally most vaccines have been administered via injection, vaccine delivery methods are becoming more creative – from nasal sprays that protect against influenza, to the development of transdermal nano-patches [3, 4]. One of the most exciting concepts is the edible vaccine; a form of oral immunisation achieved by eating genetically engineered plants. Foreign genes encoding an antigenic protein from a pathogen can be introduced into plant genomes using a gene gun, naturally occurring soil bacteria, or chimeric viruses. As the resulting transgenic plants lack any pathogenic genes, they are unable to establish infection, thus ensuring safety (particularly in the immunocompromised) [5]. Following oral ingestion of the vaccine, M cells in the intestinal lining take up the immunogenic components and pass them on to antigen presenting cells. Unlike parenteral vaccination, oral vaccination is able to activate strong mucosal immunity (via the production of IgA) as well as a systemic serum antibody response. Most mammalian pathogens interact with mucosal surfaces lining the respiratory, digestive or genital tracts as they enter the body; the development of mucosal immunity is therefore incredibly important as a first line of defence. Compared to conventional needle vaccines, edible vaccines are much easier to administer. Not only does this decrease cost and eliminate the need for trained medical staff,

the absence of needles reduces the chance of infection. Painless administration may also enhance compliance, especially in children. More importantly, edible vaccines circumvent the problem of the ‘cold chain’ – usually a tremendous challenge for effective vaccine delivery. Crucially, these vaccines are heat stable, meaning that they can be transported easily and stored near the site of use. In the long-term, many countries may also be able to reduce their dependence on foreign aid, potentially by growing transgenic plants locally [5]. Given that capital-intensive pharmaceutical manufacturing facilities are not required, and there is no need for antigen purification if it is already expressed in plant edible tissue [6], the future of edible vaccines as a cost-effective resource in the developing world seems bright. But can a large enough dose of antigen be delivered simply by eating a genetically modified potato or tomato? The biggest problem facing the development of edible vaccines is ensuring transgenic plants contain the right dosage of antigen. Whilst a regular vaccine includes a known, precise amount of antigen or dead or inactivated organism, the plant’s size and ripeness, as well as the person’s weight and age, all influence the antigen dosage of a plant-based vaccine. On top of this, the amount eaten is crucial – so problems may arise in infants who are likely to spit out or throw up the edible vaccine [5]. If insufficient antigen is absorbed, the vaccine will fail to provide lasting immune protection; alternatively, too high a dose could result in oral tolerance [6]. Maybe the most practical solution would be to process the transgenic plant into a powder or pill for ingestion. Considering all these factors, what is the likelihood of edible vaccines being a success? Clinically, oral vaccination has been seen to work. The widespread global use of

2014 63:3

28/03/2014 11:22

the Sabin oral polio vaccine (administered in droplet form) over the past 50 years has been a vital contributor towards the near eradication of poliovirus [7]. Since the early 1990s, when the concept of the edible vaccine was first conceived using transgenic tobacco [8], numerous plant vaccines (from potatoes to lettuce to rice) have effectively prevented the onset of disease in animal models [9]. Edible vaccines are currently being developed against a number of human diseases, with particular emphasis on respiratory and enteric infections [6]. To date there have been three human clinical trials in which transgenic potato vaccines against enterotoxigenic E. coli, Norwalk virus, and hepatitis B have been proven safe [10, 11, 12] â&#x20AC;&#x201C; two of which also showed evidence of a mucosal IgA response alongside the development of neutralising antibodies.

If we did manage to produce a viable plantbased vaccine, we would be able to provide an effective and safe delivery system for the prevention of disease in developing countries [5]. Ultimately, however, ongoing resistance (both in the EU and developing countries) to genetically modified food and the use of transgenic plants is holding back research [13]. Without increased funding and support from pharmaceutical companies, international aid organisations and national governments, the likelihood of a licensed edible vaccine appearing anytime soon remains slim. Full references available at: www.omsg-online.com

Claudia Snudden is a third year medical student at New College

â&#x20AC;?

Edible vaccines are currently being developed against a number of human diseases, with particular emphasis on respiratory and enteric disease

IMAGE/STOCK.XCHNG

â&#x20AC;?

2014 63:3

63-3 FINAL.indd 13

28/03/2014 11:22

The Medicines P FUSION INHIBITORS ENFUVIRTIDE COMBINATION PRODUCTS EFAVIRENZ STRIBILD RILPIVIRINE COBICISTAT DISOPROXIL ATRIPLA COMPLERA

63-3 FINAL.indd 14

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS HIV INTEGRASE STRAND TRANSFER

ABACAVIR ZIDOVUDINE ZALCITABINE LAMIVUDINE EMTRICITABINE AZIDOTHYMIDINE

PROTEASE INHIBITORS (PIs)

AMPRENAVIR INDINAVIR LOPINAVIR

TIPRANAVIR SAQUINAVIR RITONAVIR

RALTEGRAVIR DOLUTE NONNUCLEOSIDE REVERSE TRANSCRIPTASE IN ETRAVI RILPIVIRINE DELAVIRDINE EFAVIR NEVIRAPINE

CCR5 CO-RECEPTOR ANT

MARAVIROC

2014 63:3

28/03/2014 11:22

s Patent Pool

AND TRANSFER INHIBITORS

MOVIN ABEYWICKREMA outlines four reasons why pharmaceutical companies should join

EPTOR ANTAGONIST

In 2010, an initiative was created to improve global access to HIV/ AIDS treatment throughout the developing world: the Medicines Patent Pool. Currently, the Pool comprises four member companies [1] and I would like to propose four reasons why other pharmaceutical companies should join too.

DOLUTEGRAVIR TRANSCRIPTASE INHIBITORS (NNRTIS) ETRAVIRINE EFAVIRENZ

HIV DRUGS MARKET OPEN FOR BUSINESS

1. ACCESS Latest figures show that 1.7 million die from AIDS worldwide annually [2]. The problem faced by a large part of the developing world is that new HIV/AIDS drugs regularly cost over $5,000 per person per year [3]. With 69% of HIV sufferers located in Sub-Saharan Africa [2], where almost half of the inhabitants live below the poverty line [4], something is clearly going wrong. Regular use of anti-retroviral treatment means that the risk of disease transmission from HIV/AIDS sufferers immediately after diagnosis can be reduced to zero [5]. The expense of these drugs excludes the poorest HIV/AIDS sufferers from obtaining them, thus debilitating their lives further and leaving others at greater risk of contracting the disease. 2. THE PATENT PROBLEM In 1994 the Trade-Related Aspects of Intellectual Property Rights agreement was released by the World Trade Organisation. This put forward that all inventions, including pharmaceutical ones, must be granted patents for a minimum of 20 years [6]. Consequently, with no other competition for a certain drug, there is no incentive for the original manufacturer to lower the price. The positive impact of competition is evident in the case of India, where the law on patents is more open for generic drug manufacture [7]. In 2001 the Indian company Cipla released anti-retroviral treatment at $600 per patient per year to other developing countries. This was in stark contrast to the lowest cost of other available treatment, which was $10,500 [7]. Unsurprisingly, Médecins Sans Frontières (MSF) has called India the “pharmacy of the developing world” [7]. The Medicines Patent Pool revolves around this issue. The concept is that drug inventors license the specific HIV/AIDS patents to the Pool, allowing generic drug companies to manufacture these medicines, resulting in multiple drug providers. This brings a higher level of compe-

IMAGE/ROSALIE BROOMAN-WHITE

2014 63:3

63-3 FINAL.indd 15

28/03/2014 11:22

Currently the Medicines Patent Pool focuses on HIV/ AIDS drugs. Yet for other life-threatening diseases, ranging from malaria and TB to chronic cardiovascular disease [9,10], competition would make the often internationally-imported treatment more widely available [11]. This would also reduce incidence of patients turning to cheaper counterfeit medicines with harmful side effects [11]. It has been estimated that further access could save 36 million premature deaths from chronic diseases alone by 2015 [12]. 3. BETTER DRUG COMBINATIONS AND TARGETING Companies individually agreeing to the Pool could also potentially facilitate better drug combinations. The standard first-line treatment for adult HIV patients consists of TDF, 3TC (or FTC) and EFV [13], often combined as a single pill. However, further attempts to combine multiple drugs into one easy-to-take pill are obstructed by the so-called ‘intellectual property’ rights of individual companies that hold drug patents [3]. Involvement in the Pool would permit this to occur. The Medicines Patent Pool provides a means for researchers to improve the targeting of drugs, for example towards children for whom the HIV virus behaves differently by staying in the blood in high concentrations for as long as two years after infection [5]. Previously, the rapid disease progression in children has received less attention [14]. Further research could help improve the molecular action of the drugs themselves and reduce side effects, such as those affecting the nervous system and skin when taking the TDF/FTC/EFV combination [15]. 4. ADDED INCENTIVES At first glance, there seems to be little in the way of tan-

63-3 FINAL.indd 16

”

tition between these companies, allowing the prices to be brought down [3,8].

This programme presents an opportunity to transform the lives of millions worldwide

”

gible benefit to the inventors of these drugs, relative to profit monopolisation. However, it in fact benefits both inventors and patients, for instance through the provision of royalty payments. Pharmaceutical companies are thereby rewarded financially for their involvement [3,8]. Reputation provides another motivation - pharmaceutical companies are often under scrutiny, and joining the Pool to help increase access to HIV/AIDS drugs may help to improve their public image [5].

These four reasons present clearly why other companies should participate in the Medicines Patent Pool. This programme presents an opportunity to transform the lives of millions worldwide, yet even the current four members have put forward drugs with only restricted global licences. As the executive director of MSF’s Campaign for Access to Essential Medicines states, this is hopefully “the floor, not the ceiling”. It should mark just the start of this life-saving initiative [5].

Full references available at: www.omsg-online.com

Movin Abeywickrema is a first year medical student at Lincoln College

2014 63:3

28/03/2014 11:22

In defence of

ignorance BEN JACOBS argues the case for keeping patients in the dark about rare side effects Informed consent is a cornerstone of modern medical practice. It is a concept that we are introduced to from the earliest days in medical school, pervading all flavours of clinical medicine. However, it remains surprisingly tricky to pin down. What exactly does it mean to obtain informed consent from a patient for a risky procedure or treatment? I argue that the bar for informed consent, as defined by the GMC, is set impossibly high in certain cases where small but serious risks are involved. If a particular intervention carries severe but vanishingly improbable risks, it may be counterproductive to bring these to the attention of the patient. I argue that these specific scenarios illustrate how the GMC’s requirement for disclosing all such risks actually impedes patients’ ability to make sensible, informed decisions. Ignorance, rather than information, may be the key to true informed consent. In its most recent guidance on the subject, ‘Consent: patients and doctors making decisions together (2008)’, the GMC states that: “You must tell patients if an investigation or treatment might result in a serious adverse outcome, even if the likelihood is very small [1].”

IMAGE/SIMONE PAULSON

This is problematic because any investigation or treatment could cause a panoply of serious but uncommon side effects. If we take it as given that the raison d’etre of informed consent is the preservation of patient autonomy, the important question is this: does informing the patient about very small risks enhance or degrade their autonomy? To put it another way: does knowing about these risks make patients more or less able to come to a rational and voluntary decision about whether to undergo the intervention? This issue is particularly sticky when we are talking about serious small risks.

2014 63:3

63-3 FINAL.indd 17

I take the view that knowing about unlikely but serious side effects impairs the rationality of the patient’s decision-making process. Intuitively, this makes sense. Many people, doctors included, suffer from the tendency to give undue weight to serious but unlikely risks [2]. A good example of this phenomenon is air travel; most people are more worried about being blown up in mid-air by terrorists than about dying in a car accident en route to the airport, even though the latter is by far the more likely. Empirical data support this intuition. For instance, a study by Reynolds et al. found that

28/03/2014 11:22

Ignorance may indeed be bliss

”

the perceived risk, rather than the objective probability, of an adverse side effect was the dominant factor influencing patient choice [3]. Another study found that patients profoundly overestimate the risks of drug-related side effects, even when they are given the exact probability data [4]. There are clearly intuitive and empirical grounds for arriving at the conclusion that patients may think less rationally when presented with information about unlikely risks. Is this a problem? It isn’t if you think that rationality is not the primary concern here. Thus, if the principal concern is patient autonomy, this may be preserved by keeping patients as informed as possible about all eventualities. But what if being autonomous relies to some extent on holding rational beliefs? If autonomy does require rational beliefs, then telling patients about the whole gamut of rare side effects that could befall them would undermine their autonomy by compromising their rational decision-making process. Julian Savulescu has argued that holding rational beliefs is a necessary condition for autonomy, as a patient can only look after their own interests effectively if they are thinking clearly about what they want and how they can get it [5]. So the argument I am proposing runs like this: 1. 2. 3. 4.

Autonomy requires that the patient holds rational beliefs Patients do not form rational beliefs about improbable but serious side-effects ‘Informed consent’ exists to preserve patient autonomy as far as is possible Therefore, informed consent should not require knowledge of improbable but serious side-effects

There are several plausible objections to this argument. One such objection is that the patient’s ‘right to know’ trumps concerns about rationality. In this vein, the suggestion that patients should be deliberately kept in the dark might seem anathema to many people – it might even look like an unacceptable and possibly dangerous erosion of human dignity. We are intuitively opposed to this sort of suggestion, with the atrocities committed by Nazi doctors in concentration camps well established in our collective memory. However, when faced with tough decisions, we hope that we will be able to think rationally (irrespective of circumstance) to choose the best course of action. Rationality underscores and sustains our autonomy. It follows that if ignorance of rare side effects preserves our rationality, we should adapt our definition of informed consent to embrace ignorance. I think it is high time for the GMC to update its stance on consent to accommodate these recognised issues. Full disclosure should not be a necessity; ignorance may indeed, in many cases, be bliss. Full references available at: www.omsg-online.com

Ben Jacobs is a fourth year medical student at Magdalen College

63-3 FINAL.indd 18

2014 63:3

28/03/2014 11:22

The way we treat LYDIA YARLOTT and ROSALIE BROOMAN-WHITE recount their experiences of Obstetrics and Gynaecology in Botswana The patient was barely through the door of the operating theatre before her sheets were whipped away. She was sitting up for the spinal anaesthetic procedure and somebody was already sponging her with disinfecting iodine from behind. “What are you whimpering about, woman? Stop that!” The anaesthetist approached the patient on the table, a fiveinch needle in her fist. “I haven’t even used THIS yet!” Certain moments from Botswana will stick with us for life. A patient came to clinic one day with periods so painful she was confined to bed for one week in every four. She was still walking through the door when the doctor shouted to the nurse outside that he didn’t want to see this patient – he’d already seen her once, and besides, it was well past lunchtime. “What do you think I can do about your problem?” was his gambit. “You must be very lazy spending so much time in bed.” There was certainly no sugar-coating in Botswana; health mattered but seemingly emotions did not. Neither did there appear to be any concern for the aesthetics of medicine. The side room where Evacuation of Retained Products of Conception (ERPC) procedures were performed, with what we would consider to be homeopathic doses of pethidine, was sweaty and dilapidated, with medical supplies strewn across the surfaces. We remember watching a young woman, ironically named “Fortunate”, looking for somewhere sanitary to lay down her underwear, and eventually deciding to rest it on her lap. She delicately covered the ripped couch with her kanga* before lying down on it. PHOTOGRAPHS/ROSALIE BROOMAN-WHITE

2014 63:3

63-3 FINAL.indd 19

Empathy did not seem to be expected of the medical profession, and patients invariably accepted treatment with courage and without fuss. We were frequently left bewildered by such stoicism; women miles from home, alone and facing a painful unknown. We began to wonder whether sympathy was culturally alien. Congregating in the morning in a cramped side room, the question was partly answered by the sound of the voices which invariably interrupted us. The camaraderie extended to the sharing of belongings, stories, even visitors. Patients able to walk would fetch drinks for those too ill to get out of bed, entertain them and alert nurses to their condition. These women were moulding their own support group, a reminder that kindness is never superfluous, and that we shouldn’t need substandard treatment to jolt us into showing it. Having swallowed a good volume of outrage in Botswana, we realised that the feeling was familiar. We recalled ward rounds where patients were talked over, concerns casually dismissed, patients counselled in waiting rooms, curtains where there ought to be walls. We are grateful for our experiences in Botswana, because they highlighted just how important the small things are. They did not blacken our opinion of one healthcare system only to rosetint another. More importantly, our experiences clarified a universal objective that we all occasionally forget - to treat people, whatever the circumstances, in ways designed to make them feel better. Full references available at: www.omsg-online.com

Lydia Yarlott and Rosalie Brooman-White are fifth year medical students at Green Templeton College

*Traditional colourful cloth worn by women throughout the African Great Lakes region.

28/03/2014 11:22

The Second Struggle DAVID HENCKERT explores how asylum seekers in detention are denied adequate healthcare in 21st century Britain SYSTEMATIC FAILURE "A 47-year old Asian man who has chest pain, normally uncomplaining, who is known to smoke, found to be sweaty and grey, should have prompted suspicion about cardiac problems and an ambulance should have been called." These are the dry words of Dr Iain Brew, commissioned by the Prisons and Probation Ombudsman to report on the death of Muhammad Shukat, a driver from Islamabad who died of a cardiac arrest at Colnbrook Immigration Removal Centre (IRC) in July 2011 [1]. His 19 year-old roommate, Abdul Khan, had been frantically pressing the emergency buzzer for over two hours before Mr Shukat was given more than Gaviscon and an aspirin, by which time his heart had stopped. It continues: “the emergency kit first brought for Mr Shukat was missing its defibrillator. A second defibrillator was brought, but it was faulty. Finally, nearly two hours after Kahn’s initial call for help for Mr Shukat, an ambulance was called. Unsurprisingly, Mr Shukat was pronounced dead on arrival at hospital” [2]. Then there is the case of Jimmy Mubenga, a previously healthy 46 year-old man, who died in October 2010 whilst being restrained by three detention custody officers (DCOs) escorting him onto BA flight 77 from Heathrow to Luanda, Angola. Whilst being restrained, shortly before his death, Mr Mubenga is reported to have been heard complaining that he could not breathe, saying “They are going to kill me” [3]. No attempt was made by the guards, BA staff or passengers to initiate CPR following Mr Mubenga becoming unresponsive. Again unsurprisingly, the jury at the inquest into Mr Mubenga’s death, held earlier this year, returned a verdict of “unlawful killing”. In attempting to explain the reason why neither the guards nor BA staff initiated CPR, as per their training, the coroner, Karon Monaghan QC, highlighted the “general view amongst DCOs that deportees would feign illness … to avoid deportation” [4]. And then there is “HT”, who fled Zimbabwe for the UK in 2007 after her father and uncle were killed because of their political activities. HT was detained, pending the outcome of

63-3 FINAL.indd 20

her asylum application. From this point, her health began to deteriorate: she suffered from multiple respiratory tract infections, oral candidiasis and urinary tract infections. A full 17 months after she was detained and first started having medical problems, she was finally counselled and offered an HIV test (positive), after she herself requested a GUM review. Later, having received the results of her test, when she complained to IRC staff of increasing dyspnoea, she was offered a pillow to sleep with. She went on to develop chest pains, night sweats and a cough productive of yellow sputum—the hallmarks of a severe lower respiratory tract infection [5]. HT’s story, just one from a much wider report by the charity Medical Justice [5], is typical of the sort of low level disregard shown to refugees in our dysfunctional asylum system. Over just a one year period, Medical Justice documented 79 breaches of the guidance on care for HIV+ detainees given to IRCs by the National Aids Trust/British HIV Association. Overall, there is ample evidence for generally poor, and sometimes frankly unsafe health care provision in the government’s detention estate. SEEKING MEDICAL JUSTICE These shocking accounts, and other such instances, have been uncovered by the work of Medical Justice, a network of doctors, lawyers, ex-detainees and detention centre visitors campaigning for an end to denial of adequate healthcare for immigration detainees in the UK (http://www.medicaljustice.org. uk/index.php). Medical Justice receives nearly 1 000 referrals a year—one for every bed in our ever-increasing detention estate—and arranges for independent doctors to assess detainees and press for better care where necessary. One of these doctors, Dr Helen Salisbury, Honorary Senior Clinical Lecturer in the Department of Primary Care at the University of Oxford, visits detainees at Campsfield House, an IRC on the outskirts of Kidlington, near Oxford. “It is sometimes difficult to know whether my report will do any good. There are so many variables at play,” says Dr Salis-

2014 63:3

28/03/2014 11:22

IMAGE/STOCK.XCHNG

bury, when we meet to discuss her work with Medical Justice. Nevertheless, she presses on, seeing between two and seven detainees per year since 2007. In the main, she listens to detainees’ stories of the abuse they have fled, and then examines them for physical signs to corroborate their accounts. “Which is not the same as saying their physical signs were definitely caused as they say they were,” she is careful to point out. The most she is able to do, working within the dry, precise language of the law, is to declare a person’s injuries are “consistent” with their testimony. Doctors, so much used to being masters of their own domain, are given training by Medical Justice in how to produce documentation for the court. As Dr Salisbury points out, in the desire to win, the State will often take any opportunity to denigrate a medic’s submission: “In court they’ll say, ‘What does she know about PTSD? She’s just a GP.’”

I wait for this decision, I am an asylum seeker. While I wait, I am entitled to access NHS services. Failed asylum seekers who are prepared to leave the UK are similarly entitled to use the NHS, whilst failed asylum seekers resisting deportation are barred from elective services (although there is some variation between the four home nations) [9].

It is all relative, of course, but to me this seems easier than the actual interviewing of detainees. Dr Salisbury describes, as a not unusual example, “interviewing an Angolan man about his sexual abuse via a telephone interpreter who speaks European Portuguese” [6]. It is uncomfortable but necessary to ask for precise details of every aspect of the abuse, to satisfy the courts. Still, this pales in comparison to the lived experience of those in IRCs such as Campsfield, where relatively high levels of anxiety, depression, PTSD, self-harm and suicide exist [7], compounding any sequelae of torture or other violent trauma as might exist.

MANAGEABLE NUMBERS

OUR RESPONSIBILITIES Today, if we are sympathetic, we associate “asylum seeker” with destitute migrants from war-torn countries half a world away, and if we are not, we brand asylum seekers “illegal immigrants” and wish them gone. However, regardless of our personal views, the United Kingdom is party to a number of treaties—signed and ratified in Parliament—establishing the institution of asylum. The question, therefore, is not how we ought to treat asylum seekers in this country, but whether we fulfil our legal duties to these treaties, and, from a medical perspective, whether the healthcare afforded asylum seekers is commensurate with our responsibilities. The twin planks upon which our system of asylum is built are the 1951 United Nations Convention Relating to the Status of Refugees and the 1950 European Convention on Human Rights [8]. These treaties establish the conditions under which a person may claim their right to asylum and outline the rights to which all people in Europe are entitled, respectively. It is within them that the United Kingdom must operate when dealing with asylum claims. If I claim asylum in the UK, the courts here decide whether, according to the 1951 UN Convention, I qualify as a refugee. If I do, I am given Refugee Status and allowed to stay. While

2014 63:3

63-3 FINAL.indd 21

That is how the system is meant to work. Another study by Medical Justice, released shortly before Christmas, into the mental health of detainees across the country reports that, although the ma jority of detainees describe symptoms of mental illness, many staff have had “no training in the identification and management of the mentally ill”, a problem compounded by inadequate record-keeping, problems with translation and limited options for treatment—all summating to a “crisis in mental health in detention” [7].

Immigration is never far from the front pages of the British press, whether it be David Cameron competing with UKIP’s Nigel Farage, in a race to the bottom on immigration [10], or the Home Office running a highly controversial campaign aimed at illegal migrants in London [11]. The tone is usually negative, and never more so than when dealing specifically with the issue of asylum. The impression given is that we are a soft-touch, shouldering more than our fair share of the burden. In fact, in the year to June 2013, the UK received 23 499 new applications for asylum, a number dwarfed by the United States (70 400), Germany (64 500), South Africa (61 500), France (55 100) and Sweden (43 900). The total number of refugees, asylum seekers and stateless persons in the UK amounts to just 0.27% of the population [12]. These should be manageable numbers. That the UK, the world’s sixth largest economy, should have a crisis in our management of immigration detainees sits at odds to our efforts to promote ourselves as a champion of human rights across the globe. We should be upholding the rights of migrants as we should our own, meeting our own ethical standards as well as our responsibilities to the international community. Then, those who would seek asylum and eventually settle here might be all the more able to make a positive contribution to our society, not having suffered through a second struggle. Full references available at: www.omsg-online.com

David Henckert is a sixth year medical student at Somerville College The author would like to thank Dr Salisbury for kindly agreeing to be interviewed for this article

28/03/2014 11:22

Bringing the world to the bedside: an interview with Dr Alexander Finlayson DR ALEXANDER FINLAYSON, CEO of MedicineAfrica Ltd, tells us how eHealth can build health systems capacity and what he sees as the priorities for global health.

IMAGE/CREATIVE COMMONS

edicineAfrica is an online platform to connect remote health workers in order to improve lives. We connect teams of doctors, nurses, and other non-healthcare workers in order to enable them to educate and be educated, to work collaboratively on the design and improvement of clinical services, and to deliver strategic research. Through this we have a real-time window into remote health systems and their activities. So rather than flying a few UK doctors for one week a year to ‘capacity build’, we can connect up whole hospital campuses in different parts of the world. We are trying to create an environment in which, regardless of a healthcare worker or patient’s location on earth, they can access the collective medical expertise of the globe.

63-3 FINAL.indd 22

The project started in Somaliland, a small country with a population of 3.5 million people and very poor health indicators. Because the institutions that make up the health sector are not massive yet, it’s possible to work with multiple stakeholders across an entire health system. Our basic research into the “e-readiness” of Somaliland revealed that their telecommunications capacity is disproportionately developed, so why not use the existing infrastructure to improve healthcare? The project involves developing the technology for the online platform and building the programmes of real world activity - think Facebook plus Oxfam rammed together.

To make this project scalable, MedicineAfrica provides a “meta-tool” which enables lots of different programmes of activity to take place. For example, Somaliland is a country without a single psychiatrist in the public sector. Many patients with mental ill-health are shackled and chained to the floor of their houses or institutions. A team we got together which built a new mental health facility in a town that previously didn’t have one. We are also able to offer a UK based psychiatrist mentor to every graduating doctor in Somaliland so that they can discuss their difficult psychiatric cases and problems on a regular basis. It’s a bit like a ward round but the consultant just happens to be 6,000 miles away. There is a lot of rhetoric around eHealth: the idea that having your physician on your mobile phone will solve global health. A lot of this is probably nonsense, and we’re conscious that this might be a problem with our own intervention. At some point good intentions are no longer good enough – at this point, rigorous evaluation and impact assessment are critical. I think one should have a null hypothesis that you’re not doing good and then it’s incumbent on you to prove your impact. Our evaluation of MedicineAfrica looks at two things: does it do what we set out to do, and does it do anything else which is damaging? Health technology faces all sorts of challenges in security, scalability, responsiveness, the risk of cre-

2014 63:3

28/03/2014 11:22

ating dependency - you can’t just hack your way to a solution because you can do damage. This makes it quite different from, say, Apple in that as long as people buy iPhones that’s considered success, they don’t have to prove it does good. As well as trying to develop concrete evidence, we try to do qualitative interviews with local staff to identify the extent to which any of the interventions could be disempowering or damaging. At the moment there’s a tussle about what the priorities in the global framework should be. I think the priority for humanity should be to increase the quanta of wellbeing across the globe, and to do that in a sustainable way. Healthcare will always be inadequate at some level, so what we need is a system of fixing crises rather than a definitive solution. A second order priority is reducing medical morbidity and mortality, but there’s no point in making people live longer if they’re not well. All of the thrusting for faster, quicker cancer drugs and new technology isn’t necessarily meeting the right demands. If we sort-out healthcare in Somaliland and all it does is make people more miserable and more middle-class, then actually we’ve not done a very good job! I think junior doctors should be exposed to global health in their curriculum and be encouraged to think critically and constructively about the way things are currently done. I’m also incredibly in admiration of my friends who are very committed clinical doctors in the UK. I wouldn’t like for the currency of notional “impact” to create an additional system of judgment that deemed those guys were doing less good because the burden of suffering is greater elsewhere in the globe. Both are im-

2014 63:3

63-3 FINAL.indd 23

portant and valuable. Fundamentally if everyone went around in a perpetual existential angst about the way things are, the world would fall apart. Quite a lot of the things I’ve done were a bit opportunistic, I just saw it and thought, “that would be cool to do.” I travelled a lot with my family when I was younger, although I did all my intra-medical school things in big Western institutions like the Mayo Clinic and Harvard as opposed to going anywhere exotic. I went to the odd lecture about global health and I tried to build a social network for scientists while I was at Harvard. It wasn’t until I travelled to Somaliland with Andy Leather, who founded the King’s-THET-Somaliland Partnership, that I realised the potential of online platforms to improve global health capacity. On my return I set up MedicineAfrica with some colleagues, and we all gave our time on a voluntary basis alongside our day jobs. I am now developing the project in tandem with my training as an Academic Clinical Fellow in Primary Care. Professionally it’s both the most interesting and the most painful thing that I’ve done. In the long term, I hope to become a “safe pair of hands” as a doctor and to continue to work on impactful and interesting projects that address humanity’s most pressing challenges. Full references available at: www.omsg-online.com

Abbie Taylor is a fifth year medical student at Green Templeton College The author would like to thank Dr Finlayson for generously giving his time for this interview

28/03/2014 11:22

Curcumin: More than Just a Spice?

Nicholas Black investigates the proposed therapeutic effects of this well-known condiment “It has been said that arguing against globalization is like arguing against the law of gravity.” Kofi Annan, UN secretary general, September 2000 One of the most positive aspects of globalisation is the way in which it has opened up the world, exposing us to new ideas and cultures very different from our own. In countries such as China and India, a great body of medical knowledge has developed over thousands of years, and these ideas continue to be practiced to this day. Western medicine, proudly robed in the successes of the previous century, has cast its skeptical gaze over these traditional practices and often found them wanting. Yet this is not always the case. In the tropical forests of India, the herb Curcuma longa stands apart from the rest of the undergrowth due to its auspicious height (it can grow over 1 metre tall) and brilliant white flowers. However, C. longa is far from just a pretty face. Indeed, for thousands of years the locals have ground down the underground stems of this plant to produce turmeric, the effervescent yellow spice much loved by Indians and Westerners alike. Perhaps surprisingly, the ancient Indian medical system of Ayurveda has long revered this spice for its healing properties. Even today, turmeric is used in just about every way imaginable: it is pressed on wounds to speed up the healing process, gargled to cure laryngitis and ingested to relieve flatulence! Whilst it is all too tempting to discount these herbal remedies as hocus pocus, in vitro and in vivo studies have shown that curcumin, the active ingredient in turmeric, has some remarkable properties. It has potent anti-inflammatory effects through inhibiting the activation of NFκB and reducing the production of pro-inflammatory cytokines such as IL-1β, IL-8 and MCP-1 [1]. Its ability to scavenge reactive oxygen and nitrogen species makes it a valuable anti-oxidant [1]. Studies in cancer cell lines and mice have shown that curcumin can act both as a chemotherapeutic agent and as a means of sensitising cancer cells to the effects of standard chemotherapy [1]. It also reduces Aβ fibril

aggregation and toxicity in animal models of Alzheimer’s disease [2]. The molecular wizardry behind this diversity of action is still poorly understood, but this hasn’t dulled the enthusiasm in the scientific community. In complex diseases characterized by multiple maladaptive signaling pathways, we might expect a broad-action drug like curcumin to be more efficacious than highly targeted therapy. As of July 2012, 65 clinical trials have been published and 35 trials are under way examining the effect of curcumin on a diverse range of human diseases [3]. However, the picture emerging from these clinical trials has been largely underwhelming. In part this reflects the fact that many of these studies are phase I

In vitro and in vivo studies have shown that curcumin has some remarkable properties and phase II clinical trials, which aim to determine the safety and tolerability of curcumin. They therefore use study designs and sample sizes that make the interpretation of any observed results difficult. Nonetheless, there are some early indications that curcumin may serve some therapeutic benefit. First, let’s look at the clinical evidence for curcumin as an anti-inflammatory drug. Belcaro et al. examined the efficacy of curcumin in the treatment of osteoarthritis (OA) [4]. A cohort of 100 participants with OA were given either best current therapy or best current therapy plus Minerva (curcumin complexed to phosphatidylcholine) over 8 months, and the authors found that there was significantly reduced functional impairment and significantly improved OA symptoms in the Minerva group compared to controls. Most strikingly, there was almost a four-fold increase in pain-free walking distance on a treadmill test in the Minerva group compared to controls. Although the authors conclude that Minerva shows real promise in

IMAGE/LARA HIBBS

Ra s

E l H a no u t

63-3 FINAL.indd 24

2014 63:3

P a pri k a

T u r m e ric 28/03/2014 11:22

The alkaloid piperine enhances the bioavailability of curcumin by 2000%, but it is also a potent inhibitor of drug metabolism with the potential for inducing drug toxicity the treatment of OA, I think the study would have been [7]. Work is therefore under way to degreatly improved by the inclusion of a placebo in the velop safer methods of increasing the control group to exclude the possibility that the results bioavailability of curcumin, including were due to a placebo effect. liposomes, phospholipid complexes and nanoparticles [8]. The evidence for curcumin in the treatment and prevention of cancer also remains tentative. Carroll et The field of curcumin real. examined the effect of curcumin on the number of search is still in its inaberrant crypt foci (ACFs) in smokers who had been fancy. Although the inidentified with more than 8 ACFs during a colorec- tial clinical trials have tal screening programme [5]. ACFs are believed to been inconclusive, be the first step in colorectal carcinogenesis, and they there is a great deal of are found to be much more common in smokers. 44 laboratory evidence smokers were given either a 2g or 4g daily dose of cur- suggesting that curcumin and the numbers of ACFs were assessed again cumin could have after 30 days. There was no difference in the number many therapeutic efof ACFs in those given 2g curcumin, although there fects. The challenge was a significant reduction from 17.8 +/- 2.0 to 11.1 for the future is to +/- 2.8 ACFs in those given 4g curcumin. Although develop novel forthese results are encouraging, reducing the number of mulations of curACFs does not necessarily reduce the risk of develop- cumin and to test ing colon cancer. them in well-designed clinical triDisappointingly, curcumin also appears to lack effi- als. It may turn out cacy in the treatment of Alzheimer’s disease. Last year that curries aren’t Ringman et al. published a study in which they ran- as bad for us as we domized 36 people with mild/moderate Alzheimer’s once thought. disease to receive placebo, 2g or 4g curcumin over 30 Full references days [6]. At the end of the study, no differences were available at: seen between the groups in clinical cognitive scores www.omsg-online. com and biomarkers of disease such as Aβ42 in the CSF. However, the bioavailability of curcumin is known Nicholas Black is a fourth year to be very poor. Even at oral doses as high as 12g per medical student at day, the plasma concentration will only reach 50ng/ml Merton College [7]. Hence, the negative results described above may reflect an absence of curcumin at the required site of action, rather than a lack of curcumin efficacy per se.

Early indications suggest that curcumin may have therapeutic benefits

Cu rcum a

Long a

2014 63:3

63-3 FINAL.indd 25

28/03/2014 11:22

IMAGE/BODLEIAN LIBRARY

63-3 FINAL.indd 26

2014 63:3

28/03/2014 11:22

n the morning of 13 May 1935, T. E. Lawrence (“Lawrence of Arabia”) set out from his cottage, Clouds Hill, on his Brough Superior motorcycle to post a parcel of books to his friend ’Jock’ Chambers. It was to be his last journey. On the way home he swerved to avoid two boys on bicycles and was thrown over the handlebars, fracturing his skull. He was treated at Bovington Camp Military Hospital by the neurosurgeon, Hugh Cairns, but died six days later without regaining consciousness. He was just 46 years old. Lawrence had achieved fame for his role in the Arab Revolt against the Ottoman Empire during the First World War, fighting alongside the Arab factions and co-ordinating their guerilla warfare to complement the British military strategy. His account of these years was later published as The Seven Pillars of Wisdom, written during a seven year fellowship at All Souls, Oxford.

crackers Suite’, was created. By the time it was opened in February 1940, the war was underway and it was quickly commandeered by the War Office with Cairns at the helm, co-opted as Lieutenant. The hospital grew rapidly and Cairns and his team were at the forefront of clinical developments in the field of head trauma. As part of his efforts to improve the outcome for soldiers who had suffered head injuries, he pioneered the use of mobile neurosurgical units which were deployed close to the battlefield, reducing the time between injury and treatment. In addition he worked with fellow Australian and Oxford professor of pathology, Howard Florey, to implement the use of the new antibiotic, penicillin, to reduce

Hugh Cairns (1896-1952) was profoundly affected by Lawrence’s death and began a campaign to reduce the number of motorcyclists killed by head injuries, by the introduction of appropriate headgear. He conducted research over a number of years to develop the most effective type of crash helmet and to prove their efficacy in reducing death and serious trauma. As a direct result of his research, the British army made crash helmets compulsory in November 1941. Cairns continued to campaign and publish on the benefits of crash helmets, but it was not until 1973 that they were made compulsory for civilian motorcyclists in the United Kingdom. This safety measure has prevented countless fatal injuries throughout the world. Cairns had specialized in neurosurgery since working at the London Hospital in the 1920s. In 1937 he was appointed the first Nuffield Professor of Surgery at Oxford. In spite of Chamberlain’s appeasement of Hitler in 1938, Cairns foresaw the advent of war, and formulated the idea of a special hospital for head injuries at Oxford. St Hugh’s College was requisitioned and the Military Hospital for Head Injuries, popularly known as ‘The Nut-

2014 63:3

63-3 FINAL.indd 27

T.E. Lawrence astride his Brough Superior, talking to the designer of the motorbike, George Brough, who was recovering from two broken legs sustained in a motorbike accident, 1930. Bodleian Library, MS. Photogr. c. 126, fol. 34

28/03/2014 11:22

the number of deaths from infection following surgery. Amongst his papers given recently to the Bodleian Library, there is a letter written to his wife from North Africa in 1943: “Today is my first breather since July 3. I have travelled about 1400 miles since then and have seen two of our neurosurgical teams. Florey and I have been together, and we have been making arrangements for the use of penicillin. I think our plans will work all right if put to the test, but that remains to be seen. We are both very fit in spite of temperatures up to 120F in the shade and at times a good deal of dust. This is partly due to excellent feeding, perhaps also to the fact that we were both used to this sort of thing as boys...All told the medical services are doing an excellent job (even Florey admits it) and the troops are in fine shape. But what a vast, incredibly elaborate organisation it is, and so much horrible destruction.”

Bodleian Library, Old Schools Quad 22 Nov 2013-18 May 2014 Admission free Open daily: Mon-Fri 9am-5pm Saturday 9am-4.30pm Sunday 11am-5pm www.bodleian.ox.ac.uk/whats-on/online/ great-medical-discoveries

This story is one of many which are revealed in the Bodleian Library’s current exhibition, ‘Great Medical Discoveries: 800 years of Oxford innovation’. Visit the exhibition online or in person to learn more about the remarkable contribution of Oxford scientists, medics and clinicians through the centuries.

Lord Nuffield, Brigadier Hugh Cairns and General R.E. Barnsley, St Hugh’s College, 1945.

63-3 FINAL.indd 28

2014 63:3

28/03/2014 11:22

IMAGE/WIKICOMMONS & GILES NEAL

Personal questions in a Speed Dating format A chance hearing of a programme on Woman's Hour about how a group of young adults' aspirations were radically altered after they were given access to a group of professionals to quiz on a one-to-one basis in a 'speed dating' format led to trying the idea with a group of medical students in Worcester College, Oxford. The speed dating format provided students with an opportunity to ask personal, no-holds-barred questions to their senior colleagues, in juxtaposition with conventional careers advice methods. The interactions were 'safe' in that no records were made and the discussions took place with a group completely unconnected to the Medical School. Several older medics, most of whom were connected with Worcester College and interested in the concept, met members of the current medical student body at Worcester, alongside their College Tutors, over pre-dinner drinks. Each gave a potted history of their life and interests; these included professorial academic medicine, health organisation at a national level, experience as postgraduate deans, and large amounts of travel with foreign and charity work. Following a noisy formal dinner in hall (which, incidentally, was greatly enjoyed by the seniors), 10 students had the opportunity to ask their personal questions of each of the seniors in 5-7 minute slots (times controlled in an OSCE manner to prevent the evening extending too long). This took place in a one-to-one manner. There was to be no specific feedback so questions could be freely formulated! The cost of the evening was minimal, the experience for the students extremely positive and the enjoyment of the seniors strongly evidenced by the desire to repeat the event annually and to export the concept to other colleges and other institutions. (It has already been done in Trinity Hall, Cambridge, again with great enjoyment.) This format could be used by other professional groups â&#x20AC;&#x201C; lawyers in particular have shown interest â&#x20AC;&#x201C; and is a way in which old members could give a little time back to the college and gain a great deal in pleasure. Full references available at: www.omsg-online.com

Dr Roger Bodley (1966) The author would like to thank Prof John Cunningham, Prof Simmon Smail, Dr John Lourie, Dr Ann Booth and Dr Kim Dora and Dr John Parrington

2014 63:3

63-3 FINAL.indd 29

28/03/2014 11:23

IMAGE/STOCK.XCHNG & WIKICOMMONS

Online Learning

A survey of internet education

parknotes has been around for a more than a decade, and it’s hardly exciting news. But recent years have seen an explosion of content available on the web. Any student with an internet connection now has an unprecedented range of resources at their fingertips – videos, podcasts, animations, lectures. There is a broad spectrum of educational media, aimed at audiences of all levels, ranging from the casual to the serious, from science outreach for kids to full-blown university-level courses – and all of them are absolutely free. The proliferation of content is exciting, even scary. The sheer number of people that internet-based content can reach has led some to predict that it will change the face of education. But what exactly are these resources, and what potential do they really have?

63-3 FINAL.indd 30

Anyone can pick up a camera and make a video for Youtube; and indeed, many people have, uploading their favourite pets, music, humour, and so on. Only a few, however, have seen such opportunities as an avenue for scientific outreach. The creators of Youtube channels like SciShow, Bite Sci-zed, and MinutePhysics have a vision to make science fun and accessible for everyone. They make short clips of less than 5 minutes, exploring questions like “Why do we get brain freeze?” and “Do we expand with the universe?” They entertain their viewers, explain difficult concepts in a way that non-scientists and children can understand, and have fun doing it. As “I F****** Love Science” likes to remind us on Facebook, “We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science

2014 63:3

28/03/2014 11:23

Oxford’s own podcast site is one of the largest in the UK, with 5500 hours of material and 2.5 million downloads.

and technology”. These online communicators want to banish the notion that science is a boring subject for bespectacled brainiacs. They are often young people, even university students, reaching out from their bedroom or garden shed. Their target audience is teenagers and schoolchildren – they want above all to spread their passion to the next generation. It’s not just students taking advantage of the internet – established scientists and professors have come to realise that one item that goes viral will reach more people than in all the lecture theatres filled during their entire careers. They have always loved to share their knowledge, and so they create things like JusticeHarvard, a lecture series on philosophy and justice, or the “informal yet informative” This Week in Parasitism. Oxford’s own podcast site is one of the largest in the UK, with 5500 hours of material and 2.5 million downloads. Companies like Google have joined in, giving us online resources like ZygoteBody, interactive 3D models of the human body designed for anatomy students. Users can rotate, zoom, look at different systems, search for and isolate individual features – and all totally free. This ideal of open education for everyone is embodied in Massive Online Open Courses, or MOOCs. Websites like coursera.org and academicearth.org bring together lecturers from universities all over the world – Geneva, Melbourne, Harvard, Stanford, Peking – to teach courses in their respective fields, and they are an absolute treasure trove. There is no single definition of what constitutes a MOOC; some systems are courses in that they are a series of lectures on a particular subject. Oxford has produced nine such courses on Academic Earth: Professor Binney on Quantum Mechanics; Dr Brown on the novelist D.H. Lawrence; and many more. There is a consensus, however, that a MOOC must be interactive. Coursera, for example, has exercises, tests and exams; there are forums for raising questions and discussing ideas, with input from the instructors. Courses have a start and end date, usually lasting a few weeks; students must register with their email address; and there is a syllabus or learning outcomes. A certificate is awarded upon completion, which can be officially endorsed by the university (chiefly “for identity verification”). Coursera alone has input from 107 institutions and over 5 million students have enrolled [1]. Some claim MOOCs are the beginning of an educational revolution that threatens the university-based model itself.

2014 63:3

63-3 FINAL.indd 31

Their main attraction is their claim to open world-class education to everyone: their proponents stress that “you get access to exactly the same lectures as any undergraduate at Harvard or Stanford,” regardless of race, gender, nationality or income. Unfortunately, only the lectures are really the same. Laboratory work is out of the question, even though it is central to the study of any science. Essays are problematic – it is impossible for professors to do so much marking. Some courses limit themselves to multiple choice quizzes; others use peer marking, which many students object to and boycott. Oxford has not taken part in any true MOOCs, seeing them as “an interesting development, but not one that fits with this university’s [tutorial-based] pedagogical approach”[2]. Great interest has been shown in MOOCs’ potential to benefit people in low-income countries. However, many students who register for a course never even watch a lecture; over 90% never complete the course[3-5]. Out of 34,779 students surveyed, 83% already had two-to-four-year tertiary education, 70% had jobs and the majority were male [6]. Clearly, the courses are not reaching the disadvantaged people they are claimed to benefit most. Even if a student completes a course with distinction, what then? The next course relevant to his subject may not begin for a number of months and is likely to come from a completely different institution. Moreover, it is difficult, if not impossible, to piece together enough MOOCs to be equivalent to a degree. Exams are done unsupervised on the web, and identity is verified by webcam photos of the student and their passport [7]. In their current form, MOOCs are best suited for hobbyists, used as teaching supplements, or for professional development; certainly, many journalists would benefit from learning a little science! Between them, these online resources have a staggering potential to reach people. In their current form, it is difficult to know their true impact. But combine the pizzazz of the Youtubers, the expertise of the professors, and all the potential technologies of a burgeoning information age, and you may have a winning formula. Online learning will continue to find its place in the world; meanwhile, you and I can enjoy all that content right now. Full references available at: www.omsg-online.com

Howell Fu is a first year medical student at Exeter College

28/03/2014 11:23

A Perfect Opportunity Georgina Newman considers the potential of cervical cancer screening in Sub-Saharan Africa

nce thought to be a disease almost exclusively found in developed parts of the world, the growing burden of cancer is becoming increasingly apparent in poorer nations [1]. Due to weak or non-existent healthcare, most low-income countries are ill equipped to deal with this emerging challenge. This has led many leading oncologists and public health doctors to claim that, unless immediate action is taken, cancer will become the new global healthcare crisis [2, 3]. Whilst most low-income countries lack the resources to prevent and treat cancer, the issue has begun to climb the political and aid agenda in recent years. As a result, there has been limited investment in a handful of countries to prevent and treat specific cancers [4, 5]. Used sensibly, it may be possible to take advantage of this funding to create novel diagnostic and management strategies for specific cancers; these may then be expanded to improve cancer care as a whole.

gest a rate of 31 per 100,000 in Sub-Saharan Africa, compared to 12.1 per 100,000 in Northern Africa [18]. Other studies report higher estimates [22, 23]. Trends in incidence are unclear; one study from Uganda using regional cancer registries found that the incidence has doubled since 1954 [24], while others describe unchanged rates [13].

Cervical cancer is one such cancer that has seen

clude schemes started in both Zambia and Mozambique [11, 12].

Low-income countries are ill equipped to deal with the growing challenge

When considering cervical cancer screening programmes, policymakers must decide whom to screen, how to screen, how frequently to screen, which treatments to offer and how to achieve maximum cost-effectiveness. WHO guidelines state that, due to the natural history of high-risk cervical lesions and the resource limitations in Sub-Saharan Africa, cervical cancer screening programmes should focus on population coverage rather than screening frequency to achieve cost-effectiveness [13, 14]. Computer models have supported this [15], and studies have estimated that the incidence of cervical cancer in Sub-Saharan Africa could be reduced by as much as 25-35% if women were screened only once in their lifetime (compared to every 3 years in the

a renewed interest, especially in Sub-Saharan Africa where it accounts for 20-25% of all cancer-related deaths in women [6]. The epidemiology of cervical cancer in Sub-Saharan Africa has been poorly studied, but it is thought that its increased incidence has paralleled the growth of the HIV epidemic [7, 8]. However, this claim remains controversial, especially due to the difficulties encountered when estimating cervical cancer diagnoses in the region [9]. Only 11% of the population is covered by national or regional cancer registries [1], but current estimates sug-

63-3 FINAL.indd 32

Despite conflicting data, and because of the wellestablished link between HIV and cervical cancer in the developed world [10], many of the big HIV charities (such as PEPFAR) have begun to express an interest in developing cervical cancer screening programmes. Recent examples in-

The incidence of cervical cancer in Sub-Saharan Africa coudl be reduced by 25-35% if women were screened only once in their lifetime

2014 63:3

28/03/2014 11:23

IMAGE/LARA HIBBS

UK) [16]. Deciding how to screen in Sub-Saharan Africa has also posed problems for public health con-

A PEPFAR-sponsored initiative in Zambia enrolled 58,000 women over 5 years, preventing an estimated 142 cervical cancer cases sultants. Cytology-based screening programmes that have reduced the incidence of cervical cancer by 70-90% in the developed world [17] are almost impossible to implement in low-income countries – high resource demands and high loss-to-follow-up make this approach unworkable [15, 17–19]. Therefore, attempts to implement screening programmes have trialled alternative approaches, including ‘screen-and-treat’ (where the patient is screened and treated in the same visit). One of the most successful of these screening programmes was a PEPFAR-sponsored initiative in Zambia that enrolled 58,000 women over 5 years [11] and prevented an estimated 142 cervical cancer cases [12]. Although initially started as a programme for HIV/AIDS patients, it was so successful that it was subsequently expanded to include all women. Similar schemes in Mozambique and Mali have also proved effective [20, 21]. Unfortunately, population coverage cannot be calculated, largely due to a lack of local population data. Despite the difficulties faced,

Investments need to be made in information infrastructures, primary health services, human resources, tertiary centres and public education systems

2014 63:3

63-3 FINAL.indd 33

these programmes have been established in regions where there were previously no facilities for screening and, in all three, improvements were made to nearby tertiary hospitals to ensure appropriate treatment for those found to have high-risk cervical dysplasia or cervical cancer. In this way, the programmes have been able to enhance and strengthen the health systems of the country, as well as to diagnose and treat cancer specifically. To achieve improvements in the provision of cancer care as a whole in Sub-Saharan Africa and other developing countries, investments need to be made in information infrastructures, primary health services, human resources, tertiary centres and public education systems. These costs, and other start-up costs, are common to all cancer healthcare programmes, but are often beyond the governments of most Sub-Saharan countries. The recent interest in cervical cancer screening by large organisations such as PEPFAR offers an opportunity to construct a rudimentary skeleton upon which other oncology services can be built. Cervical cancer offers a unique opportunity to do this: it is the most important cause of cancer mortality in women in Sub-Saharan Africa; it affects women in their economic prime; it is easily prevented and treated in the early stages; and it has attracted the attention of wealthy organisations. By working with organisations such as PEPFAR to improve cervical cancer screening and treatment, significant inroads can be made to improve cancer care across Sub-Saharan Africa. Full references available at: www.omsg-online.com

Georgina Newman is a sixth year medical student at Green Templeton College

28/03/2014 11:23

Should society trust the medical profession?

wanted

consultant rheumato

logist

The Bristol heart scandal of the 1980s and 1990s is a profound example of why the public may feel they cannot trust the medical profession. Sir Ian Kennedy led the inquiry into the “excess deaths” of babies who had undergone heart surgery at the Bristol Royal Infirmary between 1984 and 1995 [1]. This inquiry rocked the core of British society by demonstrating that the NHS was in some instances failing us and our children, and posed awkward questions which dug deep into the state of British healthcare. The inquiry illuminated many areas in which parents of the children involved felt they had been let down and provided several logical reasons why the public should question their trust of the medical profession.

wanted general

eliance upon the ability of doctors to deliver that which is of benefit to individuals’ health goes to the heart of what the medical profession is about. Reliance and trust, however, are two quite different entities. Just because we need the medical profession does not necessarily mean we have to trust it. In fact, at times, the medical profession has done its utmost to erode any existing trust between the public and its health service. In this article, I shall first demonstrate how the public’s distrust of the healthcare system has arisen historically, before discussing how this distrust may not be such a bad thing for the development and improvement of our healthcare system.

practiti

oner

The report suggests there were severe communication issues at Bristol between the clinicians and parents regarding their child’s procedure [1]. For years Surgeon X had been struggling with a new operation called the arterial switch. True, at the time, this operation was considered complex and high risk. When attention turned to his final “switch” patient, it transpired that Surgeon X had a mortality rate of 51% for this patient group [2], far greater than the national average at the time. Surgeon X allegedly quoted a 20% chance of mortality to the child’s parents, even though this was by no means representative of his statistics at the time [2]. Such unwillingness to share true statistical figures with parents prior to the child’s surgery was made all the more shocking when considering the surgeons had an abundance of data at their disposal [1]. In this case, the doctors were not empowering the parents sufficiently to make an informed decision regarding their child’s course of treatment. Such practice is ethically unacceptable in modern medicine. Another factor to consider is whether the medical profession warrants our trust in terms of the competence of its clinicians. The statistics in the Bristol scandal speak volumes for the success of the surgeon, but say little for his competence. Much of Surgeon X’s defence consisted of claims of exceptional peri-operative circumstances [1]. Unfortunately, there is no quantitative method of ascertaining a clinician’s competence, since every patient is unique. What seemed to be lacking at Bristol was any impetus to act on available outcome data. Indeed, internal audit is essential to maintaining performance standards.

wanted

rge u s l a t c e r colo

63-3 FINAL.indd 34

2014 63:3

28/03/2014 12:09

wanted

? Another issue at Bristol was that many individuals who appreciated the problems that were present felt they could not speak out because their concerns entailed a direct challenge to their ‘superiors’. Consequently, instead of an effective internal review of the way the paediatric cardiac surgical service was run, a toxic culture of discontent began to surface within the team. Without resisting such submissiveness to ‘superior’ colleagues, how can credible reviews be held within medicine? And without these credible reviews how can the units know that they are offering the best possible standard of care to their patients? By extension, without these reviews, patients may be justified in their distrust of the medical profession. When comparing the accounts of parents whose children had a favourable rather than unfavourable outcome in the Bristol case, it is easy to see a pattern of bias developing. Parents of the former group often report having been treated excellently by staff and seeing very little wrong in the care their child received. Conversely, the parents of the latter group seem to have far worse experiences. Perhaps the highly charged and emotional nature of medicine means that our perspective of the healthcare received will always be influenced by the clinical outcome. This is a significant fallibility that renders unreliable many of the methods of clinical outcome assessment such as patient feedback forms. Despite reliability issues, patient feedback does arm us with one essential piece of information: whether the patient trusts those treating them. Although the aforementioned factors may bias the basis for trust or distrust, trust between the clinician and patient is arguably essential for effective medical practice. With trust comes patient cooperation; with co-operation come health improvements; and with health improvements comes further trust. This is a cycle, which may readily become a vicious one and thus ultimately lead to failing medicine. Consequently, it is not a matter of whether the public should trust the medical profession, it is often a matter of them having to. Distrust is an inherent part of modern medicine. Many will see this as fatal in terms of the breakdown of the doctor-patient relationship. The Bristol heart scandal also teaches us that distrust within medical teams can lead to toxic atmospheres in which clinical benefit is limited. In my view, society’s distrust of the medical profession may bring substantial benefits. It gives an element of power to patients; their heightened skepticism encourages use of their clinical autonomy. This means that the National Health Service really is just that - a service. It is a service where clinicians are advising as opposed to forcing patients to follow a particular treatment path. This is in contrast to a traditional, paternalistic model whereby patients might dismiss their autonomous right to a say in their treatment plan because “doc knows best”. This development is a vital part of modern medicine and is surely no bad thing. We should continue to strive for the promotion of this model of care.

Vascular Surgeon IMAGE/LARA HIBBS

wanted

i g o l o c n o t CONsultan

wanted

Full references available at: www.omsg-online.com

Cian Wade is a second year medical student at Pembroke College The views expressed within this article are the author’s own and do not necessarily reflect those of the OMSG

2014 63:3

63-3 FINAL.indd 35

orthopaed

ic surgeon 35

28/03/2014 12:09

he title of this article has a sinister metaphorical implication. Taken literally, it could prompt investigation into the underlying neural mechanisms, encouraging us to explore the effects of music from a more scientific perspective. Evolutionary factors may be relevant to this – evidence suggests that the influence of music dates back at least 30,000 years. Well known poetic expressions – such as "If music be the food of love...", "Say it with music" and "Music hath charms to soothe a savage breast" – may have inspired deeper enquiry into the significance of music to the human race. It seems that such quotations crystallise the poetic expression of musical stimulation.

THE PROPERTIES OF MUSIC The cardinal properties of music are rhythm, melody, harmony, and timbre (musical quality, such as the differing sounds of various musical instruments). These properties have been investigated using modern imaging methods such as PET, fMRI and EEG. Mechanistically, sound frequencies cause resonance in the cochlea, which is connected to the auditory cortex of the temporal lobe via the brainstem. A complex cortical representation of the original sounds is produced; in this way, the pattern of a melody influences the neural response.

THE NEUROLOGY OF MUSIC A significant understanding of the neurology of music has been gained from pathological data. Take, for example, the works of the French composer Maurice Ravel. In the latter stages of his life, Ravel's ability was severely compromised by focal degeneration of his left cerebral hemisphere [1]. One of his most celebrated works, Boléro, written during the onset of his disease, has become famous for the dominant role of changes in timbre. Some take this as evidence for the involvement of the right (in his case, intact) hemisphere in processing timbre. Furthermore, cases of bilateral temporal lobe damage have been shown to result in failure to recognise any music and an inability to differentiate between melodies. Remarkably, one lady with this type of damage continued to respond emotionally to music using her frontal lobes. Disorders affecting the processing of music are known as 'amusia', a term incorporating both congenital and acquired tone deafness. Of note, fMRI has shown that amusic patients have a thicker cortex and reduced white matter in the right frontal cortex.

63-3 FINAL.indd 36

2014 63:3

28/03/2014 11:23

PET has shown that language and melody activate similar brain areas, including the primary motor cortex, the auditory cortex, and the basal ganglia. Language processing takes place in the left side of the brain, particularly in Wernicke's and Broca's areas [2, 3]. One PET study of mechanisms associated with extremely pleasant responses to music showed altered cerebral blood flow in the ventral striatum, midbrain, amygdala, orbital cortex and ventral medial prefrontal cortex, areas otherwise responding to food, sex and illicit drug use [4]. Emphasis has also been placed on the anticipatory phase of pleasurable stimuli, with dopamine as the key mediator. When considering the neural processing of music, it is clearly important to compare the brains of musicians and non-musicians. Interestingly, there are grey matter volume differences in areas of the brain concerned with motor, auditory and visuospatial responses. It seems that such disparities are acquired through long term practice. Virtually all musicians use both hands in their art and this is reflected in their larger anterior corpus callosum. Functional differences are also apparent â&#x20AC;&#x201C; there is less cortical activation in the motor area, suggesting that fewer neurons need to be activated for the same musical purpose [5]. In contrast, cerebellar haemodynamic responses are stronger in non-musicians. Absolute (or perfect) pitch refers to the accurate identification of the pitch of a musical note, without an external reference. Using PET to measure cerebral blood flows during pitch perception, it has been shown that activation of the right inferior frontal cortex is present in non-possessors of the trait in contrast to those who have perfect pitch. The conclusion is that access to working memory mechanisms is not necessary for musicians endowed in this way [6].

THE IMPACT OF MUSIC Music is recognised as a central aspect of human culture and no matter how incongruous, two of its most important spheres of influence are in liturgy and in the military. The Psalms are a fine example of the former, helping devoted worshippers to experience the Divine for many centuries. The effect of military music is, in my view, not unrelated to the toe-tapping response that is so spontaneous upon listening to any rhythmical piece of music! Soldiers on parade exhibit analogous movements, strictly in time with the beat. Of course, the sound of the bugle on

2014 63:3

63-3 FINAL.indd 37

the battlefields of old cannot be forgotten, not to mention the rousing influence of the bagpipes.

THE MEDICAL BENEFITS OF MUSIC We can regard the developing medical field of music therapy as a distillate of the underlying principles of musical processing. It is both an art and a science, embodying fundamental scientific disciplines. Although further research into this exciting concept is both inevitable and necessary, a number of practical applications can already be advanced. Moreover, the fact that music therapy appears to be free from side effects should not be overlooked [7]. Historically, music therapy can be traced back to the ancient Greeks and Egyptians. It also features in the 17th century work 'The Anatomy of Melancholy' and was used to treat soldiers with post-traumatic stress disorder during the Great War [8]. Music therapy has been used alone and in combination within rehabilitative procedures for stroke victims [9-11]. Music therapy has also been shown to improve depressive illnesses, with a concomitant reduction in the patient's cortisol levels and changes in frontal lobe activity [12]. Similarly, in schizophrenia, there have been promising results [13], although scientific approaches have proved difficult to achieve. Although the pace of research looking into the fundamental physiological responses to music has escalated in the last thirty years, numerous areas remain untapped. For example, there is a deficit of research on living deaf composers. Although it is difficult to comprehend the astonishing musical ability of the most famous of deaf composers â&#x20AC;&#x201C; Beethoven â&#x20AC;&#x201C; such abilities are thought to be related neurologically to the recall of a familiar melody by a non-musician. A useful source to initiate this sort of study would be the Royal College of Music. It will be exciting to see how this, and the field of musical neuroscience in general, may unfold. Full references available at: www.omsg-online.com

Brian LD Phillips, Exeter College 1948-52. Royal Free Hospital, London 1952-54

IMAGE/ROSALIE BROOMAN-WHITE & FREE VECTORS

28/03/2014 11:23

International health electives: who benefits? KATE MILNE considers whether ‘altruistic’ electives in developing countries may be doing more harm than good…

olunteering overseas has increased greatly since the 1980s. A government commissioned review conducted in 2004 identified 800 organisations offering placements in 200 countries. This epitomises the emergence of a new sector of the travel industry, often referred to as ‘Voluntourism’. Many projects are criticised both for a lack of sustainability and for interfering with the steady development of impoverished countries. For instance, building projects may deprive local workers of much needed jobs, while orphanages may be disrupted by the presence of individuals who only stay for short periods. Indeed, such projects perpetuate the idea of a largely westernised and idealistic worldview. The organisation Volunteer Services Overseas (VSO), who seek to recruit experienced individuals suitable for projects running for at least a year, argue that the only real beneficiaries are the travel companies – accusing them of exploiting both the well-meaning volunteers and host communities [1]. With these issues in mind, what are the potential consequences of an unqualified medical student, with as little as two and half years experience, carrying out their elective in a developing country? Data gathered from post-elective questionnaires in Canada and the US highlight the benefits to students’ skills, attitudes, and knowledge of tropical and global health issues [2, 3]. However there is limited evidence regarding the effect on the host community. Medical students may lack appropriate training and may be further hindered by language barriers. These factors may lead to unethical practice on vulnerable patients, no matter how unintentional. The GMC requires all students and doctors to work ‘within the limits of their competence’ [4], but difficult situations and inadequate support in poorly staffed and under-resourced hospitals may lead students to endorse unsuitable treatment decisions. This is further reinforced by an overestimation of a student’s ability by local care workers. A recent survey conducted by Radstone in the Soloman Islands reported that the majority of healthcare workers thought it was acceptable for elective students to diagnose, prescribe and carry out practical procedures unsupervised. They were unaware that this would not be ‘the norm’ in the UK [5].

63-3 FINAL.indd 38

2014 63:3

28/03/2014 11:23

The majority of healthcare workers thought it was acceptable for elective students to diagnose, prescribe and carry out practical procedures unsupervised

”

Nevertheless, there are practical ways to reduce the risk of inadvertently harming patients. Pre-departure schemes run by the University of Toronto allow students to discuss the ethical dilemmas and challenges that they may face [6]. The provision of formal contracts and guidelines for all parties involved may also help, providing a framework for better and safer practice. Long-term relationships between First World institutions and partners in a developing country can be hugely beneficial. For example, Moi University Faculty of Health Sciences in Kenya has four international partners – it is thought that this will help to aid understanding of the role of an elective student in host institutions [7]. More support for and from local staff will further improve the student and patient experience – not only in the short-term, but also in the future, should individuals return as qualified specialists. Here they will be in the position to deliver better training and support to host practitioners, facilitating more lasting positive effects for the local community. Full references available at: www.omsg-online.com

2014 63:3

63-3 FINAL.indd 39

IPHOTO/ALIX BRASIER MODEL/JOSHUA JUCK

Kate Milne is a third year Medical Student as St Hugh’s College

28/03/2014 11:24

Outsourcing clinical trials: a step too far?

etween 1995 and 2005 the number of countries outside the United States serving as sites for clinical trials more than doubled. In 2007, of all Phase III trials conducted by the 20 largest US based companies, almost one third were conducted abroad [1]. And this trend shows no signs of slowing – perhaps unsurprisingly, given the substantial savings to be made. In India, for example, each case report costs $1500-2000, about one-tenth of the cost in the US [2]. These savings extend throughout the trial process, primarily due to greatly reduced labour wages. Additionally, the lower level of legislative oversight involved (i.e. fewer reviews – ethical, technical and scientific) is also particularly attractive to pharmaceutical companies, saving time and reducing costs further [3]. Most would agree that it is appropriate to carry out trials for treatments of diseases such as malaria and tuberculosis in countries where those diseases are proportionally over-represented. Equally, cardiovascular disease and a number of cancers are becoming increasingly common across the world and new therapies must be trialled accordingly [4]. However, many – if not most – clinical trials prioritise diseases that are far more common in Western countries [1]. Even when treatments could be of great help to the communities involved, in too many cases the end of the trial sees the end of access to that treatment for many years. This is in contradiction to the Declaration of Helsinki (a statement of ethical principles for medical research, developed by the World Medical Association) [5]. Indeed it appears that, for the most part, the globalisation of clinical trials has not led to a sustained increase in the availability of treatments worldwide. Perhaps the greatest concern, however, is the potential for exploitation. Language barriers, high levels of illiteracy and a sometimes poor understanding of the nature of drug treatment together make it difficult to obtain genuine informed consent. In areas of high poverty, cash payments for participation (sometimes equivalent to a year’s salary) may lead people to ‘volunteer’ without considering the risks involved. There is also a great deal of controversy surrounding placebo-controlled trials. In the late 1990s, for example, a debate raged over the use of a placebo (rather than antiretroviral therapy) in a trial investigating treatment of HIV-infected pregnant women [6, 7, 8]. A number of ethical concerns have been raised, but the issue remains as yet unresolved and many such trials continue to go ahead [9, 10]. Quite aside from questionable ethics, there are also significant issues regarding scientific validity. Trials are carried

Clinical Trial

Instruction Pack

63-3 FINAL.indd 40

Instruction Pack

2014 63:3

28/03/2014 11:24

out on genetically dissimilar populations with a whole range of different, concurrent and often untreated diseases, within very different healthcare systems [1]. Whether the results can be extrapolated to a Western population seems uncertain at best. However, some argue that patients with little background treatment history, as is true for many people in developing countries, leads to more accurate results [11, 12]. The lack of regulation present in many of the countries and communities where such trials operate means that the onus is placed squarely on the pharmaceutical companies themselves to maintain high ethical standards. Unfortunately, the accountability of these multinationals is often lacking. The majority do not run the trials themselves but instead operate through contract research organizations (CROs). The most recent ‘Access to Medicine Index’ report found that, of the 20 companies assessed, only four were able to provide evidence that they enforced codes of conduct in relation to the CROs they employed. The report went on to say that “without adequate due diligence in selecting contractors, monitoring of their conduct, or enforced disciplinary action, patients are left vulnerable to clinical malpractice with little recourse to justice” [13]. It is a damning indictment of these companies that few will even provide details of their contracted CROs. Nevertheless, it would be unwise to over-simplify this trend for outsourcing, treating it as just another case of ‘Big Pharma’ exploiting vulnerable people. The undoubtedly serious concerns are by no means insurmountable and, if carried out properly, many such trials can bring great benefits [14]. Although companies may be tempted to exploit legislative loopholes, if they can be held more accountable (as the Access to Medicine Index attempts to ensure), then Western clinical standards can be successfully applied to these studies, regardless of location. Moreover, trials of drugs for diseases which disproportionately affect the country in question can bring hope to those who previously had none. The priority, however, must be to ensure such benefits actually reach the host communities in order to make a lasting difference. Full references available at: www.omsg-online.com

Peter Johnstone is a third year medical student at Corpus Christi College

uction ack

IMAGE/ROSALIE BROOMAN-WHITE

2014 63:3

63-3 FINAL.indd 41

28/03/2014 11:24

“What does ‘Growth’ mean to a Doctor?” Congratulations to Zohaib Arain, who won this year’s school 1st essay competition

This year, the Oxford Medical School Gazette launched its inaugural OMSG Essay Competition, designed to enable school students to explore scientific horizons beyond the curriculum and to foster an interest in Medicine as a career. We were thrilled to receive 71 entries on the title: “What does ‘GROWTH’ mean to a doctor?” A group of OMSG Sub-Editors shortlisted four essays for submission to our Senior Judging Panel, comprising Professor Jeremy Taylor, Dr Tim Lancaster and Dr Peggy Frith. These Senior Judges ultimately selected Zohaib Arain’s reflections on “Growth” as the Winning Entry, which we publish here.

I would like to extend my sincerest thanks to the Sub-Editors and Senior Panel for their help in the adjudication process. Most importantly, I would like to congratulate all participants for the outstanding quality of entries we received. I hope that the OMSG Essay Competition will continue to grow in years to come, according to its founding principle of extending our passion for Medicine to a future generation of doctors. Maria Mahmood (OMSG Development Officer)

Growth; the process of developing. To a doctor, growth must be interpreted in varying ways, with an awareness of the diverse associations of the concept of growth in medicine. Let’s use a scenario, ‘we’re in a prenatal clinic: Doctor Jones tells the couple, “she’s grown”, and they smile, relieved by the good news. Meanwhile, upstairs during a lung cancer consultation Doctor Smith explains with a frown, “It’s grown”; the patient grows anxious and worried by this alarming information’. The disparity between the interpretations of growth in these two scenes, illustrates the need for a doctor to be able understand growth in its multitude of both positive and negative connotations. Indeed, a doctor’s perception of growth ultimately affects their own personal growth throughout their career in medicine. Growth means so much more than anatomical growth and goes much further than simple biological processes. For instance, when a doctor thinks about growth, the development of technology is sure to come to mind. As technology has advanced during the 21st century, innovations in medicine have come at an alarmingly fast rate. Last year the da Vinci surgical system, a robotic platform offering minimally invasive options for major surgery, sold more than 2500 units worldwide [1]. The subspecialty interventional radiology has overtaken surgery in recent years [2] through its use of X-rays, CT imaging and fine catheters to provide non-surgical options. To a doctor, the growing involvement of technologyin medicine, while important in the improvement of patient care, must seem daunting.It is impossible to predict how far systems like these will influence modern surgery, with the potential of making certain specialties redundant in the not too distant future. Indeed, this growth in new technical methods will directly affect the doctor’s personal growth; forcing them to have to retrain or dangling the suggestion that they may be replaced by a machine. Growth in this sense means improved patient care and safer medical procedures, but also a cloudy and uncertain future to a doctor with respect to their career.

63-3 FINAL.indd 42

2014 63:3

28/03/2014 11:24

?” However, beyond science, doctors must also consider growth in terms of population and the fluidity in the number of certain demographics. For instance, in the UK there are now more people over the age of 65 than there are children under 15 years [3]. With this ageing population, we can expect strains on the NHS. To any doctor this means the rapid expansion of certain specialties like geriatrics and old age psychiatry, while also the subsidisation of other areas of medicine. Certainly with such pressure being exerted on the NHS due to growth of the elderly population, doctors may fall victim to increasing salary freezes and departmental cut backs. Indeed, Norman Lamb, Minister of State Care and Support, has called fora reduction of so called ‘elderly bed blocking’ through the use of fines [4]. The implementation of such aggressiveefficiency focused measures could mean the demise of holistic patient care to doctors. Undoubtedly, when considering growth, doctors cannot help but think about the growing bureaucracy and ‘tick box’ approach of the NHS and its effect on patient care. The increasing significance of so called ‘efficiency targets’ ,which push to increase the number of patients seen and reduce the amount of time taken in dealing with them, would seem ominous to a doctor. The growing influence of efficiency could lead to the eventual dehumanisation of the patient, making them little more than a disease, condition or disorder that needs to be treated, rather than a human being. Moreover, while concerns such as this were addressed in the ‘Francis Inquiry’, at the forefront of a doctor’s mind will still remain the fear that their profession may soon be reduced to arbitrary paper pushing, ‘duplicatory regulation and ‘information burdens’[5]. Admittedly,a focus on holistic patient care (dealing with all aspects of a patient’s wellbeing as a person), has seemed to have grown from this increased scrutiny towards a tick box culture in the NHS. The government recently ‘axed’ ‘10 minutes or less GP appointments’ [6], and introduced named GPs for all over 75s[7] . However, the growing influence of bureaucracy in the NHS, while acting as a catalyst for improved patient care, will always remain a threat to the traditional role of a doctor. An aspect of growth that a doctor must also reflect upon, is the threat of literal growth; obesity. In fact in the UK, ‘the proportion of adults with a normal BMI decreased between 1993 and 2011, from 41.0% to 33.6% among men and from 49.5% to 39.4% among women’. Furthermore there was a ‘marked increase in the proportion [of people] that were obese’ [8]. To a doctor, the growth of obesity means the increase of diseases such as type 2 diabetes, heart disease and stroke. With diseases like these becoming more common amongst the population, doctors would expect further strains to be exerted upon the NHS. However, while a doctor’s main aim is to treat obesity related diseases and try to encourage obese patients to lead more active lifestyles; their efforts are being effectively inhibited by the growing input or organisations like N.I.C.E (The National Institute for Health and Care Excellence). N.I.C.E has recommended that doctors are ‘respectful and non-blaming’ [9] when dealing with obese patients, and should avoid using the word ‘obesity’, as some ‘may consider it derogatory’ [10]. Such patronising approaches to patient care are preventing doctors from doing their jobs; making them constantly wary of treading on over sensitive toes. To a doctor, growth in this sense, while useful in maintaining a high standard of clinical excellence, is also worrying as it could stop them from performing their duties as doctors. To conclude, we can see that growth is hugely significant to a doctor outside of its conventional associations in medicine. To a doctor, growth in all senses of the word means both improvements in the present and the possibility of decline in the future.

IMAGE/LARA HIBBS

Full references available at: www.omsg-online.com

2014 63:3

63-3 FINAL.indd 43

Zohaib Arain, Year 12 student from Watford Grammar School for Boys

28/03/2014 11:24

d l r o w d

a M A

h t l ea

w e i lv

a b glo

When considering global health, we tend to think of primary care or the eradication of major diseases. Depression and anxiety appear to be reserved for the busy, stressful, western lifestyles that we love and loathe in equal measure. It is all too easy to look at countries facing more 'immediate' health issues and forget that we are all thinking, feeling human beings. Emotional suffering may be profound â&#x20AC;&#x201C; regardless of circumstance â&#x20AC;&#x201C; and debilitating mental disorders indiscriminately affect people across the globe. As described by the WHO, health is "a state of complete physical, mental and social well-being and not merely the absence of disease" [1]. The latter two aspects may all too easily be forgotten. So does the western system represent an ideal model for less developed nations, or are mental health problems too culturally subjective to ever have globally applicable solutions? How does the cultural, economic and political state of a country affect mental healthcare and what is required for more positive change?

SIERRA LEONE Mental health is undeniably a worldwide issue, yet the nature of the problem is far from uniform. Having endured over a decade of brutal civil war, Sierra Leone is now suffering from the effects of extreme poverty and conflict â&#x20AC;&#x201C; particularly damaging to the nation's mental wellbeing. Subjected to years of unimaginable horror, the legacy of child soldiers has left an adolescent popula-

63-3 FINAL.indd 44

h l a t n e

m n o

tion afflicted by many deep-rooted psychiatric problems [2], with adequate provision of care being an as yet unmet challenge. Within the wider context of conflict, adult caregivers have themselves often experienced equally distressing trauma, potentially undermining their capacity to offer emotional support [3]. The destructive force of such prolonged violence is felt not only by the population but also by infrastructure and services. With just one psychiatrist serving a population of over five million, mental health facilities in Sierra Leone are dangerously inadequate [4]. The relative stability now enjoyed by this previously turbulent West African state allows researchers to explore its now established psychiatric care challenges, forming evidence-based strategies to best address the mental health burden. Recent research suggests that methods to combat post-traumatic mental health issue in the young must engage with the wider community, with efforts on an individual basis showing limited efficacy [2]. Sadly, in spite of the difficulties faced by former child soldiers being well recognised, care systems remain limited [5]. A poor understanding of mental health and its far reaching impact has led to insufficient government investment, with prevailing stigma further constraining available resources [6]. This in turn exacerbates the problems created by inadequate infrastructure and unevenly distributed services. Research is the first step in overcoming this problem, informing good policy making and providing invaluable evidence to push for change.

HAITI The complex and incomplete understanding of mental health aetiology leaves psychiatric conditions open to cultural interpretation. Haiti was thrust into the global limelight following the devastating earthquake of 2010, which left the already poverty

2014 63:3

28/03/2014 11:24

stricken country in an even more desperate situation. Even before the natural disaster, over half the population had no access to formal healthcare [7]. Although quantifiable data on mental health is poor, Haiti epitomises how the perception of mental health is hugely dependent on the cultural lens through which it is viewed. Psychiatric disorders are thought to have a supernatural cause, attributed to a failure to please spirits or Vodou curses [8]. As mental health problems are not considered an intrinsic problem, western treatments such as cognitive behavioral therapy (CBT) are not readily applicable. Not only might this influence the provision of mental healthcare in Haiti itself, but also might be relevant to treatment of Haitian immigrant populations. Evidencebased medicine needs to adapt culturally to maximize relevance, applicability and efficacy [9]. The supernatural beliefs underpinning attitudes in Haiti can make life for sufferers difficult. In fact, the stigmatization of psychiatric disorders is almost mandated by the prevailing belief system. Those who have experienced episodic psychosis are sometimes thought to be permanently dysfunctional (irrespective of remission and subsequent good health) with harmful consequences for education and career prospects [10]. In Haiti, depression is not considered a mental health problem per se, but rather a state of general debilitation stemming from other medical conditions such as malnutrition, spiritual curses or an unhealthy preoccupation with personal problems [8]. Under such circumstances, support is provided by the extended family with professional involvement being rare [10]. Mental health is not a priority of the Haitian government and there are few psychiatric professionals working in the public sector. Moreover, half of health services in Haiti are concentrated in the capital, Port-au-Prince, and about 80% of the population turn to traditional medicine as the first recourse [11].

rights issues in relation to mental health [12]. However whilst such need in China has long been acknowledged [13], the first national mental health law was only introduced in October 2012 [14]. In contrast, the UK first saw the introduction of the Mental Health Act in 1959, with subsequent revisions reflecting an increased concern for the interests and wellbeing of psychiatric patients [15]. Psychiatric services in China exemplify the inverse care law: a disproportionate concentration is seen in large cities with correspondingly poor provision across vast rural areas [16]. In part, the new legislation hopes to improve access to these services and establish a better balance between specialised psychiatric hospitals and improved community based care. However, this doesnâ&#x20AC;&#x2122;t directly respond to the problem of peopleâ&#x20AC;&#x2122;s hesitation to access services: 92% of individuals in China with mental disorders fail to seek professional help [17], representing an ingrained reluctance to acknowledge the importance and impact of mental health.

CHINA China is the worldâ&#x20AC;&#x2122;s most populous country and its complex political history makes it an interesting example of the relationship between government and public health. In 2005, the WHO highlighted the need for national legislation to address human

IMAGE/STOCK.XCHNG

2014 63:3

63-3 FINAL.indd 45

28/03/2014 11:24

HAITI

SIERRA LEONE

Yet Chinaâ&#x20AC;&#x2122;s new legislation doesnâ&#x20AC;&#x2122;t as easily address psychiatric stigma. Some efforts have been made to include clauses highlighting the responsibility of the workplace to provide psychological support [14] (hinting at a growing awareness of the importance of prevention and maintenance of healthy mental wellbeing), although these are few and far between. Prior to the law of 2012, the formation of a National Mental Health Plan in 2002 [16] outlined detailed targets for improving psychiatric services and creating a cohesive system of care. Why then did it take a decade for national legislation on the matter to materialise? One idea is that longstanding stigmatisation biased the law towards protecting the public from the perceived threat posed by the mentally ill, rather than protecting psychiatric patients themselves. In addition, the financial burden falls upon local governments who must fund services in line with the national mandate, making such legislation an unpopular move for the poorest (yet most in need) regions [18]. Changes in mental health legislation are a crucial first step, driving better adherence to human rights and providing an essential framework. However, the ensuing challenges faced by primary care providers mean that the law alone is not enough; it is the implementation of change that is important.

IMAGE/WIKICOMMONS

TOWARDS A GLOBAL PERSPECTIVE? A country can provide the best services possible, but unless attitudes are such that people are happy to seek out that care, then the burden of mental health disorders will continue to grow. Improving care is twofold: the provision of services must be matched by the creation of a cultural climate in which people will readily utilise the help on offer. The examples discussed here represent just the tip of a global public

63-3 FINAL.indd 46

CHINA

health iceberg, though they provide some insight into wider themes of mental health care improvement strategies. For example, it is clear that western approaches and ideals will not be successful where fundamental beliefs are significantly different; hence context is paramount. The notion of cultural competency is important for health professionals around the world, allowing adaptation of effective treatment methods for different ethnic groups and circumstances. With a global perspective, it is easy to fall into the trap of elevating western ideals to a superior, though perhaps unwarranted, status. In 2011, the WHO found that legislation pertaining to mental health in England and Wales met just 90 of the 166 examined standards [12]. Although only a constituent part of mental healthcare as a whole, this brings into question whether services and attitudes in the UK are worthy of acclaim. Regardless of intrinsic success, cultural parameters mean that the methods in place may never be truly applicable to other countries. Mental healthcare is a function of cultural systems with wider beliefs ultimately dictating attitudes and treatment compliance. Indeed, the emergence of eastern mindfulness-based therapies suggests that we still have much to learn from other cultures. Attitudes and ideas surrounding mental health are as diverse and varied as any other aspect of culture. An appreciation of this fact is crucial, as is the universal nature of mental health problems. Full references available at: www.omsg-online.com

Emma Pencheon is a second year medical student at Somerville College

2014 63:3

28/03/2014 12:09

Robotics - a revolution? D

uring my first clinical attachment, our Urology consultant invited us to watch a robotic prostatectomy. We had observed a few other prostatectomies, both open and transurethral, so I was intrigued to see how a mechanical device could achieve the same result. I came away hugely impressed that such delicate surgery could be carried out in this way; a surgeon miming the precise actions of the instruments to operate them remotely, using a magnified 3D view of the patient's body. Quite an odd concept at first, but it made me wonder whether this new surgical technique will one day become the norm.

So to what extent is robotic surgery being implemented in theatres across the UK? In the USA, where the da Vinci surgical system was introduced in 2000, it has become much more commonplace. At the end of 2012, there were 1878 robots in the US (compared to 29 in the UK), performing over 80% of the robotic procedures worldwide [3]. Although demand is increasing on this side of the Atlantic, robots are not yet viewed as an essential piece of surgical equipment. Despite substantial media focus raising the profile of robotics in recent years – presenting it as a technique destined to revolutionise all types of surgery – a lack of evidence-based efficacy thus far has limited its use to relatively few specialties. In this respect, I was lucky to start off in Urology, because along with Gynaecology, this is where the robots' success has largely been concentrated. Other surgical specialties are increasingly exploring the possibilities afforded by robotics, notably orthopaedics – where some of the latest technology for knee and hip arthroplasty involves robotic assistance [4].

2014 63:3

63-3 FINAL.indd 47

IMAGE/ROSALIE BROOMAN-WHITE

In Oxford, the robot was acquired in 2009 and has been in regular use (primarily for urological procedures) ever since [1]. Speaking with the surgeons, they highlighted how fortunate we are to have one at the Churchill: they are still fairly sparse around the UK and remain an expensive investment (at over £1 million before additional specialised training) [2]. The robot itself essentially comprises a set of four arms, manoeuvred from a two-seated console at one side of the theatre, where training and teaching can be simultaneously delivered.

28/03/2014 11:24

Widespread uptake of robotics should not be thought of simply as natural progression in surgery

So why choose a robotic option when non-robotic techniques may be just as effective? In an age of increased patient autonomy, both the patient and surgeon will have input into this decision. Robotic surgery is associated with a slightly shorter hospital stay (due to its less invasive nature with smaller incisions) and a decreased infection risk [7]. Given the extent of media coverage regarding the introduction of surgical robotics, some patients may be enticed by the perception of "high-tech" techniques. Indeed, surgeons themselves are likely to want to trial new technologies. Yet its relative infancy as a field means that there is a lack of substantial long-term evidence, either in support or opposition. As such, a recent BMJ article highlighted the need for a prospective,

63-3 FINAL.indd 48

validated system of evaluation and surveillance of robotic procedures [8]. Robotics is a rapidly developing and exciting branch of surgery. However, as fast as the field advances, especially within Urology, there is still uncertainty as to whether robots will be universally adopted in the long-term. Whilst the public perception of robotics might be of highly advanced medical care, we must be careful to avoid widespread uptake without sufficient evidence of benefit. For example, four years later, Oxford is able to boast weekly robotic theatre lists, but only in a couple of specialties. It will be interesting to see whether the implementation of robotics progresses to the point where it becomes almost indispensable as a surgical tool, or whether it will remain a mere adjunct to established and successful conventional techniques. Full references available at: www.omsg-online.com

Amrit Gosal is a fourth year medical student at Brasenose College

IMAGE/DARIUSH MICALLEF

â&#x20AC;?

In Urology, a number of studies have attempted a cost-benefit analysis of robotic surgery versus more conventional techniques [5, 6]. Yet a recent systematic review concluded that the higher cost of robotic prostate surgery (relative to open or laparoscopic approaches) is not fully compensated for by the reduction in time spent in theatre or in hospital post-operatively. However, it did suggest there might be a shorter learning curve for the surgeons' training [7]. As with any new innovation though, it is likely that prices will fall in due course, perhaps shifting these data in favour of the robot.

â&#x20AC;?

2014 63:3

28/03/2014 11:24

The Anatomy of Violence: The Biological Roots of Crime Adrian Raine Allen Lane £16.75

The Future of Aging: Pathways to Human Life Extension Gregory Fahey Springer Amazon Price: £215.50

Reviewed by Edward Chesney

Reviewed by Eleanor Watts

Adrian Raine begins The Anatomy of Violence with a simple question: "Is there a significant biological contribution to the causes and cures of crime?" Easy to ask but (as five hundred pages show) harder to answer. And especially hard to answer in a society scared of the questions any answer may itself pose – if, for example, your brain is biased towards violence, what does this mean for our current system of justice?

While many aspects of medicine don't apply to those of us learning about them, the aging process affects all of us. But does it have to? The Future of Aging: Pathways to Human Life Extension is a collection of seventeen articles on possible directions in the field of senescence prevention. Life extension science has, at least historically, not been given much serious thought, but given our role as medics involves postponing the inevitable, trying to make the inevitable evitable seems the next logical step. We can worry about overpopulation later...

Raine obviously understands the implications of the question, and his delight in explaining the results of work both he and others have undertaken in this area is clear in his writing. He covers dangerous ground – as he carefully points out, Mussolini's racial laws and the later eugenics movement both grew out of a poor analysis of the biological features of criminals – but it's hugely exciting. Broadly, arguments are illustrated either through descriptions of patient case histories or through re-examination of published studies. As is often seen in medicine, stories of individuals are more engaging and Raine describes these cases with impressive clarity and insight. Larger cases studies are, however, covered with less consistent success. It is here that Raine seems to sometimes overstate and overstretch his conclusions. This is perhaps best illustrated in his sections on domestic violence; by describing sociological and biological factors for these crimes sequentially, rather than in combination, he is able to lend support to some disturbing verdicts. But what Raine lacks in consistency he more than makes up for with absorbing perceptiveness and sharpness in an otherwise wise murky area. And, importantly, he recognises that current questions surrounding the psychopathology of crime cannot be conclusively answered. By leaving his last enquiries open-ended, he leaves a lasting impression on the reader. The Anatomy of Violence sets out to ask questions about how we do and should punish criminals, but it also – very powerfully – invites us to reconsider the causes and consequences of our own actions.

Ed Chesney is a 6th year medical student at New College

2014 63:3

63-3 FINAL.indd 49

The book works through a number of ideas, with those that might be achieved soon appearing first. Besides the well known, like calorie restriction, we encounter the role of telomeres and telomerase in aging, ways we might one day be able to correct mutations in mitochondrial DNA and - in the last chapter – nanorobotics. All pretty cool sounding, to be honest! Depending on your level, you may be slowed somewhat by the need for some serious Wikipedia input, but this is equally rewarding (SMAD3, a.k.a. Mothers against decapentaplegic homolog 3 – wonderfully witty or mildly absurd?). At the very least, The Future of Aging provides a compilation of the very latest discoveries, although many without clinical application for the foreseeable future. And although the book is consistently stimulating and well written, its weight and price may discourage all but the most motivated of bibliophiles. At nearly 900 pages and £215.50, you're unlikely to pick it up on an impulse but, given the opportunity, it's most definitely worth a read.

Eleanor Watts is a 3rd year medical student at Keble College

28/03/2014 11:24

Gulp: Adventures on the Alimentary Canal Mary Roach Oneworld Publications Amazon Price: £8.39

High Price: Drugs, neuroscience and discovering myself Dr. Carl Hart Penguin £9.99

Reviewed by Abhijeet Tavare

Reviewed by Giles Neal

From the influence of smell on taste and the psychology of eating patterns, to faecal transplants and the science behind flatulence, Mary Roach certainly takes the reader on a wild adventure through the gastrointestinal tract. But does she succeed in making a stimulating and enlightening read out of such a foul topic?

Dr. Hart starts with a clear and important aim: "to show... how emotional hysteria ... related to illegal drugs obfuscates the real problems faced by marginal people". By weaving together both his own experiences of a drug-exposed, deprived upbringing and his detailed knowledge of illicitdrug research, he presents an intelligent and progressive discussion.

The book is divided into a series of short chapters, each of which focuses upon a particular part of the digestive system. The apparent flow from chapter to chapter effectively and imaginatively mirrors the flow of the digestive system, yet without pause for real deliberation and examination. When combined with the relatively short length of this book, it makes for a very easy read that doesn't drag. I did, however, find the constant use of footnotes immensely irritating – these were, for the most part, a major distraction without particular redeeming quality.

Firstly, 'High Price' is a great success story. There is little arrogance expressed during his self-discovery, and it is humbling to see the amount of credit he gives to his many mentors. Secondly, drawing from his life, Dr. Hart highlights several key issues in the drug debate. For example, he examines the 100:1 punishment ratio for crack:powder cocaine possession before Obama. In light of good evidence showing the two forms have very similar effects on humans – and that white people consume far more (predominantly powder) cocaine, but that black people have been disproportionately affected by the legal consequences – he becomes exasperated that the now 18:1 penalty should not be seen as progress. He talks, albeit unfortunately little, about his experience with the Drug Policy Alliance and how their sponsor's priorities (for example, marijuana policy reform) take the forefront over more pressing issues, such as the demonization of cocaine and methamphetamine users. Amongst many striking examples of myth busting - another pertinent theme - one that stood out was "meth teeth"; Adderall causes parallel xerostomia, but those prescribed it often have perfectly fine oral hygiene. Yet the idea that statistical significance outweighs 'Breaking Bad' in scientific merit still clearly evades many influential sources.

But where Gulp really shines is in the way it's written. Roach has an elegant and unpretentious writing style, illuminated by the use of dry humour – sometimes complex but often crude. For example, when Roach discusses Jonah and the whale: "While a seaman might survive the suction and swallow, his arrival in a sperm whale's stomach would seem to present a new set of problems." I challenge you to find a more innocuous sentence containing the words sperm, suction, swallow, and any homophone of seaman. Although it may not appeal to everyone, I certainly found that it brightened my read. Gulp's major weaknesses lie in its large emphasis on flatulence (spanning many chapters) and its lack of hard science. Often Roach left me wanting that extra detail – but perhaps this is to be expected in a book written largely for the general public. Nonetheless, it was still an interesting aside, filled with entertaining anecdotes and curious observations. Ironically then, Gulp's light-heartedness and its succinct chapters make it an ideal addition to the smallest room in the house!

The conclusion focuses on the idea of decriminalization, but not legalization, of illicit drugs. The Portugal experiment, especially in light of his own son's shattered career prospects following a string of minor drug offences, provides a compelling argument for its further debate. Shrewdly, however, no one side is taken. The emphasis throughout the book on skepticism and his detailed examination of the available evidence is inspiring. Personally, I would have preferred more cutthroat dialogue. Yes, I put the book down feeling more aware, but I didn't feel like the activist that I thought I could have become. Too much civility is given to the attorney presenting emotive drivel about "America's children" and the policeman's spiel that "Taser gun's are ineffective at stopping [meth users]". What's even worse, the government gave these people equal weighting to expert scientists at a conference aimed at better informing the press on hard drugs! Had Dr. Hart had the cojones to outright call these people fantastic idiots and the current system an utter nonsense, I would - without a doubt - be calling this book revolutionary. Sometimes fire needs to be fought with fire, and the gas canister he fashions for himself is certainly robust enough. Still, despite the book's passivity, it is a neat and welcome stepping-stone at the very least.

Abhijeet Tavere is a second year medical student at Balliol College

63-3 FINAL.indd 50

Giles Neal is a 2nd year medical student at St. Edmund Hall

2014 63:3

28/03/2014 11:24

PEER REVIEW

63-3 FINAL.indd 51

28/03/2014 11:24

Reducing hospital readmissions linked to alcohol misuse Lihini Wijeyaratne, fourth year medical student at the University of Bristol

ABSTRACT Background: Alcohol-related readmissions are a major burden to the health service. National guidelines for managing alcohol misuse have varied implementation. Methods: A retrospective audit comparing the inpatient care and discharge of patients with alcohol-related readmissions against NICE guidance for management was performed. Results: Over six months, 10.5% of alcohol-related admissions were readmissions. Reasons for readmission included inadequate monitoring of withdrawal, few interventions offered to manage alcohol misuse, and lack of psychiatry referral. Conclusions: An enhanced management pathway could be implemented during the patient’s first admission to potentially prevent alcohol-related readmission. INTRODUCTION It is estimated that up to 30% of all hospital admissions are alcoholrelated, and that 75% of these admissions are due to chronic disease. [1,2,3] The approximate cost of alcohol misuse to the National Health Service is £3.5 billion per year [3], 45% of which is spent on inpatient care. [4] Alcohol-related readmissions place a significant burden on the NHS. An audit of patients with alcoholic liver disease in a Glasgow hospital found that 75% were readmitted an average of 3 times over 1 year, for 12 days per admission. [5] Readmissions may be unavoidable due to chronic illness, or potentially preventable. Preventable readmissions can have medical (suboptimal primary and/or secondary healthcare causing a relapse or exacerbation of the illness), patient-related (poor self-management) or social (lacking a stable support network or accommodation) causes. [6] Despite posing a substantial problem, the reasons and solutions for alcohol-related readmissions have not been sufficiently investigated. Although the National Institute of Health and Clinical Excellence (NICE) has issued guidelines on managing alcohol misuse [7], their implementation and effectiveness varies in clinical practice. An audit was undertaken comparing the in-hospital care of patients with alcohol-related admissions against the published NICE guidance for the management of alcohol misuse. METHODS The audit was approved by the hospital audit committee. A retrospective audit was conducted in a district general hospital in the South West using patient case notes. The audit population was 190 alcohol-related emergency admissions in a 6 month period (September 2012- February 2013). Readmissions that were classified as ‘non-preventable’, and were therefore excluded, were presentations of: oesophageal variceal bleeding (2), decompensated ALD (1), semi-elective readmission for nasogastric feeding following chronic pancreatitis (1) and a GP referral due to continuously deranged liver function tests following an overdose (1). Of these excluded readmissions, the first four were considered non-preventable as they were due to the natural course of these chronic progressive conditions, and the fifth was an unresolving biochemical problem. The audit criteria were developed based on NICE guidance, and were audited for the first admission for patients with preventable readmissions (Table 1). Targets were 100% for all criteria. Patients with a fixed abode were assumed to have stable accommodation.

63-3 FINAL.indd 52

On completion of the audit, an additional exception for criteria 4, 5 and 6 was that one patient was transferred to inpatient mental health services after admission.

Table 1. Audit criteria and exceptions Audit Criteria (Standard Statements)

Exceptions

Duration of inpatient stay (first admission and readmission) Was the patient considered for referal to a psychiatrist?

No comorbid mental health disorder

Was a formal alcohol withdrawal assessment tool (CIWA-Ar) used throughout the hospital stay?

Not withdrawing

After successful withdrawal, was a Not withdrawing pharmacological or psychological Not in hospital long enough to intervention offered? complete withdrawal Was a community-based intervention (e.g. GP referral, community mental health services, Addiction Recovery Agency etc.) for promoting abstinence/moderate drinking offered? Was stable accommodation arranged before discharge?

Self-discharges without stable accommodation

RESULTS Of the 190 admissions studied, 10.5% (20) were readmissions, 75% (15) of which were preventable (Table 2). The following results refer to the 15 preventable readmissions. Patients were readmitted a median of 2 times. The median length of stay (LOS) was 5 days for the first admission, equivalent to the average inpatient LOS in the UK, and 3 days for each readmission. 40% of patients selfdischarged during the first admission, after a median LOS of 4.5 days. During the first admission 42.9% of patients with a mental illness were considered for referral to a mental health team. The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) was used on 80% of withdrawing patients. After successfully withdrawing, pharmacological and psychological interventions were not offered to

2014 63:3

28/03/2014 11:24

Figure 1. Compliance for criteria

100.00%

100.00% 90.00%

80%

80.00% 70.00% 60.00% 50.00% 40.00%

57.10%

42.90%

30.00% 20.00% 10.00% 0.00%

Referral to a psychiatrist

CIWA-‐Ar

Community-‐based intervention

any patients. 5 patients left hospital (due to planned or self-discharge) before withdrawal was completed. 57.1% of patients were offered a community-based intervention to reduce their alcohol intake. Patients were discharged with stable accommodation in 100% of cases. DISCUSSION This audit has illustrated that a number of alcohol-related readmissions may be preventable. Opportunities to intervene and reduce preventable readmission were missed, and the NICE guidance poorly followed. It is difficult to ascertain why only 42.9% of patients requiring mental health input were referred, despite the hospital employing a mental health liaison nurse. This may have been due to a lack of identification of mental illness or a lack of a system for referrals. Alternatively it may have been decided that mental illness was due to alcohol misuse, and would resolve after withdrawal. If this were the case, steps to encourage recovery from withdrawal and monitor mental health after withdrawal would be essential. However, withdrawal was not adequately monitored in 20% of cases. The CIWA-Ar is integral to the management of alcohol withdrawal as it monitors its severity and guides medication. Without it patients may not have had the medical management required to help them avoid the physical and psychiatric complications of withdrawal, leading to future readmissions. It is important to note that 30% of patients presented with unplanned withdrawal in the first admission, and 80% of these patients were then readmitted for the same reason. Readmissions could be reduced by monitoring patients during withdrawal, and discharging them with a plan for support within the community or referral to specialist services. As there is a high self-discharge rate in withdrawing patients, due to the unpleasant effects of withdrawal, interventions should be provided within a certain timeframe. Only 57.1% of patients were offered a community-based intervention. NICE guidance states that patients who are informed of these services should be actively supported and encouraged to use them. [7] It is important to offer this information since the motivation to recover, and the aims, methods and stage of recovery varies between patients. The introduction of a designated staff member, such as an alcohol liaison nurse, with the skills and resources to support and motivate each individual patient could prevent readmissions. Although it is positive that stable accommodation was ensured in all cases, it was difficult to assess the level of stability for accommodation

2014 63:3

63-3 FINAL.indd 53

Pharmacological or psychological intervention after withdrawal

Stable accommodation arranged before discharge

based on patient notes – although patients with a fixed abode were assumed to have stable accommodation, this is not always the case in reality.

From the results of the audit, there are many areas for improvement in managing alcohol misuse during the inpatient stay and post-discharge planning. In the literature, several treatment models for alcohol misuse have been proposed. A few include chronic disease management (case management, integration of services and personalised followup) [9], alcohol care teams [10], and assertive community treatment with long-term telephone contact. [11] Although cost-effectiveness has been considered for these models, the evidence for their effectiveness is sometimes questionable [10] and there is a lack of comparison between models. Taking aspects from each model and the results of the audit, we propose the introduction of the following care pathway. (Figure 2). A patient that that has an alcohol-related admission is assessed for withdrawal using CIWA-Ar. This ensures appropriate treatment of withdrawal and allows identification of serious complications. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire is then used to identify alcohol misuse. [12] Patients misusing alcohol are referred to the Inpatient Care Team (ICT). The ICT consists of a care co-ordinator, mental health nurse, alcohol liaison nurse and social worker. They provide a Package of Care (PoC), which aims to enable implementation of NICE guidelines. [7] Since all audited patients who self-discharged did so within 4.5 days, the PoC is executed within 4

Table 2. Causes of preventable readmission (number of patients) Medical (13) Intoxication-related (7)

Social (2)

Withdrawal-related (6)

Falls, musculoskeletal Withdrawal only chest pain

Return after absconding

Alcohol overdose +/other drugs

Seizures

Lack of independence at home

Hyponatraemia

Fall

Non-compliance with medication

Mallory-Weiss tear

Acute-on-chronic pancreatitis

28/03/2014 11:24

days of admission. The ICT can address the issues identified from the audit. A compulsory mental health review by a mental health nurse would identify and refer those patients requiring psychiatric care. The alcohol liaison nurse serves to assess the motivation of the patient and provide appropriate information on community-based services. They may also discuss pharmacological and psychological interventions for those who have successfully finished withdrawing. In conjunction with the patient and doctor the appropriate interventions in hospital, and referrals following discharge, are agreed upon. The social worker serves to assess the support network and stability of accommodation ready for discharge. The care coordinator oversees these processes and identifies any lapses in care.

In conclusion a high proportion of alcohol-related readmissions are preventable, and we have identified missed opportunities to reduce these. We propose that the cycle of preventable readmissions could be broken, and the NICE guidance better met, through implementation of our ideal pathway. Our pathway ensures appropriate in-hospital and post-discharge care, giving patients the best chance at recovering from alcohol misuse.

Figure 2. An ideal care pathway

After discharge, there are currently large regional variations in the availability and waiting times of specialist alcohol services. [1] Therefore a community care team (CCT) is formed. This consists of the same members as the ICT, plus specialist psychologists and psychiatrists. The CCT engages with all patients with alcohol-related admissions; it can provide an opportunity to intervene in patients who were unwilling to engage with the ICT and those who self-discharged from hospital in less than 4 days. If interventions are delayed, the CCT can provide appropriate therapy (assisting withdrawal, psychological and pharmacological therapies) for the first 30 days post-discharge in a communitybased day centre. [7,13] Our pathway is limited by the potential for its abuse by patients who may delay recovery to benefit from efficient mental health and social services. Other healthcare services may delay interventions and increase the burden on the CCT. Incentives for limiting waiting times for entering specialist services are required. There is also an ethical dilemma. Is it justifiable to increase resources for a pathway that requires high numbers of staff, organization, and funding for a subgroup of patients who are unmotivated, disengage from treatment, and may not recover? When considering the extensive consequences of alcohol misuse on the patient, their families, society, the healthcare system, and the economy at large, it does appear to be justifiable. Full references available at: www.omsg-online.com

Lihini Wijeyaratne, fourth year medical student at the University of Bristol REFERENCES 1.

1. National Treatment Agency for Substance Misuse. ALCOHOL TREATMENT IN ENGLAND 2011-12 [Internet]. 2012 [cited 28th June 2012]. Available from http://www.nta. nhs.uk/uploads/alcoholcommentary2013final. pdf. 2. The British Society of Gastroenterology and Bolton NHS Foundation Trust . Alcohol Care Teams: reducing acute hospital admissions and improving quality of care [Internet]. 2011 [cited 28th June 2012]. Available from http:// www.alcoholpolicy.net/2011/09/alcohol-careteams-qipp-to-reduce-acute-hospital-admissions-and-improve-quality-of-care.html. 3. Eastwood P. Statistics on Alcohol: England [Internet]. 2013 [cited 28th June 2012]. Available from https://catalogue.ic.nhs.uk/publications/public-health/alcohol/alco-eng- 2013/ alc-eng-2013-rep.pdf. 4. NHS confederation. Too much of the hard stuff: what alcohol costs the NHS [Internet]. Jan 2010 [cited 28th June 2012]. Available from http://www.nhsconfed.org/Publications/Documents/Briefing_193_Alcohol_cost s_the_ NHS.pdf.

63-3 FINAL.indd 54

5. Heydtmann M. Alcohol and hospital readmission (1). Clin Med. April 1, 2010;10(2): 201

6. Purdy S. Avoiding hospital admissions. What does the research evidence say? [Internet]. 2010 [cited 28th June 2012]. Available from http://www.kingsfund.org.uk/sites/files/ kf/Avoiding-Hospital-AdmissionsSarahPurdy-December2010.pdf.

7. National Institute of Clinical Excellence. CG 115, Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence [Internet]. February 2011 [cited 28th June 2012]. Available from http://www.nice.org.uk/nicemedia/ live/13337/53190/53190.pdf 8. Ward D, Murch N, Agarwal G, Bell D. A multicentre survey of inpatient pharmacological management strategies for alcohol withdrawal. QJM. 2009;102(11): 773â&#x20AC;&#x201C;80 9. Saitz R, Larson M, LaBelle C, Richardson J, Samet J. The case for chronic disease management for addiction. J Addict Med. 2008 June 1; 2(2): 55-65.

10. 10. McLellan AT, Hagan TA, Levine M, Mey-

ers K, Gould F, Bencivengo M, Durell J, Jaffe J. Does clinical case management improve outpatient addiction treatment. Drug Alcohol Depend. 1999 Jun 1;55(1-2):91-103. 11. 11. Passetti F, Jones G, Chawla K, Boland B, Drummond C. Pilot study of assertive community treatment methods to engage alcohol- dependent individuals. Alcohol. 2008 Jul-Aug;43(4):451-5. doi: 10.1093/alcalc/ agn025. Epub 2008 Apr 24. 12. 12. Review of the effectiveness of treatment for alcohol problems. The National Treatment Agency for Substance Misuse [Internet]. 2006 [cited 28th June 2012]. Available from http:// www.nta.nhs.uk/uploads/nta_review_of_the_ effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf 13. 13. The National Treatment Agency for Substance Misuse. Models of care for alcohol misusers (MoCAM) [Internet]. 2006 [cited 28th June 2012]. Available from http://www. alcohollearningcentre.org.uk/_library/BACKUP/DH_docs/ALC_Resource_MOCAM.pdf.

2014 63:3

28/03/2014 11:24

CROSSWORD 63(3)

GLOBALISM 1

9 10

17 20

23 24

Cover FINAL.indd 2

26/03/2014 10:59

OMSG 63 (3)

OMSG 63 3

WWW.OMSG-ONLINE.COM

Cover FINAL.indd 1

GLOBALISM

BLOOD MONEY 4

THE WAY WE TREAT 19

SPIN DOCTORING 8

THE SECOND STRUGGLE 20

BATTLE SCARS 10

ONLINE LEARNING 30 26/03/2014 10:59