Evidence

I am sooooo overworked these days. So I'm doubling up on responsibilities. Today's post is actually a preview of my MicroSoft Small Business Forum column:


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Recently, I attended a scholarly conference on the topic of evidence-based decision making. For those not in the know, "evidence" has been a hot topic in all areas of physical, medical and now social and political science for many years now. The idea is that one should base one's decisions on the best available information, rather than on other, presumably softer, criteria.

It might be surprising to many lay people to learn that Evidence-Based Medicine, or EBM, was fairly revolutionary when first introduced a few years ago. The assumption that most people make is that medical therapies, supposedly rooted in the rigour of Western science, is informed by clinical observations in controlled surroundings. For the most part, they are. But a large part of an individual doctor's decisions about his patient is also based on personal experience, or anecdote, and the personal experiences and hearsay of his teachers and colleagues.

The conference pitted two seemingly opposing viewpoints against one another. On one side was the hard science argument, that good evidence must always be at the core of decisions, especially decisions made by government in response to important phenomena, such as the appropriate policy responses to medical crises. The H1N1 pandemic is a good example.

On the other side was a proponent of the so-called "precautionary principle", which holds that sometimes it is not possible to wait for sufficient evidence to make a fully informed policy decision. Rather, sometimes it is incumbent upon policy makers to act within a milieu of great uncertainty.

Arguments about the degree of evidence required to justify official action are themselves tainted by ideologies. Climate change is a good example. Those convinced that the phenomenon is real (and I count myself among that number) hold that the evidence is sufficiently convincing and the threat is sufficiently dire that the precautionary principle holds: we must act now and not wait until 100% are on side. The deniers would argue that we must wait until every last scientific hold-out is on-side.

But ultimately it is a false dichotomy. First of all, pitting "evidence" against the "precautionary principle" is misleading because the first involves a discussion about the nature of scientific rigour, while the second is a discussion of the nature of decision making.

Second, and most interesting to me, is that the discussion is ultimately a non-starter. Cynics (and again I count myself among them) would argue that decisions are almost never made with evidence prominently in mind. Rather, policies --especially those stated by governmental bodies-- are more likely to be informed by values, ideologies, politics and utility. Only after those avenues have been exhausted do decision-makers turn to the evidence, and then usually it is to justify a decision that has already been made.

I cannot estimate the extent to which this process is also prevalent in the business world, but I would not be surprised to find evidence getting short shrift there, either. But is this really a problem? I hope to explore this in a later segment.

Nothing To Do With Skin

As some of you are aware, I'm the new editor of the national newsletter of the Canadian Society for Epidemiology and Biostatistics (CSEB). The first issue with me as editor was just published this morning. The newsletter is only available to paying members, but I am reproducing the first feature article here:

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Nothing To Do With Skin
By Raywat Deonandan


I remember well the first time I saw an epidemiologist on a movie or TV show. It was the creepy 1995 John Carpenter remake of the classic British horror flick, Village of the Damned. In the film, Christopher Reeve heroically tries to understand why all of his town’s children are blonde and demonic and possibly alien. At one point, the entire town goes unconscious simultaneously, long enough to attract the attention of the CDC (Centres for Disease Control), who send an epidemiologist to investigate.



A sveldt Kirstie Alley plays Dr. Susan Verner, a tough no-nonsense outbreak investigator who arrives –get this—brandishing a badge and a gun and leading a battalion of policemen. Ahhh, thought I, this is the career for me! Aliens, guns, badges, excitement, action... why doesn’t every young person want to be an epidemiologist?

A more serious portrayal of the outbreak investigation aspect of epidemiology was presented in the 1995 film, Outbreak, in which Dustin Hoffman played a military epidemiologist studying a new, weaponized type of haemorrhagic fever. He not only carried a gun, but also had a helicopter! The famous stills from the film include Hoffman in the biocontainment “spacesuit” that so many lay people now falsely associate with epidemiology. I’ve been trying to buy one on eBay ever since.



And, really, this is the crux of society’s misunderstanding of our science: their conflation of epidemiology with virology and other bench sciences. We all have stories of being introduced at parties as an epidemiologist, and being met with uncomfortable silence, or worse, medical questions about skin rashes. For the last time, epidemiology and dermatology are different sciences! (I’ve been toying for some time with the idea of writing an epidemiology-for-the-masses manifesto called, “Nothing To Do With Skin”!)

A former professor of mine was once held at the US border as inspectors searched her luggage for “possible dangerous insects” after she self-identified as an epidemiologist. All the border guard could hear, apparently, was “entomology”. And I’m surprised that people don’t regularly ask me about the origins of words. (That’s an etymology joke, by the way.)

Now, Village of the Damned and Outbreak were both released over a decade ago. In the interim, we’ve seen real epidemiologists all over the mainstream media in the wake of such emergencies as the SARS outbreak, the Walkerton disaster and last Fall’s H1N1 pandemic. Surely, the media has learned some sophistication in the mean time?

Well, one of my favourite current TV shows is Fringe, which is an American science-fiction program about weird science and its intersection with crime. In one episode, someone was systematically murdering “epidemiologists” by infecting them with a virus that that grows to the size of your head. Yes, a single virus the size of your head. Leave aside the fact that such a thing would physically have to be multi-cellular, and therefore not a virus, and we’re left with the disappointing realization that once more the media has confused epidemiology with a bench science; because every murder victim on the list of “epidemiologists” turns out to actually be a virologist or microbiologist.



Yes, I know that some epidemiologists actually are lab scientists, as well. And even more epidemiologists are also physicians. But most are not, at least not in this country. So who is responsible for the failure of society to appreciate the role and contribution of the population epidemiologist? The lowly cubicle jockey with his SAS licence and penchant for odds ratios needs his day in the sun.

Our contributions are profound and dramatic, after all. It was epidemiologists who figured out how to address AIDS at the population level, long before the HIV virus was discovered. It was epidemiologists who eradicated smallpox from the face of the Earth. It’s epidemiologists who regularly figure out where governments should best apply their dwindling health care dollars, and which vaccines to manufacture, and whether something that appears serious really is serious. But you know the drill; I’m preaching to the converted here.

Maybe the responsibility is ours? Maybe we need to engage the world more openly and actively and push for our worth to be acknowledged and our function accurately portrayed? I recall fondly one of my favourite New Yorker cartoons, in which a party hostess is congratulated by her friend, “And it was so typically brilliant of you to have invited an epidemiologist.”



Well, I thought I was doing my part some years ago. I advised a script-writer for the Canadian TV show ReGenesis on some protocols for outbreak investigation and infection control, in order to make the content of the show more reflective of real life. ReGenesis is (supposedly, I’ve never watched it) about bioterrorism and the brave, shiny and young crime fighters and scientists who take on global biological evildoers.

To thank me, the writers created an extremely minor character who would be an epidemiologist and who would be named after me. This new, accurately portrayed Dr. Deonandan would only appear in one or two episodes, but would at last be a fairly representative example of Canadian epidemiology. Better yet, I was promised, she would be female and really quite attractive.



As an enterprising, self-obsessed, heterosexual man, I began to wonder whether I could engineer a new DSM diagnosis, based on me, for someone who is sexually attracted to his own fictional portrayal on television. Some sort of “trans-media narcissism”?

Imagine my disappointment when the Dr. Deonandan of TV turned out to be, not only male, and not only a physician, but a surgeon. Yes, a surgeon-epidemiologist. I’m sure such a thing does exist, and I’m sure they are superstar intellects who do extraordinary niche research. But it’s not exactly the representative portrayal of the population epidemiologist I was hoping for.

Sigh.

So what’s the lesson here? I’m not sure that there is one, except that maybe we should never expect our media to accurately portray any profession and any aspect of science. And that maybe we epidemiologists need to take a more active role in promoting the details of our work, responsibilities, skills and accomplishments to greater society.

Munk'd

A few days ago I hunkered into a lecture hall at the University of Ottawa to watch the most recent Munk Debate, this time between the teams of Nigel Lawson & Bjorn Lomborg vs Elizabeth May & George Monbiot, streamed live from Toronto. Had I known the debates could be accessed from the web, I would have stayed home to watch it with several strong glasses of port. But no....

The topic: Be it resolved, Climate Change is Mankind's defining crisis, and demands a commensurate response.

Nigel Lawson came across as a fussy old fuddy-duddy, underinformed and full of ideological bluster.

Elizabeth May I've never really taken a liking to, given her screechy delivery and overly confrontational demeanour. However, she at least said the one thing that needed saying: that these four are the not the experts; the scientists are the experts. This lack of true expertise hindered further substantial debate, I think. She is a lawyer/politician. Lawson is a journalist/politician. Monbiot is a journalist. And Lomborg is a statisition cum self-promoter.

George Monbiot has been a favourite figure of mine for some time. What an eloquent, passionate and well informed speaker. His website's earlier incarnations were actually the model for the direction my own website eventually took, so I admit to having a slight bias for all things Monbiot. Having said that, even the great George came across as slightly unscientific, given his background as a journalist. His famous self-imposed travel ban, meant as a gesture to encourage minimal carbon footprints worldwide, was suspended for this special occasion, allowing him to physically be in Toronto. I always felt this self-restriction to be a bit precious, if you know what I mean.

Bjorn Lomborg, meanwhile, is no stranger to this blog. I have discussed him in the March 5, 2004 post, the Jan 14, 2005 post, the Aug 31, 2007 post, and the Oct 17, 2007 post. In short, I detest everything Bjorn Lomborg stands for. I will not mince words here. The man is insidious and, in my opinion, simply for sale. His landmark book, The Skeptical Environmentalist, was the Climate Change denier's bible for years, effectively used as ammunition to slow down change on the policy front.

In recent months/years, Lomborg has begun to rehab his reputation. He no longer denies that Climate Change exists, is a big deal or is human-caused. This is rather convenient, now that the book has made him insanely wealthy and positioned him as a preferred champion for the anti-Climate Change business sector. There is speculation, implied by May during the debates, that his position earns Lomborg a pretty penny. Instead, Lomborg's new mantra is that:

(a) there are more important things we can be focusing on; and
(b) since we don't seem to be making headway on Climate Change, why not apply these energies and monies to --I dunno-- eliminating poverty or disease?

On the face of it, this is not a bad position to have. Indeed, his position seems to have won over many in the audience. The debate statistics show that public response was thus:



In essence, more people changed their minds in favour of the Lomborg/Lawson position than in favour of the May/Monbiot position.

Apparently, Time Magazine once listed Lomborg as one of the most important 100 intellectuals in the world, according to his intro during the Munk Debate. This surprises me, given his brazen anti-intellectual behaviour during the debate itself. Lomborg's position, as I summarized above, is fundamentally untenable, and I'm afraid May and Monbiot did a poor job of explaining this to the audience. It comes down to this:

It doesn't matter that poverty and disease remain as plagues upon the world. Climate Change exacerbates those things, making them increasingly worse. And it doesn't matter that pro-environmental legislation slows down economic development. What is the point of creating wealthy nations if there's no food or water left to buy with your newly created wealth?

These were the basic aspects of environmental and health science poorly conveyed during the debate. I proudly commented afterward that I'm certain my undergrad students could have debated Lomborg into a corner, given how much I've tried to encourage them to think in terms of interrelated networks and systems.

Let's look at Lomborg's claim that we are better off tackling global health than Climate Change. The world needs to understand that many of the problems in global health are either as a direct result of Climate Change, or will be exacerabted beyond repair as a result of Climate Change. As Stephen Lewis once commented during a live address in Ottawa, "I fear we are looking at an Apocalyptic event."

When Monbiot (or was it May?) commented that Climate Change makes HIV/AIDS worse, Lomborg gave us his theatrical hands-in-the-air disbelief pose. "How is that even possible?" he demanded to know. Sadly, only Monbiot bothered to explain a mechanism, but only told part of the story. The incident, though, causes me to ask whether Lomborg is really so uninformed (causing me to wonder how Time would dare list him among the world's top intellectuals) or is he instead disingenuous. If the latter, then he is insidious and dangerous indeed.

Monbiot's mechanism was basic: Climate Change is causing droughts, which forces men off the land and into the company of prostitutes, hence spreading sexual disease, including HIV. In truth, it's more than this. Drought leads to poor nutrition, which prevents proper uptake of the anti-viral drugs that treat HIV (which need good nutrition to work properly). Environmental collapse causes economic collapse and produces more disease issues, further overwhelming healt care systems and prventing a society from addressing its HIV epidemic.

The ecology of much of the developing world, including sub-Saharan Africa, which has the greatest HIV burden in the world, is already operating at the margins. The crops there already subsist at the very edge of tolerance for temperature and humidity perturbations. With Climate Change comes more dramatic perturbations and thus a certainty of widespread famine in those regions.

No amount of structural adjustments, as Lomborg champions, will give such nations the economic might to overcome such famine, not when most of the region is similarly affected.

In short, unlike crises in the past, Climate Change represents humanitarian challenges that one cannot buy one' s way out of. Again, you can't buy water that does not exist. In response to Lomborg's assertion that human societies will develop adaptations, Monbiot powerfully retorted (and I paraphrase): in these parts of the world, the only adaptation is the AK-47.

There are many other mechanisms by which Climate Change exacerbates health, and thus wealth. Among them:

The changing of vector behaviour. Mosquitos and their like determine their ranges by temperature and humidity. As these factors change, the nature of related diseases will also change.

Water quality. Because rivers are changing paths and rainfalls are misscheduling, the predictability of the safety of drinking water is uncertain. Already, 2 million deaths a year, mostly among young children, are due to diarrhea, directly caused by unsafe water. WHO estimates that today 2.4% of diarrheal deaths are due to climate change. (WHO uses very conservative methods to reach these estimates.)

Changing agriculture. Agriculture is affected by temperature, precipitation and soil quality. According to a 2008 article in Science: southern Africa could lose more than 30% of its main crop, maize, by 2030. In South Asia losses of many regional staples, such as rice, millet and maize could top 10%.

Migration. There is a long established intersection between migration and health. The sudden stress of large numbers of people is ecologically bad. Environmental refugees must be fed, sheltered and cared for, and the world has a poor track record of caring for mass migrants. According to a 2007 article by Christian Aid: "The growing number of disasters and conflicts linked to future climate change will push the numbers far higher unless urgent action is taken. We estimate that between now and 2050 a total of 1 billion people will be displaced from their homes."

Insecurity. Ecological collapse can cause war. According to a 2007 report by The Pentagon:
Global warming constitutes a security threat to the USA, as there will be wars based on diminishing fresh water supplies, refugees, and higher rates of famine and disease.

Economic effects. Less money means less spent on health and poverty reduction. As an example, according to a 2008 article in the American Journal of Preventive Medicine, Coral bleaching can lead to collapse of the world’s fisheries in a matter of decades.

Air pollution. One US model predicts that by 2050, due to global warming, ozone-related
deaths will increased by 4.5% and there will be 60% more alert days.

Heat waves. According to WHO, heat deaths in California alone will double by 2010.

Natural disasters (floods and storms). According to WHO, flooding will affect 200 million people by 2080.

Here is an interesting little graphic showing deaths due to Climate Change in the year 2000, almost a decade ago. The truth today is much more daunting:



There are a lot more data and many more details. There is no dearth of studying on the topic. I don't know how anyone who's familiar with even a fraction of the data can conclude anything other than Climate Change is indeed the single most important crisis facing humanity now and in the next two centuries. More than the threat of nuclear war, and possibly on par with the threat of direct cometary impact, runaway greenhouse affect might very well drive civilization itself into the dust within our lifetimes.

In Praise of George W. Bush....?

Image stolen from BBC News

Ever read Maximum City? It's one of the best non-fiction books I've read in decades. It's about life in Bombay (Mumbai). I had the pleasure of meeting its author, Suketu Mehta, a couple of years ago in Ottawa. There, we talked about a scene in the book in which Suketu is given "one hit for free" by the leader of India's biggest organized crime syndicate. That's right: he's got a coupon for one free assassination. When asked to whom the crime lord should turn his attentions, many thoughts in the room flirted with members of the outgoing Bush administration.

(Very important disclaimer, for any members of US security reading this: I advocate violence against no one, not the least of which a sitting US President. So please don't send scary men with guns, body armour and baseball caps to my door.)

Fast forward to 2009 with Bush gone and the saviour Obama in his place. Much has been expected of Obama and, I must say, the fellow has not quite delivered. This is particularly true for US involvement in global health and development initiatives around the world.

So it was with great interest that I invited superstar epidemiologist Ed Mills to give a guest lecture in my 4th year global health class this past week. I knew Ed would drop the following bombshell on the students, that no one has done more for HIV/AIDS victims in Africa than one George W. Bush. The man is a hero in sub-Saharan Africa. And while Obama has personal, familial, political and racial connections to Africa, the current President has actually dialed back some of Bush's more impressive accomplishments in the region.

As summarized in this blog post, it was largely through Bush's PEPFAR program (President's Emergency Plan for AIDS Relief) that he effected what appears to be widespread positive change. Apparently, after a $15 billion investment, the AIDS mortality rate in 12 of the 15 targeted PEPFAR countries (the other 3 were outside Africa) declined by 10.5% over 5 years.

Even Bob Geldof said of Bush's commitment to AIDS: "There are no votes in helping the poor of Africa, but Bush did it anyway."

In the words of Dustin Dehez:

"[George Bush] elevated development assistance to Africa to a serious foreign policy field. Indeed, due to Bush's Africa policy, development now complements the other two d's: diplomacy and defence. Under his leadership development assistance has more than doubled from a marginal 10 billion to more than 22 billion. And his anti-AIDS programmes have fostered progress in countering the disease, indeed they are ideal types of how bureaucratic hurdles can be bypassed to make development assistance more effective. Like it or not: In Africa President Bush saved thousands of lives."

Here is an African voice singing similar praises. How did Bush achieve this feat? Mostly by allowing his investments to focus on ARV (anti-retroviral) access. There are all sorts of barriers to poor HIV stricken people accessing these life-extending drugs, some of them valid and others less so: patent protection driving up drug prices, distribution challenges, lack of trained personnel to dose them accordingly, suspected poor adherence to the drug regimen, poor food quality diminishing the drugs' ability to be absorbed, the inability to store them long term in a tropical climate, local corruption preventing free and easy access, and so on. PEPFAR funding, it seemed, succeeded to some extent in overcoming these barriers.

But hold on.... is all this praise really well founded? It's based, after all, on the assumption that declines in AIDS mortality rate have to do with PEPFAR monies. Leaving aside the always present problems with assigning causation, are the mortality data even accurate?

I don't know. But Mead Over seems to think they are not. As Over details in this article, the mortality data used to pronounce the glories of PEPFAR were based on UNAIDS projections. This is a widely performed and acceptable strategem, since such data are slow to return. However, Over suggests that in this case the data are inappropriate for evaluating PEPFAR success.

Then there are ethical issues with PEPFAR in general. The conditions for receiving PEPFAR money include the inclusion of abstinence as a pillar of prevention and refusal to fund needle-exchange programs. Both conditions were lifted in 2008, but after years of implementation.

In addition, PEPFAR only funded branded drugs, rather than cheaper generic drugs, but started allowing the latter after 2005.

Full criticism of PEPFAR is available here, and an easy to read description of PEPFAR can be accessed here. Obama is continuining the program, but with a few changes.

So what's the bottom line here? Is George Bush the saviour of Africa? Well, I don't think it's wrong to acknowledge that the man seemed to care a fair amount about the plight of HIV victims in Africa, and managed to push through policy directives which, while flawed and beset with ideological caveats, nonetheless managed to improve the lives of tens of thousands of people. For that, he should be applauded.

But let's not forget that Bush also disassembled many civil liberties domestically, pushed his nation into the deepest debt it has ever seen, started two fruitless wars, invaded a country that posed no threat to him or his people, lied repeatedly to his citizens, and, according to at least one study, is responsible for the deaths of half a million Iraqi children.

Give the devil his due. But let's not ignore the horns.

Will The Work Never End?

What is this? Tow blog posts in two consecutive days? It's like the old days, no?

For the second consecutive year, I also attended the opening cocktail party of the Harbourfront Festival of Authors. Remember last year's photo? Here's the new one:



Before I forget to bring this up, I stole the following from Graham S.'s Facebook page:



I also found an old letter of recommendation I wrote on behalf of myself, to be signed by my former boss. I was just checking to see if he actually read it:




I'm working like a mad man trying to get stuff done before catching a train to tomorrow in the morning. I was in Toronto this morning, Ottawa the day before, and Toronto the day before that. Yes, I know. I know.

Oh, it gets better. I'll be up all night doing paperwork, then off to the Canadian Conference on International Health at 8:AM to hear Jeff Sachs speak, then hop on the train, then rush to a Board meeting at Harbourfront Centre in Toronto, then rush to the opening ceremonies of the Canadian Conference on Science Policy.

This is the sort of rushed, stressful schedule that can make you sick. Might even allow you to contract the flu! (Nice segue, eh?)

Following up from yesterday's post, here's a graphic from InformationIsBeautiful.net:



It's yet another attempt at providing evidence for the anti-vaccination crowd. See, according to this graphic, the current H1N1 pandemic is no big thang.

Let's consider this an educational moment. Can you see the problem with using this graphic, assuming it is correct, as an argument against the seriousness of H1N1? It's the difference between absolute and relative measures.

Here's an example of what I mean: if you hear that the incidence of cholera in Alberta doubled between 2007 and 2008, that sounds pretty serious, right? "Doubling" is a relative measure. But what if I tell you that the number of new cases went from 1 in 2007 to 2 in 2008? Yes, it doubled, but the actual number of additional cases was one. That's an absolute measure.

To beat this dead horse, it's clear that if media and policy makers relied on the relative measure to inform their decisions, a lot of emotional and financial resources would be misspent.

Now, for the graphic above, it's important to look at the denominators. The case fatality rate is a relative measure. According to it, SARS was a much bigger deal than H1N1 (swine flu), about a 19.2X increase in mortality rate.

However, the number of people who actually contracted SARS in Toronto in the 2003 outbreak was a mere 358. If we believe the graphic's 9.6% case fatality rate statistic, this translates to 35 deaths in absolute terms.

In absence of the seasonal vaccine, seasonal flu would be contracted by tens of thousands in Toronto. Assuming an infection denominator of a conservative 10,000 unvaccinated people, that translates to 100 deaths in Toronto alone due to seasonal flu.

See the point? The absolute measure provides more meaningful information.

Okay, I've got work to do now. As you were.

That Vaccination Question Again

(Writing this on my mobile phone in the Porter Airlines lounge in Toronto, so please forgive the typos.)

In any given year I receive a handful of emails from random strangers wondering whether they should get vaccinated against certain diseases. With the current H1N1 pandemic, the emails now come weekly.

In the elevator of my spanking new condo last week, I was privy to a conversation between two 30-something construction guys, both of whom had decided to eschew the flu vaccine.

The thrust of their argument was, "I never used to get sick. Last year was the first time I got the flu shot, and I got sick." So, according to this reasoning, it's the flu shot that made them sick.

I kept my mouth shut, but I hope the spuriousness of this logic is clear to most people. Spurious logic was best described in The Simpsons, when Lisa told Homer, "It's like me claiming that holding this rock protects me from polar bear attacks because when I hold it, no polar bears attack me."

"Lisa, I'll give you 20 bucks for that rock!"

The spuriousness here is the association between getting the flu shot and becoming ill. The fellow probably got sick from the common cold and mistook it for the flu. Whatever the reason, there is no mechanism by which one can get the flu from the flu vaccine: the vaccine does not contain live or whole viruses.

The question of risk always arises. The human animal, it seems, is incapable of feeling its way through risk and probability. Decisions are made emotionally rather than logically.

After 9/11, for example, people were afraid of the "risk" of flying, so turned to the "safety" of driving. Driving is actually much more dangerous than flying, so I suspect that the excess deaths due to traffic accidents increased in the post-9/11 period. (I'm writing a paper on this now, so stay tuned.)

The risks of the flu vaccine in general, and the H1N1 vaccine in particular, are, in my opinion, inflated by the media. A small number of people with egg allergies will have serious reactions. Most people with egg allergies know who they are. About 1 in a million may suffer Guillain-Barre syndrome, which is serious indeed. A hefty number will experience soreness and maybe 24 hours worth of flu-like symptoms just after the injection. The overwhelming majority of recipients will experience no effects whatsoever.

Do keep in mind that no vaccine is ever 100% effective. Remarkably, the H1N1 vaccine is proving to be about 90% effective, which is actually better than the regular seasonal vaccine. This means that some people will get the flu despite being vaccinated, and may mistakenly think the vaccine gave them the illness.

The H1N1 vaccine comes with something called an adjuvant, which is just something that boosts the immune response. As far as I can tell, it's just vitamin E, polysorbate (a typical food emulsifier) and even some shark liver oil. Some people have freaked out about the latter, but there's no evidence that it's bad for you.

Perhaps the biggest nonsense surrounding the flu vaccine, and vaccines in general, is their supposed link to autism. I do not see any convincing evidence for this. The one study that drew a connection was poorly done, and has since been debunked many times over. This is the way that real science works. I've talked about this before here, here, here and here.

One commenter put the risk question this way: yes, I suppose the flu vaccine carries some risk. But in terms of severity of that risk and extent of that risk, actually getting the flu is much worse. Conclusion: get the bloody shot.

Keep in mind that every year in Canada, literally thousands of people die from the regular flu. Worldwide, thousands more have died from H1N1. So far in Canada, almost a hundred people have died from H1N1, and hundreds more are seriously ill. I have students who have taken leaves of absence due to serious complications from H1N1.

But how many have died from the vaccine? How many typically die from the vaccine? The number is trivial, if it exists at all. Almost all people who get influenza vaccine have no serious problems from it. Nonsense like this and this don't help anyone.

Let's keep the risk of H1N1 in perspective. Depending on who you are, there's a chance you will not be exposed to the virus. If you are exposed, there's a good chance you won't get the disease. If you get the disease, it is very unlikely you'll get seriously ill. Most likely you'll end up in bed for a few days, miserable but recovering. So not getting the vaccine probably won't be too bad for you.... Mostly due to something called "herd immunity".

Herd immunity is when your unvaccinated ass is protected by everyone else's more responsible behaviour. The logic is that you are less likely to be exposed to the disease because all your friends took the time to get the vaccine. Dumbasses who regularly crow about they don't need to get vaccinated because of their "strong immune systems", evidenced by the fact that they rarely get ill, need to understand herd immunity. Their illness free status may have little to do with their innate superhuman status and more to do with the fact that the rest of society has chosen to be disease resistant.

A small percentage of people who get H1N1 will actually get seriously sick and possibly die. Children are particularly at risk because it seems that we old folks have some sort of partial immunity after having weathered so many flu seasons.

But really, why would you want to be home sick for a week? Why would you want to even risk being home sick for a week? Why not save yourself that little bit of Hell with a simple jab in the arm? More importantly, why risk the lives of the children in your life? If you don't want them to be vaccinated, at least get vaccinated yourself so you don't infect them!

This speaks to a wider societal concern that I hope to write about in the future: society's growing anti-intellectualism and anti-science stance. We flock by the millions to unproven therapies, like reiki or whatever unscientific nonsense Suzanne Summers is selling on TV. But many of us refuse to believe that humans walked on the Moon, despite it having been broadcast on live TV and within living memory. The singular triumph of our technological civilization is denied by a generation tragically divorced from this hard-won heritage of reason's victory over the darkness of brutish ignorance.

Vaccines are the victim of their own success. Their triumph was too easy, too profound to be valued by our generation inured to things "too good to be true". People don't think they need the rubella vaccine, for example, because they've never seen anyone with Rubella. You know why you don't see Rubella? Because people take the Rubella vaccine.

There are those who vocally denounce modern vaccinations as useless and dangerous science propaganda. I'd like to take them in a time machine to Canada 150 years ago, when every neighbourhood had people dead from Measles, Rubella, Smallpox and, yes, the flu. Screw the time machine, how about any number of communities in the global South?

We in Canada are a spoiled lot. We have free, socialized medicine. How incredible is that? We had months of forewarning about the H1N1 pandemic. Our medical infrastructure responsibly kicked into high gear, acquiring for us a sufficient stockpile of high tech vaccination against the pandemic --in mere months! That vaccination is being rolled out all across the country today, absolutely free of charge.

Think about that for a second. In the history of humanity, this is such a rare boon. Pandemics of all stripes have decimated societies and civilizations. Our modern civilization found a solution and implemented it, free of charge and in record time. it's available to us today. What would have shut down society 100 years ago is but an inconvenient trip to the flu clinic today.

And yet there are significant numbers of people today who will not only eschew this boon but will vocally denounce those who accept it and those who provided it.

With every crisis, humanity continues to prove to me that it's too stupid to deserve survival.

I will reiterate that everyone has a choice whether or not to seek vaccination. Your choice is your choice. But, as in all things, you are responsible for the consequences of your choice. I don't need to spell out those consequences, or potential consequences, for you.

The technique of modern vaccination is a veritable gift from science. Like all things, it comes with some risks and with variable effectiveness. But how wonderful is it to have the option? How blessed are we? Never forget that or take it for granted.

And as for those who make the simply retarded argument that the flu vaccine is a ploy by big pharama to make money, I beg you --nay, I implore you-- to stick to your guns when you contract H1N1 and are admitted into the hospital's ICU. Please, refuse to accept those antibiotics, antivirals and steroids that will be needed to save your life since, as you probably know, they too are created by "big pharma to make money".

End of sermon.

Update:

Some have pointed out to me that there is no data about the vaccine's safety in infants or pregnant women. This, to my knowledge, is true. The overwhelming medical opinion appears to be that there is no convincing reason to suspect that it is not safe for these groups. However, I would certainly understand if a pregnant woman, or a parent of a child with a developing brain, was hesitant about exposing the infant/fetus to a potential mutagen. If those individuals choose to not become vaccinated (in the case of the pregnant woman) or to not vaccinate their infant, then I hope they would at least advocate for all adults in the vicinity to get vaccinated. I fail to see a strong argument for a non-pregnant adult to eschew vaccination.

Related:

From today's Globe and Mail:

"Refusing to get vaccinated is selfish" by Juliet Guichon and Ian Mitchell.

"Canadians have a free choice. But they also have responsibilities: not to act as agents of flu dissemination, and to minimize their burden on the health-care system. To perform these obligations, they need to act positively, developing two kinds of literacy.... [scientific literacy and statistical literacy]." -Editorial

Spinal Therapies

The quest to reverse/cure/control my degerenerative lumbar disc disease continues. Last time I talked about my experience with Bowen Therapy. I haven't tried anything new yet, but I've been poking around for other options. Among them is non-surgical spinal decompression therapy, using a device called the DRX-9000.

I'm quite skeptical of medical claims made my companies with no formal association with recognized clinics or hospitals. However, this therapy appears to have no negative downside, so I am considering it. My physiotherapist is rightly skeptical of its claims, as well, but agrees that it cannot hurt me. The worst that could happen is that I experience no change, and would be out a chunk of change.

Well, it's more than a chunk of change. From what I gather, the DRX9000 programme requires about 20 sessions, each costing about $200. It's essentially a system of controlled, sustained traction. Sounds rather comfortable, actually.

Being a medical scientist, I first turned to the published literature to see what studies had been conducted on the device's efficacy and safety. I've only found this one so far, "Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review" by Macario et al at Stanford. Here's the abstract:



The chart review study --which is not the most rigorous design, admittedly-- indicates cause for optimism with respect to the DRX9000. So I'm a tad excited.

Further research led me to a product called NuCore:



NuCore is essentially an artificial gel that is injected into the disc as part of a surgical procedure. The gel hardens into a consistency comparable to that of the natural disc, providing support for the otherwise hardening and shrinking disc. Its trials are making the news in the USA, as this Fox News broadcast indicates.

As far as any reputable research goes, I've only been able to find this study from Switzerland:



The long and short of it is that this study is also optimistic about NuCore's potential, but only as an adjunct to the traditional surgical procedure of microdiscectomy.

The plot thickens. Stay tuned, my droogies.

The Bowen Technique

Wooden fish, stolen from donj.co.uk

I got my MRI results back this week for my chronic lower back issues. Ready? Apparently I suffer from multilevel degenerative disc disease, which essentially means that several of my intervertevbral lumbar discs have slipped out and are impinging on nerve roots and even the spinal cord. There may be physiotherapeutic solutions, or maybe some more exotic surgical interventions, but the likely eventual path in the long term is spinal fusion surgery.

So of course I freaked out. My condition is likely the result of both genetics and a history of abusing my body through decades of high impact sports. Some people want to blame my recent reliance on chiropractic treatment. But I started those well after symptoms had already appeared. Maybe chiropractic adjustments worsened my condition or maybe they made it better or maybe they did nothing at all. Hard to say. I will agree, though, that my various chiropractors should have better diagnosed my condition earlier on.

The bottom line is that I immediately started looking for other options. Spinal decompression therapy looks interesting, both non-invasive and surgical. A discectomy might be an option, as well. I've already tried traditional massage, acupuncture and Tui Na massage, with negligible results. And I've made an appointment with an osteopath, but from what I gather he won't be doing anything more than what my excellent physiotherapist already does. (So stop emailing me, you osteopath zealots!)

Today I took a stab at Bowen therapy. This youtube clip summarizes the "scientific" rationale underlying the Bowen approach. I tried it mostly because there's no possible down side, no contraindications, and it was a good way to spend a morning.

I arrived with curiosity but trepidation, given the therapy's popularity amongst the sandal-wearing set. My fears were not allayed when the therapist started using that most detested of lazy words: "energy". Zod knows I hate it when New Age types use that word in a non-physics context. The therapy involved some extremely light touches followed by minutes left alone for me to contemplate the touches. The therapist then returns after these intervals to ask about my sensations.

When I say "light touches", you must understand that it was so slight and seemingly meaningless that it was like being tapped on the shoulder or accidentally brushed by a passerby on the bus. This was supposed to be physical therapy?

To be honest, I found the process sort of silly. But I decided to give it a fair shot and enjoy the time alone and horizontal with my thoughts and odours. Surprisingly, things started to happen. In response to the "treatments", I had some random muscle twitches, then my pinkies went numb, and my left elbow just spasmed outward! Somewhere along the line, my breathing patterns shifted noticeably. I even stopped breathing entirely at one point; but didn't find it alarming at all, just interesting.

Then a really weird thing started happening. I started to hallucinate! With each "treatment" --which, remember, just involved some light poking on the knee or scalp or something-- I received a vivid waking dream. At one point I was staring intently through a window and could not look away. At another, I was following a long thin tube intensely through a building's ventilation system. In another "vision" I was --get this-- wrestling a giant wooden duck. Immediately afterwards, I was swimming in an ocean of wooden fish. In the final and most intense hallucination, I was falling towards the right. I hope the last wasn't a premonition of an upcoming political shift.

I don't know what it all means --if anything. Maybe I was dehydrated from my morning workout. I do know that this particular drug trip was cheaper without drugs. For that reason alone, I will try it again. I still don't believe in any New Age "energy" nonsense. But I do believe in neurology, and I believe the neurological explanation offered in the video above might --just might-- have some credence.

I will also add this: it's now 3 hours later and I'm mostly pain free. Mind you, I haven't moved or stressed my body at all, so who knows what that means.

You're Fired!....Guv'nor.

Cousin Ajay sends us this. Is funny:




Cousin Ajay also sends us this, with the comment that he fears it might turn kids retarded:



Cousin Ajay is on a roll. (It's a figure of speech; he's not actually riding bread.) He also sends us Helen Keller's twitter feed. Go look.

Special Ed sends us Captain Kirk's Best and Worst Moments. (Yes, it's the real Kirk, not this new poser.) The list is missing the bit where Kirk has nasty Captain sex with the hyperfast accelerated woman who can kill him with a scratch, yet somehow manages to avoid any and all abrasions. That's skill.

Special thanks to Dr Qais Ghanem for hosting myself and Dr Robert Huish on Dr Ghanem's radio show last Friday. Hopefully the MP3 of the interview will be posted very soon.

A further thanks to the organizers of the CSEB student conference this weekend for inviting me to be a judge in theit epidemiology poster competition. Ironically, this weekend I also judged a literary contest with co-judge Shanthi Sekaran. Shanthi's new book is getting a lot of attention; I can't wait to read it.

What am I doing now? Procrastinating. How? By watching the UK version of The Apprentice. Man, I love this show! Well, I love most things British. It's so delicious watching Brits argue. Their turns of phrases sound so cute and alien to me that it's impossible for me to get too emotional about it, only highly entertained. And I love that their equivalent of Donald Trump, Sir Alan Sugar, is an enormous prick who doesn't take shit from anyone, and whose firing decisions appear to be both consistent and justified! What a change!

Okay, back to TV...

The Hum

Has anyone heard of this very weird global health phenomenon called "The Hum"? Very weird. Apparently, hundreds of people around the world --typically around certain geographical loci (in Canada, cases are clustered in Vancouver, for example)-- are being driven crazy by a very low frequency humming noise that no one else can hear.

You can listen to a simulation of the sound here.

And this fellow claims to have recorded The Hum here.

Pretty weird, huh? Several explanations have been proposed, running that gamut from medical to environmental to psychological.

Hmm, maybe it's a precursor to spontaneous human combustion? Who knows? Well, the BBC reports that there is now some evidence that the culprit might be oversensitive hearing.

In Other News...

Today's Daily Perv Link (TM) is brought to us by Russians in Florida. How can that combination spell anything other than WIN?

More About The Swine That Flew

One of Google Image hits from a search for "sick pig"
Yesterday's Swine Flu post got a lot of attention, and I'm still fielding many questions. The Maytree Foundation's DiverseCity Voices project, of which I'm a member, issued the following blurb on their e-alert today:

"From the Swine Flu to SARS, global health specialist, professor, author and journalist Dr. Raywat Deonandan is available for comment on the societal and public health impacts of infectious disease outbreaks."

As of today, the global distribution of Swine Flu cases looks like this:



Unsurprisingly, the cases are clustered in North America and in other OECD nations, which suggests two things: cases are still predominantly people who have traveled to Mexico; or, cases in non-OECD nations have not been detected due to lesser surveillance methods. I do hope it's the former.

After my very calming and conservative post yesterday, I thought it best to now talk a little about the potential threats posed by the disease. This seems reasonable, given that President Obama has announced $1.8 billion to protect Americans from the flu, and that California's Governor Schwarzenegger has declared a state of emergency in his state, for the purposes of receiving more funds for pandemic preparation. Indeed, I'm sorry my back condition prevents me from attending the City of Ottawa's pandemic forum next Tuesday, where their pandemic preparation plan will be unveiled and discussed.

Our PM Harper has declared that we in Canada are doing all we can to prepare for pandemic flu. I believe this is true. Canada has one of the better flu response plans among OECD countries. Our experience with SARS forced us to take this seriously. One of my consulting gigs was to help the CPHA develop an educational plan for family doctors regarding pandemic flu, and another looked at whether a certain class of drugs could be used as prophylaxes in the case of widespread outbreaks. Canada has some pretty good protocols in place, including management and legal frameworks to fast track into production vaccine shots for every Canadian. In fact, we keep a steady supply of hens and eggs just for this very task. (Flu vaccine is incubated in chicken eggs, which is why people with egg allergies should avoid them.)

Even with all this excellent preparation, it's important to note that a vaccine is only possible once the virus strain has been adequately identified, and assuming it's not mutating so fast that a vaccine no longer has any traction. Moreover, vaccine production takes weeks, if not months. Add to that the time for packaging, distribution and the time for the recipient's biological response to the vaccine to take effect, and it's clear that rapid vaccination production is not a perfect solution for a very fast moving and lethal airborne pathogen.

See, this is a big deal. Kind of. Even if nothing comes of this infection, to be prepared for a big one is vital. We've all been waiting for the return of the 1918 Spanish Flu. Heroic efforts by the much maligned WHO have quashed several potential pandemics of avian flu over the years. But you just never know which pandemic strain will be the one that takes that important mutative step to become a worldwide plague. So it's best to always err on the side of caution --but not of panic.

This is sort of why everyone is freaking out. Let's remember that the 1918 Spanish flu simply devastated the developed world, and was very much unlike our annual flu pandemics in that it was taking out people in the prime of their lives (20-44 year olds). Usually, the flu only has a fatal effect on the very old, very young, or the weak. The current strain of swine flu appears to have the same demographic preference... which is not to say that the old and weak are safe, but rather that the young and strong are a little more vulnerable than they (we?) currently believe ourselves to be.

This has implications for care, as hospitals may tend to not treat young, healthy people for flu symptoms, and focus on the elderly and infirm. This may in fact be a cause of some of the heightened fatality rates coming out of Mexico: it's a function of care, not of disease virulence.

For the last couple of decades, we've been obsessed with avian flu from East Asia being the likely candidate for the Next Great Pandemic. H5N1, as it is called, has a serious fatality rate (about 50% of humans infected die). But outside of a few poultry farmers, the disease has not managed to mutate its way into the general population. That H1N1, pig based, from Mexico has jumped into the milieu kind of took everyone by surprise, even though the same bug freaked out the USA in 1976. There is strong evidence that the 1918 Spanish flu was also of the H1N1 variant, but is not the exact same disease.

What then am I trying to say? Again, I stress calmness. With only a handful of cases in this country, all contained and mild, there's no reason to fear your neighbour. BC has reported the first human-to-human transmission in this country, which is not a good thing. But the excellent public health platform of that province has it under wraps.

What we should be worried about, I believe, is whether this strain of H1N1 makes it East Asia or the more crowded centres of the Middle East. There, if it infects someone who already has been exposed to a variant of H5N1, then there emerges a chance that the two strains will swap DNA and become something significantly more virulent. Or not.

So in many ways, we are lucky that the disease has found footing first predominantly in well developed nations, where public health infrastructure can best help to stomp into out, lest it seep into the well of more H5N1 endemic zones.

Fascinating, no? Let's keep watching to see what happens. For a better discussion of the issues than I can provide, check out this article.


In Other News...

Apparently Barbie has turned 50. Darth Vadum sends us this appropriate video of this new era of Barbie's life:

Cougar Barbie


Meanwhile, Cousin Ajay sends us the following tasering video. Warning: you will find this either really hilarious or really disturbing, or both. A flamboyant naked man resists policemen's orders to clothe himself, then physically resists their attempts to cuff him, so they tase him publicly and repeatedly:



It's an interesting case. On the one hand, he really was physically resisting the lawful orders of police. On the other hand, at the end of the day, he was tased for being naked. Is being naked worthy of a tasing?

Of course, the real story here is why is a man with the smallest penis in the world so eager to display it to everyone?

Lastly, you've probably noticed that I've disabled the Daily Twitter function on this blog. I'm going to try to post Weekly Twitter updates manually instead. Hope that'll stop all yer whinin'.

Back When Swine Flew

I'm an epidemiologist, a word derived from "epidemic", which means that I'm supposed to know something about diseases. This past week, several people have approached me for "expert" commentary on the emerging swine flu pandemic. The university has asked me if I'm comfortable enough with the topic to field inquiries from the media, and the Maytree Foundation has asked me to offer an official statement, also for media digestion. As well, concerned friends have been asking for advice on how to protect themselves.

I'm wary of misrepresenting my expertise. A few years ago, I wrote an article for The Toronto Star called "Are We Overdue For A Pandemic?" It garnered so much attention that CBC Newsworld invited me to go on-air to be interviewed by Evan Solomon. Uncharacteristically responsible, I told them that I am not a flu expert, but rather a global health generalist, and that I could only discuss the issue on those terms. They thanked me for my honesty and retracted the offer.

The same day, CanWest Global called with a similar offer. I told them the same thing. The producer then asked me, "Are you good looking?"

"Um," I said, "My mother thinks so."

"Can you be controversial?"

"Sure," I said, thinking about all the penis jokes I could offer.

"Then come on down!"

So I went down to the Global "studios" in Ottawa to be interviewed remotely by Bruce Dowbiggin in Hamilton. It was quite a farce. I was on with Donald Low and a couple of other experts in what quickly devolved into a WHO-bashing session. The "studio" was me standing in the middle of the Global TV offices, alone with an unmanned camera and a wonky microphone and earpiece, with no local producer or technician to guide me, and no monitor to show me what was going on in the Hamilton studio, but with a buzz of unconcerned office drones scribbling away behind me in their cubicles.

My audio cut off early into the segment, and I spent the rest of the time looking like a mute doofus, tapping my ear in frustration. After 15 minutes of that, with no one telling me whether the segment had ended, I just took off my earpiece and went home.

I don't think I'll be doing Global TV again anytime soon.

Thus, with the current flu panic, I am loathe to stretch my expertise too thin, lest I find myself knee deep in another media travesty. Having said that, I thought I'd put up one token blog post to summarize what little I know about the current swine flu epidemic.

If you're an old codger like me, you may remember the first big swine flu scare in 1976. Panicky public health officials convinced President Gerald Ford to push for a widespread vaccination programme across the USA, for fear that another 1918 pandemic was imminent. (The 1976 virus was believed to be closely related to the 1918 strain). Well, the side effects of the vaccine --predominantly Guillain-Barre Syndrome-- ended up hurting more people than did the flu itself.

For history's sake, here's a PSA from 1976 advertising the swine flu vaccine:



The current strain of swine flu is a new strain that, I believe, is unrelated to the 1976 variety. Today we have reports of the first death in the USA, while Canada's tally holds at 13 cases, but no fatalities.

These numbers are to be expected. They are the result of travelers returning from the endemic zone of Mexico. As far as I can tell from news reports, there have been no cases in Canada of someone contracting the disease from someone who has just returned from Mexico. This means that the system is working as it should: those returning from Mexico with the disease are being quarantined and treated... for the most part.

The fatality rate thus far is about 5-7% (which is actually higher than the 2.5% rate of the world-changing pandemic of 1918). Also, the cases in Canada have all been of the mild variety, which means there is a reasonable expectation of full recovery for each case. This is not the Bubonic Plague. In other words, if current controls are kept in place, there is every expectation that our very thorough and professional public health infrastructure will keep civilization quite safe from this disease.

Having said that, it is too late to fully contain the disease. It is already among the population. But its mildness suggests that most people contracting it will recover on their own. Flu viruses tend to mutate very quickly. If an individual is infected with several viruses simultaneously, those viruses may swap DNA and become something new. With more infections in the population, there is an increased chance of a virus mutating into something really lethal... or into something quite banal and barely noticeable.

Let's not forget the killer bees scare of the 1970s. Back then, there was genuine panic that as the killer bees migrated north from Brazil, they would destroy scores of people, animals and infrastructure as they went. But as the interbred with tamer species, by the time they reached the northern climes, they were barely noticed. The same is always possible with varieties of influenza: with greater mutation and DNA exchange, there's always the chance the predominant strain will be something quite manageable.

Every flu pandemic is compared to the 1918 Spanish Flu, which killed so many people in the prime of their lives that it is thought to have contributed to the stoppage of World War I. As the current swine flu is actually more fatal than the 1918 variety, there is cause for concern. But the world today is much different from that of 100 years ago. In terms of disease threats, we now have a great many more people, each of whom represents a possible vector for disease. We also have a lot more international travel and a lot faster travel. This means that a voyage from Mexico City to Toronto actually takes less time than the incubation period for most diseases --a far cry from the situation in 1918.

On the other hand, we also have a great many advantages today. We have a remarkable communications infrastructure, which allows us to know of outbreaks everywhere in the world, pretty much as it happens. Combined with our much more advanced public health system, we caqn then theoretically marshall resources rapidly in preparation for anticipated stressors on our health care system.

Lastly, today we have technologies for treating the flu which were not available in 1918. In Canada, our hygiene options are much greater than they were 100 years ago when many more people lived in agricultural environments with limited access to fresh water and indoor plumbing. We have hospitals with quarantine protocols and the experience of SARS to guide us. And we have superdrugs, like neuraminidase inhibitors (that I did some work on), which can serve as both prophylaxis and treatment for many varieties of influenza.

So it looks as if we are in a very good position to avoid a major influenza pandemic.

Frankly, though, I don't know. No one knows. The next few days will tell the tale. Is the epidemic outside of Mexico dying off, or is it yet to fully manifest? I think it's foolish to give an opinion one way or another.

As for what we can do to protect ourselves, just do what your mother told you: wash your hands, sneeze into your elbow pits, don't touch your face or mucous membranes before washing first, avoid extremely crowded areas (like sporting events, theatres, etc) and keep yourself in good health to maintain a robust immune system. You can do the latter by practicing good daily health: eat fresh foods, particularly fruits and vegetables; enjoy moderate exercise regularly; get lots of sleep; drink lots of fluids; avoid stress; practice basic hygiene; and avoid unhealthy products like alcohol, tobacco and preservatives.

Oh, and don't worry about pork products. That's just ridiculous. The food chain is safe from this particular disease. I avoid pork for an entirely different reason: eating pig is just gross.

The Biggest Loser

Well, I broke my carb embargo in spectacular style today, as Ed and Meiling Wong once more stupefied us with unbelievably delicious (and a tad fattening) brunch food. The lady of the house makes something particularly yummy and life-shortening called "monkey bread", which we devoured with such voracity that I'm pretty sure we'll all need insulin shots within the week.

That means I lasted about 6 weeks of an extremely low carb existence. Mind you, I've been sliding slowly back to the land of breads and sugars this past week, with the unavoidable Christmas drunkenness and the occasional bite of cake. But otherwise I've been pretty strong. I feel pretty gross right now, though, and need to wash it all back with a litre of Metamucil!

The gastric adventure coincided with my first exposure to an episode of The Biggest Loser, that American reality show in which a bunch of fat people compete to lose pounds. I found the show ver very troubling. Here are a few observations:

• The show advances the belief that most fat people are just mentally weak. While I certainly subscribe to the school of thought that most people lack discipline, and that discipline is one of the surest paths to success in almost all aspects of life, there is a bit of wiggle room when it comes to extreme weight gain: mental health issues, metabolic diseases, poor nutritional education, insufficient access to proper foods and scheduling demands that prevent proper shopping and exercise among them.
• I suspect that the show deliberately selects for contestants whose weight issues are discipline based, allowing them to promote their boot camp mentality and further propagate the above belief.
• The show promotes weight loss as the end all and be all of fitness. This is perhaps the most dangerous of its failings. It's easy, for example, for a large muscular man to lose weight quickly. If he focuses on aerobic activity and ignores hydration, he will drop muscle mass and water weight very quickly. This is not healthy weight loss. There are many more acceptable metrics of progress:

1. Inches (or centimetres) around the waist.
2. Pinchable fat at the belly, hips and triceps.
3. Body tissue electrical resistance, a proxy measurement for body fat ratio.
4. Body mass index.
5. Energy levels and psychological disposition.
6. Serum cholesterol, blood pressure, arterial inflammation and cardiac enzymes.
7. Clothing size!
8. Physical fitness benchmarks

So far, I am not impressed by this show. Maybe I'll give it a few more viewings.

Last Night In Guyana

Reclining in the Tower hotel, digesting rum and Chinese food, watching CNN and blogging on my phone.

Today we zipped out to Kaieteur Falls near the Brazilian border. It was my second time, but no less fun. Kaieteur really is a natural wonder of the world.

I just realized that Venezuela is going to the polls soon, as Hugo Chavez bids for an end to term limits and gives credence to American charges of dictatorship. I am reminded of a drunken Amerindian we encountered in Kamarang a few days ago. He was ranting about Chavez's virtues,
particulary of how Chavez is, in his opinion, the champion of the the oppressed against the Americans and the "white people".

The big news today, however, is a follow-up from yesterday's farce. The transportation of the two patients, resulting in a car crash, made page 2 of the newspaper this morning. The article reported that "there were no injuries", completely missing the point that these two Amerindians, flown in from the bush for medical care, have been doubly traumatized in a world they do not understand.

When one of our number, Bekkie, went to see them at the hospital, she found a pathetic, tiny woman with a bruise on her face and a pain in her chest and no one tending to her needs. Her husband with the hip issue had been more-or-less cared for, but she had been admitted with minimal care.

In fact, she had not been fed in a day, and no one had offered her clothes or a towel. It seems the hospital only feeds you if you have your own plate. So Bekkie bought her a new nighty, a cup and plate, and a towel.

These people are impoverished, traumatized and have no one to care for them. In many ways, it would have been better for them to have stayed in the interior and suffered with their illnesses. As the Amerindians say, people come to the city hospital to die.

I am sadly reminded of the snake bite woman who was flown here and who died of the bite. Her final hours must have been horrific, spent alone and terrified in an unfriendly, dirty and alien place. It would have been better to leave her to die in her village, surrounded by love and care.

This place needs advocates for the poor and remote. Soon.

Return to Georgetown

Greetings from the lobby of the Hotel Tower in Georgetown, Guyana, where I am miraculously able to access free wifi (while mosquitos eat me alive).

What a day.

Last night, I craved rain. So a local taught me a rain summoning chant: "Mike mike musawa!" I repeated it three timesd and the heavens split open to crap down a river of unending rain. In the morning, I washed in the raised and blackened river, as nameless flotsam floated by.

I presented my snake boots to our boat captain as a gift, and was immediately beset with personal requests for more boots from everyone else in the vicinity. One 10 year old girl, who claims she wants to be a scientist, implored me, "You must remember us!"

We left Waramadong on schedule at 7:30 am on an emormous bark canoe. But this time we took with us an old man with a broken hip, who had to be lifted on in a sling, his wife, a woman with a broken arm, another abused woman with human bite marks on her arm, her baby, another woman and her baby who suffers from a strange flaccid paralysis, and a random selection of rivergoers.

Arriving in Karamang at 9:30, we were abashed to find the weather disfavourable for an aerial pickup. We lingered for hours before our two bush planes could land. Most of us, and our bags, left for Georgetown in the first plane. But two (thankfully not me) stayed behind to carry the man with the broken hip into the second plane.

You need to understand that these are remote river folk. None of them had ever been in a car, let alone an airplane, before. And now they were being compelled to fly to the nation's only city at a time of great medical distress.

Well, most of us arrived in good order and headed to the hotel to wash up. The second plane, however, was delayed 2 hours. Upon arrival, no ambulance was available to take the man with the broken hip to the hospital. Instead a station wagon was found for him and his wife, while the others went on to the hotel in another taxi.

Both vehicles took the same route. But the hotel bound vehicle was stopped because of an accident up ahead... the station wagon had crashed! The man with the broken hip was thrown forward. His wife crashed through the windshield, earning an enormous hematoma on her face. A miscreant from the crowd then attempted to steal their meager belongings. The taxi, too, was totalled, removing the sole source of income for the driver. (There is no real insurance here.) In one brief moment, three lives were altered, possibly permanently.

You also need to understand what a nightmare Georgetown public hospital is. People will attend to your basic medical needs. But no one will ask about your emotional disposition or if you understand the system or if youu have a place to go. There is plenty of tragedy to go around.

Last Day In The Interior

Once more I am huddled in my tent in Waramadong village on the Kamarang river, a distant stone's throw from the Venezuelan border, frantically squishing monstrous and nameless jungle bugs like the big sissy that I am. Outside, a torrential downpour is sending the river into frenzies as gorgeous sheet lightning frames the otherworldly flat mountains near the Venezuelan border.

Today was our last working day in Guyana. Tomorrow morning we are scheduled to pack up our tents and take a motorized canoe downriver to Kamarang, whence a bush plane will fly us the two hours to the capital city Georgetown.

But what an eventful day it has been.

While we are indeed cut off from phones, tv, most radio and all internet, news still travels astonishingly fast. Remember the poor woman who was bitten by a snake? The one whom a colleague and I had to carry up 30 feet of stairs from her canoe to the clinic? She was flown to Georgetown with her worried husband a few days ago. Today we learned that she died there.

My heart goes out to her and her family. The government pays for aboriginals to be flown out for medical care, but not for their return. The impoverished husband is now all alone in the "big" city without people who speak his dialect, facing enormous amounts of racism, and possibly without any way to get himself or his wife's corpse back home.

We had another snake bite victim right here in Waramadong. But thankfully, after spending a night in the health post (where we have cast our tents), this morning he walked home on his own power.

When I get home, I really must look into some way to get antivenin made and stored locally here.

We also made our final --and biggest-- presentation today, this time to 400 high school students. Once again, I pretty much winged it, but it went well. Half way through our condom demonstration, however, we were ordered to move on to another topic!

Which brings us to today's real drama. In the wee hours, the local principal came knocking with 2 women in tow: one a mother, the other her 13 year old daughter who had been impregnated by an older man. For some weird reason, the mother ran out to fetch the purported father, and a whole little Maury Povich show erupted in our little camp. My kingdom for a paternity kit!

I'm not sure what was resolved, if anything. But the lesson here is that these communities need counselors, community organizers (Gobama!), condoms and a greater intervention by the law.

To bed.

Another One?

Today was our first full day in Waramadong village, a remote riverbound Amerindian community notable for its gorgeous boarding school of 300-400 high school students who have been shipped in from around the region.

Guess what? We have another snake bite victim: a middle aged man with three fer-de-lance (labarria) bites on his leg. He's resting in the adjacent room right now.

There's something idyllic about a place where everyone, young and old, says good morning, good afternoon and good evening, and where children --at least outwardly-- are content to be children.

Problem is that there's a little epidemic of teen sex going on here, which is where we are targeting our message. Enter the great bugaboo of this kind of development work: the community is very religious (Seventh Day Adventists) and are forbidding us from giving out condoms because, "condoms encourage them to have sex."

People, they're already having sex! Let's at least stop them from getting diseases and babies!

Today was punctuated by a surreal meeting with the headmaster and the entire faculty, which lasted well into the blackness of the unlit night, wherein all of their frustrations with the "White man's world" and development strategies to date came to light. I found myself giving them strange advice: to take control of their situation, to start their own epidemiology projects in order to sue for government support with real data, and to take the initiative in documenting their own heritage, particularly dwindling knowledge around medicinal plants.

But we must acquiesce to their wishes. So tomorrow I will speak to 300 high school kids about condoms... While not providing any.

Up The River Without A... Toilet?

Greetings from Waramadong (hope I spelled it right.) I am encased in a tent inside the health centre as a bat and all manner of bizarre insect crash against my thin tent wall, and outside a much needed tropical rain finally begins.

This is a community 2 hours upriver from Kamarang, populated entirely by Amerindians, and serviced only by the bark canoes that laze up and down the Mazaruni and Kamarang rivers. There is no electricity or running water here, so I suspect I may have to crap in the woods. Sigh.

The snake bite woman was evacuated from Karamarang to Georgetown this morning as I gave my outdoor talk to adorable school kids. I hope she will be all right.

We are in poisonous snake endemic zone right now and I have decided to donate my boots to the community when I leave.

To bed.

What? No Ghost?

Well, it turns out my fellow travellers are not very observant. There really was someone else on the plane with us-- our cook. So no, there was no ghost.

I do have a more serious story to tell, though. This evening, well after sundown, word came that an Amerindian had arrived with a snake bite. Three of us rushed to the landing where we carried a tiny aboriginal woman from a bark canoe up 30 feet of steep steps to the clinic.

She had been bitten by a labaria --fer de lance-- 24 hours earlier. Standard bush medicine had been applied: advil and an antibiotic. That's pretty much given for everything.

She's presently lyng in bed across the way from us while her worried husband sits by her side. All our doctors could do for her was to give her steroids and antihistamines and hope for the best. We'll know in the morning.

Ghost On A Plane

Greetings from Kamarang, a community of 350 people, mostly aboriginal, set up explicitly to service the mining industry. The only contact with the outside world is via satellite phone (yes, I called my mother yesterday), so I am storing these blog posts on my phone/pda and will upload when we return to "civilization" on Friday.

To get here, we took a speedboat from Bartica to an airstrip further down the Essequibo, then flew in two 8-seater airplanes, for about an hour, toward the southwest and the Venezuelan border.

This town is essentially an airstrip, which functions as its main street, with a police station, school, hospital, general store, two guest houses and a series of bars and houses lined up along the airstrip.

We are close to the middle of nowhere. From here, one can see Mt Roraima less than a hundred miles away. The Roraima region is among the rawest, untamed jungle in the world. Its geography dates back to the origins of the world and its flora are pehistoric. The place is so untamed that Arthur Conan Doyle was inspired by the plateau to write The Lost World.

There is raw physical beauty here, enhanced by its remoteness. The general store sees visitors speaking English, French, Portuguese and Spanish, as the mining rush sees all sorts of characters sift into the region.

There was a moment of Zen as a few of us slipped away to swim in the river. There we were, soaking in an Amazon tributary in the outskirts of the rainforest as a jungle storm rolled upon us. Later, safe in our hovel, lightning and thunder bore down upon us, and the weird and wonderful sounds of the forest berated us from all directions. This aint Kansas anymore.

The funny thing is that on the flight here, I would glance occasionally to the rear of the plane where a Black dude in a red baseball cap would wave at me. At one point, he commented how much he hates flying.

What's so funny about that? Well, it turns out that no such person was on the flight. Either I was hallucinating or saw a ghost.

Tomorrow morning I will speak to the local high school about basic biology and sex education. Wish me luck!