The Federal Drug Administration has given accelerated approval to aducanumab as a treatment for Alzheimer’s disease, while asking the manufacturer, Biogen, to conduct a phase 4 confirmatory trial. ‘There remains some uncertainty,’ according to the director of the FDA Center for Drug Evaluation and Research, ‘about the drug’s clinical benefit.’
‘Old age’, ‘senile dementia’, ‘cerebrovascular disease’ and ‘Alzheimer’s disease’ are all designations of a process of dementia that occurs in older people. The name has changed over time in subsequent editions of the International Classification of Diseases.
Cattle plague was a lethal disease of bovines cause by the rinderpest virus, an agent closely related to measles. It came to Britain from Europe in the mid 1860s and killed at least 420,000 cows. Rinderpest is not a coronavirus. Its R number is probably three times greater than that of Covid-19, and its mortality rate is much higher. But as a model it still has relevance to contemporary events.
Bill and Melinda Gates have asked for privacy after their divorce announcement, but a storm of attention seems more likely. Interest in their marital arrangements isn’t merely prurient. They are public figures and their personal lives have political ramifications. The urgent question in global health circles is what will happen to their powerhouse foundation in the wake of their split. Large amounts of funding hang in the balance.
Last April, we began to see children admitted to hospital with a new inflammatory disease. Paediatric inflammatory multisystem syndrome temporally associated with Sars-CoV-2 infection (abbreviated to PIMS-TS in the UK or MISC-C in the US) can occur two to six weeks after an initial Covid-19 infection. Many of the children will have been asymptomatic, or have had very mild symptoms, and Covid swabs usually come back negative when they present with PIMS-TS. Antibody tests might show evidence of a recent Covid infection, but hospitals are not routinely testing for Covid antibodies. The symptoms were initially attributed to other inflammatory conditions. News began to come in from other parts of the world, however, confirming that what we were seeing was a novel illness. Cases have been rising again over the last two months.
Covid-19 is not only a new nasty virus, but the techniques used in its discovery, monitoring and medical management are also new, particularly from my perspective as someone old enough to be in the highest priority group for vaccination. If the prime minister had suffered from the virus when I was a junior doctor at St Thomas’s Hospital, he wouldn’t have been treated in the Intensive Care Unit, because there wasn’t one. Residents of Lambeth with severe respiratory problems – and there were many because cigarettes were cheap and sulphurous smogs were common – were given oxygen on thirty-bed Nightingale wards, with tracheostomies if they were really sick. Monitors didn’t bleep. There weren’t any.
In my first year of secondary school, a science teacher began a lesson on nutrition by asking us to tell her what we ate for dinner so we could categorise the components of our meals into their correct food groups. She looked aghast as child after child muttered ‘chips and beans’. For some, ‘chips and beans’ was cover for something less wholesome and dependable. The teacher quickly abandoned the exercise and instead reverted to the mythical meal on the ‘food wheel’ poster Blu-tacked to the wall, a testament to our parents’ failings.
The first recorded polio epidemic was in Sweden in the 1880s, though inscriptions in Egypt suggest the disease dates back to ancient times. In 1916 the virus devastated New York and swathes of the north-eastern United States, killing six thousand people, mostly children, and leaving thousands more paralysed. Unlike other deadly epidemic diseases, such as tuberculosis, polio appeared to have no correlation to poverty. ‘Once the terror stalks, mere wealth cannot buy immunity,’ as the Ladies Home Journal put it in 1935. ‘The well-fed babies of the boulevards are no safer than gamins from the gutter from the mysterious universality of the crippling midget, once it’s on the rampage.’
In 1964 there was a typhoid outbreak in Aberdeen caused by contaminated corned beef from Argentina. Opinion among older Aberdonians is sharply divided about Ian MacQueen, the local medical officer of health. Some say he saved the city. Others say he did more damage than good. Dr MacQueen ran daily press conferences. At the beginning he said the outbreak was under control and the number of cases would be small. Then, as case numbers continued to rise, he started doom-laden talk about a second wave, and predicted as many as 40,000 possible cases. But as case numbers fell, his waves turned into a series of wavelets. At the end of the outbreak, 507 cases had been diagnosed. There were no waves, or even wavelets. Three people died, none of typhoid.
In 2004 I described the basis of attacks on the MMR vaccine as ‘unsubstantiated speculation masquerading as science’, and finished the piece: ‘I despair.’ Measles is now busier in Europe than it was fifteen years ago.
‘Chlorinated chicken’ is pejorative. Chlorine gas doesn’t come into it. The meat isn’t bleached. Poultry carcasses are washed with dissolved antimicrobials such as sodium chlorite, chlorine dioxide and trisodium phosphate. The EU banned it in 1997, not because the washes leave the meat dangerous to eat but because it might incentivise poultry producers and processors to give hygiene a lower priority. This argument was used in the 1930s by opponents of milk pasteurisation.
A recent review by scientists in Australia of 73 historical studies of insect decline concluded that insect biodiversity is threatened worldwide, and 40 per cent of insect species are threatened with extinction over the next few decades. But there is a puzzle. The classes that are declining fastest are butterflies, bees and dung beetles. No one is going out of their way to eliminate them. Other insects that we attack deliberately and for which extinction would be a cause for celebration are doing well.
Romaine lettuce in the US is currently under the cosh of a Food Safety Alert: don’t eat it, whether head or heart or baby; don’t sell it; and don’t eat ready-mixed Caesar salad, which contains it. Contamination with E. coli O157:H7 is the reason. An outbreak started in October, with 50 cases across 11 states, as well as in Ontario and Quebec, with 13 in the US admitted to hospital. The lettuce may have been grown in California, unlike the produce that caused the first romaine outbreak this year, which was grown in Yuma, Arizona. That outbreak lasted from March to June, and was the biggest E. coli O157:H7 outbreak in the US for many years, with 201 cases (96 hospitalised) and five deaths.
Health officials in Kerala have confirmed a number of deaths from Nipah virus in the south Indian state. In the Democratic Republic of Congo, there is an outbreak of Ebola. Earlier this year, a team of virologists, bacteriologists and infectious disease experts met at the World Health Organisation’s headquarters in Geneva to determine which diseases and pathogens pose the greatest public health risk because of their epidemic potential and an absence of effective drugs and vaccines for treatment and prevention. Both Nipah and Ebola are on the list. The 2018 Research and Development Blueprint, released in March, also includes Zika virus, Lassa fever (a viral haemorrhagic disease occurring primarily in West Africa), MERS-CoV and Sars – and something called Disease X.
Jeremy Hunt announced last Wednesday that as many as 270 women may have died because an error in a computer algorithm prevented 450,000 women being invited for routine breast cancer screening appointments. Stories about IT glitches will be increasingly common as artificial intelligence enables more and more healthcare to be automated. As things stand, people are still better than computers at detecting early signs of cancer on mammograms, and the neural networks currently being designed to analyse the images are intended for use as an aid rather than a replacement for human decision making. The hope is to engineer systems that combine the different strengths of humans and computers, with outcomes that neither is capable of independently. The sad reality is that we seem to end up with systems that combine an all-too-human capacity for error with a computer’s blunt force, and so wreak havoc at an inhuman scale.
The UK has the highest incidence in the world of poisonings caused by the toxins produced by E.coli O157:H7. It killed 17 people in the outbreak centred on Wishaw in central Scotland in 1996, still a world record for lethality. My involvement in attempts to stop a repeat led to an invitation to visit the Defence Science and Technology Laboratory at Porton Down. Security was impressive. The heavily armed welcome at the gate left an abiding memory. It is reasonable to guess that the Russian chemical warfare facility at Shikhany is as well guarded. The notion that nasty substances of high purity could leave it without some kind of authorisation seems highly unlikely.
The Parliamentary and Health Service Ombudsman found last month that Averil Hart, who had anorexia nervosa and died in December 2012, was failed by ‘every NHS organisation that should have cared for her’. ‘Sadly these failures, and her family’s subsequent fight to get answers,’ the PHSO report says, ‘are not unique.’ In October 2009 I went to see my GP to ask for help with my anorexia.
On receiving the 1945 Nobel Prize in Medicine for discovering penicillin, Alexander Fleming finished his lecture with a warning: ‘There is the danger,’ he said, ‘that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.’ Antibiotic resistance is now one of the biggest threats to global health, food security and development. It could kill as many as 10 million people a year by 2050.
Some reviewers of the film Goodbye Christopher Robin are saying that A.A. Milne had post-traumatic stress disorder. Yes, he was at the front during the Battle of the Somme; in August 1916 he was a signals officer there, and worked in no man’s land. But PTSD didn’t send him home. He was brought down by trench fever (bartonellosis). A bacterial infection spread by body lice (not those of the head or pubes), it causes a high fever, which repeats itself a few times every five days. It doesn’t kill, but sometimes leaves its victims feeling weak for many months. This happened to Milne. After being invalided home, he lost weight and developed fatigue, said to be caused by ‘overwork’, but much more likely due to the persistent effects of Bartonella quintana. In the early autumn of 1917 he spent three weeks at Osborne House on the Isle of Wight, then a convalescent hospital for officers.
Last summer, a young Syrian woman in Istanbul gave birth to a baby boy with a severe umbilical hernia, which required surgery. But after three months he still didn’t have an ID card, and doctors wouldn’t perform surgery without it. Songül, one of their Turkish neighbours, took the baby and his mother to all the hospitals and emergency clinics she knew of, to no avail. One hospital took a blood sample and gave them a referral for surgery, but they were turned away for not having an ID. They were told to go to the police station to get a copy of the baby’s birth certificate. They did, but the hospital wouldn’t accept it – only an ID card would do, they said.
The fentanyl crisis in British Columbia continues unabated. There were 128 overdose deaths in November, the worst month on record until December’s figures were released this week: 142 deaths. There were nine fatal overdoses in Vancouver on the night of 15 December alone. Last year, 914 people died in the province from illicit drug overdoses, an increase of 80 per cent on the previous year. (The problem isn’t restricted to Canada. According to the Centers for Disease Control and Prevention, ‘the death rate of synthetic opioids other than methadone, which includes drugs such as tramadol and fentanyl, increased by 72.2 per cent’ in the United States between 2014 and 2015. In 2013, more than 2000 people died from opiate overdose in the UK.)
The ‘much loved’ status of red squirrels in Britain probably won’t be damaged by the discovery that some of them are lepers. The finding that individuals on Brownsea Island are infected with a leprosy bacterium with a DNA sequence close to that of one circulating in medieval England seems unlikely to provoke significant concerns for public health, either. We don’t hunt, skin, eat or cuddle red squirrels so the opportunities for transmission are remote.
On 17 October 2000, four people were killed and 70 injured in the Hatfield rail crash. A high speed train derailed because of metal fatigue in a section of track that had been tagged for replacement months earlier. Railtrack, the company which had managed the permanent way since British Rail was privatised in 1994, never recovered. In 2001 it went bankrupt, more than £3 billion in debt. In October 2002, responsibility for maintaining railway infrastructure was essentially renationalised with the formation of Network Rail.
Ousainou Sarr came to the UK from Gambia more than two decades ago. For two years he experienced typical tuberculosis symptoms – weight loss, profuse night sweats, a persistent cough – but his GP never suspected he might have TB. He was living rough on the streets of London, the TB capital of Western Europe, when the Find & Treat van offering TB screening arrived. The van is a specialist NHS outreach service that aims to tackle TB among homeless people, drug or alcohol users, vulnerable migrants and ex-prisoners across the UK, by providing screening and access to care. More than 9000 cases of TB were diagnosed in the UK last year.
The announcement on 26 October that the Wellcome Trust, the Gates Foundation and the UK, US and Brazilian governments will spend $21.7 million over the next two years releasing Aedes aegypti mosquitoes infected with Wolbachia in Rio de Janeiro and Medellín is excellent news. Wolbachia, a bacterium that lives in the reproductive systems of insects and worms, is one of the commonest parasites in the world. In some of its invertebrate hosts it either kills males or feminises them. For others, infection with it is essential for fertility. Discovered in 1923 in the ovaries and testes of mosquitoes from Boston and Minneapolis, it remained an entomological curiosity for half a century before its importance began to be realised. Now it has its own website, and the Anti-Wolbachia Consortium, A-WOL, is funded by the Gates Foundation.
Last April, British Columbia’s chief health officer took the unusual step of declaring a public health emergency after 200 people died from (suspected) fentanyl overdose during the first three months of 2016. By August the number of deaths had risen to 488. This is a record high, a 61.6 per cent increase on the same period in 2015 (302).
London Fashion Week will begin on Friday, and with it comes the usual dismay about the thinness of the models and the impact of this on women and teenagers – including the models themselves. The Women’s Equality Party (founded last year) has launched the #NoSizeFitsAll campaign to challenge the UK fashion industry to do better. One of its demands is for Fashion Week to include models of UK size 12 and above. (Size 12, though smaller than average, is considered 'plus-size'.) 'The softly, softly approach has been tried for years and is not working,' the manifesto says. Well: not for women, anyway. Nearly a year ago I complained about the mannequins at the entrance of the ladies’ department in John Lewis on Oxford Street. ‘It’s nothing to do with us, it’s head office, you’ll have to fill in a complaint form,’ the sales assistants told me. A few months earlier, Topshop had been publicly shamed for its ‘ridiculously thin’ mannequins after a customer’s open letter went viral.
The 21st International Aids Conference was in Durban last week. The last time it was held here, 16 years ago, Aids denialism in South Africa was rife, people were dying on the front lawns of hospitals, unable to access treatment, and President Thabo Mbeki had announced that Aids was caused not by a virus, but by poverty and poor nourishment. A lot of progress has been made since then.
Since I wrote about Zika in February, genome sequencing has shown that the virus has three lineages: West African, East African and Asian. Analysis of a 1966 Malaysian strain and a 1968 Nigerian one point to an Asian origin for the Brazilian viruses; it is likely that Zika has been circulating in Brazil since 2013. The virus has been evolving in expected ways (its RNA genome has a high mutation rate); no change that could account for an enhanced ability to damage the brain has yet been found. None of these findings has hit the headlines.
In 2014 the prime minister commissioned Jim O’Neill to conduct a review and make recommendations to ‘defeat the rising threat of superbugs’. O’Neill’s final report, published on 19 May, predicted that superbugs could kill 10 million people a year by 2050, the equivalent of one person every three seconds, more than cancer, with a cumulative cost of around $100 trillion.
In its last week in print, the Independent carried a piece under the headline: ‘One more thing imperialism has to answer for: dysentery.’ It’s a striking statement, but is it true?
The persistence of Ebola virus transmission in Sierra Leone, Liberia and Guinea took everyone by surprise. Previous outbreaks had lasted only weeks. The World Health Organisation’s response to Zika in South America has been significantly influenced by criticisms of the speed of its response to the events in West Africa. But a recent note in the Morbidity and Mortality Weekly Report from the US Centers for Communicable Disease Control and Prevention is a reminder that the absence of virologists, public health doctors and nurses wasn’t the only reason for the size of the Ebola epidemic.
‘Around 6000 people lose their lives every year because we do not have a proper seven-day service in hospitals,’ Jeremy Hunt said on 16 July 2015. ‘You are 15 per cent more likely to die if you are admitted on a Sunday compared to being admitted on a Wednesday.’ A Department of Health statement later clarified that the figures came from an analysis ‘soon to be published in the BMJ’. Nick Freemantle, a professor of epidemiology at UCL, had been invited by Bruce Keogh, the chief medical officer, to update a 2012 analysis of hospital data, apparently on the suggestion of Simon Stevens, the new chief executive of NHS England. The resulting paper wasn’t accepted by the BMJ until 29 July, after Hunt’s speech. When it appeared in September, it contained no reference to the 6000 figure.
On 18 April 1947 in a cage on a tree platform in the Zika Forest in Uganda, rhesus monkey number 766 developed a fever. Its serum was inoculated into the brains of mice. They fell ill. Zika virus had been discovered. The sentinel monkey researchers were the virologist George Dick and the entomologist Alexander Haddow, based at the Rockefeller Foundation Yellow Fever Laboratories in Entebbe. Haddow went on to build a 120-foot steel tower in the forest to study high-flying mosquitoes and their viruses. The best time and place to find Zika virus was in the evening, 80 to 100 feet above the forest floor.
Not so long ago, I had a bicycle accident in the quarter of Camden Town that forms the background for many of Frank Auerbach's paintings. The front wheel lost its grip as I rode over a manhole cover, made more slippery that morning by overnight rain. It was bad luck, but my good luck it wasn't worse — my bike slipped away to the left, I fell to the right, my hip and chest took most of the impact, I wasn't wearing a helmet, it happened on a side street used by few cars, two people picked me up.
Shares in the Nahl Group, part of the ‘no win no fee’ legal industry, fell by 25 per cent overnight after the chancellor of the exchequer announced in his autumn statement that the government ‘intends to introduce measures to end the right to cash compensation for minor whiplash injuries’. He also said that the government would be consulting on the details and expected average savings of £40 to £50 per motor insurance policy to accrue. In 2012, the Ministry of Justice characterised the UK as ‘whiplash capital of the world’. In 2012-13 there were 476,938 claims for whiplash, making up 58.2 per cent of all road traffic accident personal injury claims. The quick jerk of the head caused by the sudden stop of a vehicle can cause real injury. But in cases of minor whiplash the diagnosis relies on symptoms alone. This is the problem.
In Yes Minister, 'one of the best run hospitals in the country' turns out to have a major advantage: it has no patients. This week, the Care Quality Commission said that the hospital I work at, Addenbrooke's in Cambridge, is 'inadequate', despite acknowledging that the care provided to patients is 'outstanding', with one of the lowest standardised mortality rates in the UK. This outstanding hospital is so inadequate that it's been placed in what are euphemistically termed 'special measures'.
The Morecambe Bay Investigation, chaired by Bill Kirkup, published its report on 3 March. ‘The name of Morecambe Bay,’ it says, ‘has been added to a roll of dishonoured NHS names that stretch from Ely Hospital to Mid-Staffordshire.’ The report isn’t about the town of Morecambe, but deals with the dreadful things that happened for nearly a decade across the bay at Furness General Hospital (FGH) in Barrow, part of the University Hospitals of Morecambe Bay Trust.
There’s been excitement this week at the announcement of a new antibiotic. Called teixobactin by its discoverers, it is produced by a soil bacterium, also new to science because it needed the development of a novel system to enable it to grow and be tested in the laboratory for antibiotic production.
The current Ebola virus outbreak in Guinea, Sierra Leone and Liberia is the biggest ever in terms of fatalities, geographical distribution and duration. A person sick with it flew from Liberia to Nigeria, the most populous country in Africa, from which many travellers arrive in the UK every day. So it was no surprise to hear that COBRA has met. Announcing that it has met is in itself crisis management: ‘We are aware of the problem and something is being done.’
Sooner or later the Brazilian football team will be treated like lepers, or perceive themselves to be so. Unfair to lepers, but appropriate for an off-pitch reason. The official World Cup mascot, Fuleco, is a Brazilian three-banded armadillo. Humans apart, the armadillo is the only animal that gets leprosy. Admittedly, the evidence refers to the nine-banded kind; it is not known whether the three-banded armadillo is susceptible. It would be very hard to find out, because the Brazilian species is very rare and in danger of extinction. Fuleco's name is a portmanteau of ‘Futebol’ and ‘Ecologia’.
Bacillus cereus has infected premature babies in London, Brighton, Peterborough, Cambridge, Luton and, possibly, Southend and Basildon. One has died. Contaminated intravenous nutritional food was the route of transmission. Bacillus cereus is everywhere. Its natural home is soil, water and vegetation, and it is found in most raw foods, particularly cereals. It produces tough spores, which are heat resistant (they survive boiling), and toxins.
A cluster of nine cases of tuberculosis in cats in Newbury at the end of 2012 and early 2013 spread to their human owners, causing serious lung disease in two of them and infection without disease in another two. Unsurprisingly, when the results of the investigation were published, it became a top news story. It would have been an even bigger one if it hadn’t had to compete with Ebola in Guinea. TB in domestic cats is not new.
At the centre of Monday night’s Panorama programme on fraud in the NHS was an interview with Jim Gee, an expert on the financial cost of healthcare fraud. Gee showed the presenter a newly published report, of which he was the first author, and talked about its findings. He turned to a key page and the camera picked out a bar chart as the two discussed some of the figures it contained. The report was also given wide coverage in the print media this week. Stories were run in all the broadsheets and across the tabloids with many local papers picking up the story and giving it a local spin. The figure, highlighted in Panorama, that most journalists seized on was the estimate that fraud was costing the NHS around £7 billion a year, enough – the Express pointed out – to pay for 250,000 nurses.
According to the front page of yesterday’s Guardian, the NHS is to start selling our confidential medical records. Every doctor has a duty to keep patient-identifiable data secure, and only share it as far as is in the patient’s immediate best interests. At the same time, in order to run healthcare organisations or to carry out medical research, it is necessary to compile statistics about diseases and treatments. It therefore makes sense for some information collected in the course of caring for patients to be made more widely available – shared with managers, bureaucrats and researchers – but only if it is anonymised.
Rukshar Khatoon, from Sahapara, Howrah District, West Bengal, has joined Saiban Bibi, a Bangladeshi beggar living on a platform of the railway station at Karimganj, Assam, and an unnamed cow grazing in Tamil Nadu, as markers of the success of vaccination programmes in India, successes which confounded all the critics. Rukshar was 18 months old when she developed paralytic polio in January 2011. Saiban was 30 when she developed smallpox on 24 May 1975. The Tamil Nadu cow developed rinderpest in September 1995. All three diseases are now extinct in India.
The UK fossil fuel extraction industry has always been dangerous for its workers, even if things are orders of magnitude safer today than they used to be. In 1938, 858 coal miners were killed in accidents, including 90 in explosions, 408 by roof falls, 194 in haulage and transport accidents underground, and 76 on the surface. Others died from Weil’s disease caught by contact with rat urine. Thousands developed pneumoconiosis, and paraplegia from roof falls was common.
Late in the evening of 6 July 1988, the Piper Alpha oil platform 110 miles north-east of Aberdeen was destroyed by two big explosions; 167 men were killed. The Cullen Inquiry found that the platform had been inspected 12 days before the disaster to check on progress following a fatal accident nine months before. The inspector had spent ten hours on the platform and concluded that ‘lessons appear to have been learned’. Lord Cullen was not impressed: 'the inspection... was superficial to the point of being little use as a test of safety on the platform. It did not reveal any one of a number of clear-cut and readily ascertainable deficiencies.’ Recent events surrounding the Care Quality Commission and the University Hospitals of Morecambe Bay NHS Foundation Trust seem little different in principle. Whatever transpires regarding the alleged cover-ups, there is agreement that the CQC should have done better as an inspectorate.
The virus in eastern China that since late February has killed 26 out of 128 confirmed cases has been officially named ‘avian influenza A (H7N9)’. Analysis of its genes shows a mixture derived from several bird flu viruses, and that the virus has been evolving for some time.
The despair I expressed nine years ago in a piece for the LRB on the MMR disaster – ‘Why can’t doctors be more scientific?’ – persists. Anti-vaccination proponents still peddle junk science with vigour. So it’s a relief to see on TV the families in South Wales queuing to get the MMR vaccine for their children. The last time citizens there queued like this was during the smallpox outbreak that started in Cardiff in January 1962; 47 people fell ill and 19 died.
The British aversion to eating horse is strong and longstanding. ‘Horse-Eating’, the lead piece in Charles Dicken’s Household Words for 19 April 1856, explains why: Prejudice, and nothing else! the same prejudice which makes the English refuse to taste frogs and escargots, though both are esteemed and expensive dishes on the continent; which makes the Orientals reject the flesh of the hog, though here we know how good it is; which causes, in short, nearly one-half the world to loathe nutriment which is greedily consumed by the other half; which has given rise to the true, but unreasonable fact, that one man’s meat is another man’s poison. The problem isn’t taste. On his last march, Captain Scott’s diary entry for 18 February 1913 read: ‘Temp -5.50. At Shambles Camp.’ Captain Oates’s ponies had been shot there on the way to the Pole. ‘Here with plenty of horsemeat we have had a fine supper... new life seems to come with greater food immediately.’ On the next day: ‘To-night we had a sort of stew fry of pemmican and horseflesh, and voted it the best hoosh we ever had on a sledge journey.’
Eliminating an infectious disease by deliberately eradicating the causative agent has happened only twice: smallpox fell in 1977 and rinderpest – cattle plague – in 2011. Polio should be next, but the murders in the last week of vaccinators in Pakistan – one in Charsadda, two in Peshawar, five in Karachi – have stopped the eradication programme. Nothing new for the Taliban, who blocked polio immunisation in Waziristan earlier this year. Things haven’t been helped by the disclosure that Dr Shakil Afridi, whose activities helped to locate Osama bin Laden in Abottabad, operated under the cover of a bogus immunisation programme run by the CIA.
With two million cases in the UK every year, norovirus exceeds all other causes of diarrhoea and vomiting by many orders of magnitude. If a malevolent person had set out to create it as the nastiest virus known, their only disappointment would be a lethality failure; the vast majority of victims get better after two or three days without specific treatment. Just as well, because there isn’t one.
A coronavirus particle has spikes on its surface with knobs on the ends, making it look a bit like the sun and its corona. Hence the family name. Human ones were first seen in the 1960s by the electron microscopist June Almeida, in collaborative common cold research with the virologist David Tyrrell. Growing the viruses was very difficult. Almeida and Tyrell were enthusiasts for organ culture (I am reminded of it daily; I worked with June and have a scar on my forearm where skin was taken in a vain attempt to grow wart viruses). Bits of tissue kept alive in test tubes were infected with sneezings from common cold sufferers. It turned out that a quarter of colds are caused by coronaviruses.
Legionnaire's disease got its name in a blaze of publicity when attendees at the 1976 Philadelphia State Convention of the American Legion were struck down with severe pneumonia. They had stayed at the Bellevue-Stratford Hotel from 21 to 24 June: 182 fell ill and 29 died; 39 passers-by were also affected, five fatally. Funerals and marching legionnaires made good television. The story was top of the news for five nights. But the cause was a mystery until a cold review of samples from victims was conducted six months later. It turned out to be a bacterium. This was unexpected. The pathology didn’t fit a bacterial cause, and it was widely believed that bacteria did not spread on the wind.
Lambing is just starting. But the pictures on TV in the last few days have been of stillborns, and of newborns with bent legs, seized-up joints and crooked necks. Their mothers had been infected during pregnancy with the Schmallenberg virus, called after the German town where it was discovered last year. It belongs to a family – the bunyaviruses – that are mostly spread by insect bites.
It’s increasingly hard to find anyone apart from Andrew Lansley and David Cameron who supports the Health and Social Care Bill. Most doctors, nurses and other NHS workers are against it. A Cambridgeshire GP who used to be the vice-chairman of his local CCG and an enthusiastic supporter of the reforms has written in the BMJ that GPs were 'duped' and the bill will 'wreck the NHS'.
Andrew Lansley’s Health and Social Care Bill, due to return to the Lords next month, is looking less and less well. A poll of more than 2500 GPs carried out by the RCGP found that 98 per cent were in favour of rejecting the bill if the other Royal Colleges agreed. When Ed Miliband challenged David Cameron with these figures on Wednesday, the prime minister responded by claiming the reforms were not only supported but being implemented by one Dr Greg Conner, a GP from Miliband's Doncaster constituency. A spokesman for Doncaster Primary Care Trust later told GP newspaper that ‘Dr Conner was no longer chairman of the Doncaster clinical commissiong group and he had in fact left the area.’
In 1997, I did a research project at the National CJD Research and Surveillance Unit at Edinburgh’s Western General Hospital, supervised by Robert Will and James Ironside, who co-authored the 1996 paper in the Lancet that proposed the existence ofvCJD in the UK. The only reliable way to diagnose the disease was by post-mortem examination of the brain, which would reveal the tiny holes in the brain tissue caused by massive cell death – giving it a sponge-like appearance – and allow us to test for the presence of abnormal proteins.
Near the end of Steven Soderbergh’s epidemipic Contagion, as the bodies pile up around the world, a scientist goes to visit her dying father in hospital. She takes off her face mask. ‘What are you doing?’ he asks. ‘It’s OK,’ she says, and kisses him on the forehead. In a previous scene we’ve seen her inject herself with an experimental vaccine, and now she's testing it. ‘Do you remember Dr Barry Marshall?’ she says. ‘He thought that bacteria, not stress, caused ulcers. Gave himself the bug and then cured himself. You taught me about him.’ The New York Times journalist Lawrence Altman called his history of self-experimentation in medicine Who Goes First? When I got home from the cinema I found a flyer with a jaunty space-invader graphic lying on the floor among the kebab-house menus and cab-company cards. ‘Help us beat cold and flu bugs!’ it said. ‘Help save extra lives.’ I read on:
Cell suicide by a programmed process – apoptosis – is necessary for human health. It starts long before birth, sculpting us as embryos. It is essential for the proper functioning of our immune systems and of organs that continually produce new cells, like the intestines and bone marrow. When it goes wrong, it can lead to strokes, heart attacks and cancer. Its subversion by microbes plays a crucial role in Aids and many lethal infections. Todd Rider and his colleagues at MIT's Lincoln Laboratory may have found a way to use the enzymes that make it happen – caspases – as antiviral agents.
Don’t think that because your salad sprouts are organic, grown on your window sill, and supposedly good for you, that they haven’t accumulated many food miles or are safe to eat raw. Compelling evidence published by the European Food Safety Authority yesterday points to fenugreek sprouts as the vector of the E. coli that caused the enormous German outbreak in May and June (more than 3000 cases, with 47 deaths) and a French outbreak at Bègles, near Bordeaux, in June. The only common factors in the outbreaks were genetically identical E. coli O104:H4 – and fenugreek from the same Egyptian source.
'It's the sprouts,' the head of the Federal Robert Koch Institute in Berlin, Reinhard Burger, announced on 10 June. No surprise. Bean-sprout food-poisoning outbreaks occur regularly. The first big one was caused by Salmonella in the UK in 1988, when 143 people fell ill after eating contaminated mung bean sprouts. The outbreak in Sakai City in Japan in 1996 was caused by radish sprouts contaminated with E.coli O157. In the UK last year 231 people were infected with Salmonella from bean sprouts.
The E. coli outbreak in Germany is enormous. In case numbers (so far) it falls short of the 1996 outbreak in Sakai City in Japan, but the number of those in Germany going on to develop haemolytic uraemic syndrome (HUS), the main complication, which affects blood cells and kidney function, is far greater than in any previous outbreak – 520 on 2 June – and the proportion of those infected that have gone on to develop HUS is also much greater. Germany usually sees about 65 HUS cases every year. In Sakai City only 106 out of 2764 microbiologically confirmed cases developed HUS. The number of deaths in Germany already exceeds the 17 in central Scotland in 1996.
Dr Roy Macgregor isn’t the only GP with severe doubts about the merits of the health bill going through Parliament. According to a survey carried out by the doctors’ newspaper Pulse, more than half of GPs have no confidence in the health secretary, Andrew Lansley. Meanwhile, a poll at GPonline is showing that 65 per cent of the profession think GPs should take industrial action against the proposed reforms. So much for the government’s claims that there is ‘overwhelming enthusiasm’ for their plans among GPs.
Big news from the Institute of Mental Health and the West London Mental Health Trust suggesting not only that grandmas don't know how to suck eggs but that there’s much less of it – mental health – around than we imagined. Perhaps imagined isn’t the right word. One thing people with Personality Disorder don’t have is delusion. It’s practically the sole defining characteristic – at least the only symptom not mentioned. At least 4 per cent, or possibly 13 per cent of us suffer from it. In fact, the definition is so broad that it may be we all suffer from it, all of us who don’t actually see things that aren’t there when we’re awake and not drunk or drugged.
The prime minister admitted last week that supplies of seasonal three-component influenza vaccine in some English general practices had run out. The health minister, Andrew Lansley, had to appear on Newsnight to defend using old stocks of the single swine flu vaccine to meet demand. Leaving the ordering of vaccine to individual GP practices instead of maintaining a central stock was clearly a flawed policy.
The swine flu virus – Influenza A (H1N1) 2009 – is behaving as expected: it’s back as the dominant seasonal flu. Maybe a little early, but so is the winter. It’s also behaving like all previous influenza-A strains in that some infections have been fatal; usually, but not exclusively, in people with pre-existing health problems. We’re much better at handling flu than we used to be. Severe infections can be treated in intensive care units; the last pandemic before swine flu was in 1968-69 when ICUs hardly existed, and the development of extracorporeal membrane oxygenation (ECMO) machines was a long way off. Essentially, ECMO does the work of patients’ lungs for them; most of the 14 machines in England are currently being used to treat flu cases. We have effective anti-virals. And vaccine development and delivery is now very quick: six million doses were given in response to swine flu without significant safety issues. But vaccine uptake in those who need it most has been disappointing.
The popular view of the National Institute for Health and Clinical Excellence (NICE) is that it’s a mean, penny-pinching government watchdog set up by Labour to denysick peopleaccess tolife-saving drugs. So the news that the government will be stripping NICE of its power to determine which new drugs should be available on the NHS has been broadly welcomed. NICE wasn't expecting the move, though perhaps it should have been. The Daily Mail, predictably enough, is ecstatic, claiming a ‘victory for patients’ and heralding an end to ‘the ordeal of tens of thousands of patients being denied life-extending drugs every year’. Avastin all round! Except that just because NICE won’t be responsible for drug rationing from 2014, that doesn’t mean rationing will go away.
Many infections kill slowly. Hardly any are lethal within 24 hours of the onset of symptoms. Bubonic plague takes days to kill and haemorrhagic smallpox takes a week. Cholera and inhalation anthrax are about the only diseases whose victims can wake up feeling fit but be dead by nightfall.
Further to Carl Elliott's piece in the currentLRB on the dangers of clinical trials, here's Elliott's account of the case of a schizophrenic young man who killed himself while taking part in a psychiatric drug trial at the University of Minnesota.
The revelation that meat from the bulls Dundee Paratrooper and Parable has been eaten by people created a media storm this week. It happened because the animals were the offspring of the cloned product Vandyk-K Integ Paradise 2, a Holstein cow in Wisconsin. Particular outrage has been expressed by Compassion in World Farming, the RSPCA and the Soil Association. They have said that the cloning process causes animals to suffer, and have raised food safety concerns. The Food Standards Agency is the main regulator; it has pointed out that milk and meat from clones and their progeny is a 'novel food' and requires authorisation from them before it can be marketed. They say that this was never sought. I have no doubt that the milk and meat from these animals was safe to consume.
There's a study in the BMJ today looking at the relationship between socioeconomic inequality and mortality rates in Britain over the past ninety years. Here are some of the findings: by the year 2007 for every 100 people under the age of 65 dying in the best-off areas, 199 were dying in the poorest tenth of areas. This is the highest relative inequality recorded since at least 1921.
Deirdre Hine’s ‘independent review of the UK response to the 2009 influenza pandemic’ was published yesterday. Her team was based in the Cabinet Office, which played a central role in the implementation of the pandemic plan. That’s one reason the word independent had to be in the title of her review. But there’s no doubting Hine’s independence. As the chief medical officer for Wales, she got into trouble during the BSE crisis for criticising the work of officials above her pay grade at the Department of Health in London. She was right then, and she has got it just about right this time too.
Are you washing your hands as much as you should? Sure? We’ll come back to that. Meanwhile, as the viewing public is discovering, sufficient unto the day is the World Cup coverage thereof. Wads of cash are already being blown on wagering the outcome – north of £1 billion by British punters alone. The England team’s script is written already, and all that awaits is its pitiful enactment. 'We' grind out a series of low-score stalemates, as in last Saturday’s deadlock with the US, and scrape through to the quarter-finals or more rarely the semis, only to crap out on penalties after another bore draw, this time against a former fascist dictatorship. Vide Italy 1990, France 1998, Germany 2006 etc. I’m backing North Korea this time, as the lone standard-bearers for utopian socialism left in the tournament. If it’s a big dark red horse you’re after, look no further.
Good to hear that the Prince's Foundation for Integrated Health has stopped its operations with immediate effect. Disappointing, though, that the reason is not because its founder has taken on board Oliver Wendell Holmes's views on homeopathy – 'a mingled mass of perverse ingenuity, of tinsel erudition, of imbecile credulity, and of artful misrepresentation, too often mingled in practice, if we may trust the authority of its founder, with heartless and shameful imposition' – but because of a more mundane alleged deceit: two people have been arrested on suspicion of fraud and money laundering. When Holmes wrote his essay in 1842 he believed that homeopathy would soon go the way of touching for the scrofula – another Royal Cure – and Bishop Berkeley's Tar Water ('good for so many things').
A year ago US healthcare reform seemed inevitable: no one knew whether it would include a public option (a government-backed competition with private insurers), or how much it would try to control costs, but all the smart money expected that some plan to insure America's uninsured, or at least many of them, would go through. Eight weeks ago the smart money went the other way: Republican Scott Brown's surprise election to the Senate not only killed the Democrats' Senate supermajority, but spooked already nervous Democrats in the lower house so badly that it seemed they would not, could not take the necessary votes.
Jerry Morris, a doctor and epidemiologist who established that bus conductors, in general, have longer lives than bus drivers, who was an authority on exercise and life expectancy, and who firmly believed in the importance of the public health service, died last week aged 99. From the Camden New Journal's obituary: To think of Jerry's life in terms of his immense contribution to public health overlooks his fanatical interest in culture. He read widely, a subscriber to the London Review of Books, the New York Review of Books, the New Yorker and the British Medical Journal. He was also an insomniac and would read two to three thrillers every week. Intelligent and racy reading may keep you and your heart going.
Barney Frank and the dining-room table:
Swine flu has been spreading in Britain for three months. The virus has got about quite well, although the great majority of infections have been mild. Until two weeks ago reassurance about our preparedness for a pandemic was the order of the day. But the media tone changed with the reporting of the deaths of six-year old Chloe Buckley and Dr Michael Day. Chloe was said to have been infected with the virus but didn’t have the ‘underlying health conditions’ usually present in fatal cases, and Day was the first healthcare worker to have a lethal infection. Coincidentally, the tenor of official public pronouncements altered too. The chief medical officer for England mentioned the possibility of 65,000 deaths. On television he was quick to qualify: that figure was a worst-case scenario, necessary for planning, not a prediction. But the number, not the caveat, got the publicity. There was also a change in the way that case statistics were announced, with a shift from laboratory confirmation to estimates based on GP consultation rates and clinical diagnoses. The overnight five-fold increase in ‘cases’ was inevitable. Lab tests tend to underestimate, and consultation rates increase because of the media coverage.
The first death caused by swine flu virus outside the Americas occurred in Scotland on Sunday. The announcement generated more media interest than the declaration three days before by the World Health Organisation that the spread of the virus had moved into pandemic mode. But the declaration was expected and generated less fear than anticipated. The public can see that in Britain the virus is doing well – which is all that was needed to meet the pandemic criterion of sustained community spread in a region outside the Americas – and the message that the virus is mild is also well established, tempering the notion that the word 'pandemic' carries lethal overtones. But this means that a death requires explanation. There is no such thing as a naturally avirulent influenza virus. Even the mildest ones that infect humans can kill. They do it routinely every winter.
There's a kind of hum all over the world. But only some people can hear it. It turns out not to be aliens – though I don't see why aliens wouldn't hum as they went about their world-conquering. Sometimes it's from local factories, electricity wires, fridges, or in my case a nearby airport that emits a thunderous roar when they're testing engines. All these things hum officially and it's not hard to find the source, not as hard as tracking down the humming aliens. But in two-thirds of cases, there's no obvious cause, and it has been decided that if you can still hear the hum you're suffering from vicious-cycle over-sensitive hearing. I think we may be on the verge of a new syndrome.
The spread of the novel influenza A(H1N1) virus through North America is nearly complete. Only three continental US jurisdictions (Wyoming, West Virginia and Alaska) and three Canadian provinces or territories (Newfoundland, Nunavut and the Northwest Territories) haven't reported cases. Its progress elsewhere is still slow, however. Japan (163 cases), Spain (103), the UK (102) and Panama (54) lead; vigorous containment is still the order of the day in the UK. But unless the North American epidemic slows soon, the continued export of the virus – in the coughs and sneezes of infected travellers returning home (particularly to the southern hemisphere, which is just entering its flu season) – has a good chance of defeating all best-laid plans. And it is doing well in Japan.
Influenza virus has only eight genes. The molecular structure of the most important proteins they code for is known in intimate detail. The coming and going of its epidemics have been studied by statisticians continually since the 1840s. But predicting pandemics remains a fools’ game. It falls into the category of Alvin Weinberg's 'trans-science' – a question of fact that can be stated in the language of science but is unanswerable by it. Weinberg’s examples focused on the impossibility of predicting the probability of extremely improbable events. There have only been three influenza pandemics in the last century: in 1918, 1957 and 1964. The uncertainty is massively amplified by evolution – the random and frequent genetic mutations and the swapping of genes between bird, pig and human viruses.