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The Complexity Matters blog features the Thursday Complexity Post as well as other complexity inspired news items.

 

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Community Health Vital for Healthy People

Posted By Prucia Buscell, Thursday, August 28, 2014

Leana Wen, MD, an emergency physician who has worked in inner city hospitals in St. Louis, Boston and Washington, D.C., writes in her blog about the painful experience of administering short term fixes to patients whose long term afflictions lie beyond her realm.

She describes a 19-year-old who has come to the emergency room three times with cuts and broken bones and gunshot wounds. An 8-year-old without an inhaler living among relatives in an overcrowded house with lots of smokers comes to the emergency room struggling to breathe. A 38-year-old single mother diagnosed with cervical cancer four years ago never got to see a doctor as she struggled with three part time jobs, the care of four children and inadequate insurance. By the time Dr. Wen saw her in the emergency room, her cancer had spread to her lungs and intestines.

"We in the ER provide a necessary service, but it's far from being sufficient," she writes in her blog The Doctor is Listening. "We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime and poverty. An MRI here, a prescription there, these are Band-Aids not lasting solutions. Our communities need innovative approaches to issues like homelessness, drug addiction, obesity and lack of mental health services." The route to good health, Dr. Wen says, is in the community. Dr. Wen is coauthor of the book When Doctors Don't Listen.

When he was still writing the Wonkblog for the Washington Post, Ezra Klein described an experiment in Oregon to rebuild the state's Medicaid program around community health rather than individual fee for service treatments. Klein tells a story Oregon Gov. John Kitzhaber loves to tell. Kitzhaber, a former emergency room physician himself, calls it an illustration of what's wrong with our healthcare system. A 90-year-old woman with well-managed congestive heart failure lives in an apartment without air conditioning. When her apartment gets too hot, the strain on her cardiovascular system causes heart failure. Medicare will pay for an ambulance and $50,000 to stabilize her, but not $200 for a window air conditioner.

The 90-year-old may be hypothetical, but the story illuminates a common paradox, and Oregon's experimental approach starts with creation of 16 Coordinated Care Organizations (CCOs) that are responsible for assessing the health of their communities. Kitzhaber has given the CCOs flexibility on how they can spend Medicaid money. They can buy that air conditioner. An NPR story describes a Medicaid purchase of a minivan for community health workers who can be available around the clock to pregnant women trying to stop substance abuse, and to help mothers get to doctors' appointments, school and jobs. What makes CCOs different from accountable care organizations, or managed care, is the community component. Once they assess needs, they have to come up with ways to address them. So money can be spent on care coordination and community health workers with the aim of preventing some expensive emergency care. Gov. Kitzhaber told Klein, "We're investing in health. It's just a paradigm shift."

With thanks to Annette Garner, who teaches in the nursing program at the Health & Science University, Portland, Oregon.

Tags:  buscell  complexity matters  health  healthcare  medicine 

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Learning from Sleeping Bears

Posted By Prucia Buscell, Thursday, March 6, 2014

While bears hibernate through bitter cold winters, they don't eat, drink, or excrete, their kidneys shut down, their heart rate falls to a few beats a minute, their oxygen intake and blood flow plunge, and because they're living off their own mighty stores of fat, their cholesterol skyrockets. And when they wake up they're fine. They're not suffering from diabetes, hardening of the arteries or gall stones, and they haven't lost muscle or bone density.

Scientists think the mysteries of bear hibernation may have much to teach us about human health issues ranging from obesity to kidney disease to organ preservation and long distance space travel.

Kevin Corbit, a senior scientist at the biotechnology company Amgen calls hibernation by black bears and grizzly bears an "astonishing feat of evolution." In a New York Times story he explains that when bears halt their renal functions during hibernation, the result is badly scarred kidneys and levels of blood toxin that would kill a human. Yet full function is restored when the bear wakes, and scientists find no lasting damage. Before hibernation, bears eat and drink prodigiously, and quickly gain the weight and fat they'll need for their long sleep, which can last up to seven months. During hibernation, Corbit writes, bears become insulin resistant, making them in effect diabetic. Unlike diabetic humans, however, they maintain normal blood sugar levels. And again, when they wake up, their insulin responsiveness is restored.

At the top seasonal weight, male black bears can weigh up to 900 pounds and females can weigh up to 500 pounds.They may lose up to 30 percent of their body weight during hibernation. See a Nova report and a National Park Service piece on bear hibernation.

"Bears naturally and reversibly succumb to diabetes," Corbit writes. "Since we know when they make this switch, we hope to pinpoint how they do this."

The bears scientists have studied don't handle fat the same way humans do. It doesn't cause tissue inflammation in bears, and Corbit writes that bears store their excess winter weight harmlessly in fat tissue, rather in the liver and muscles as humans do. Corbit's research on bears, supported by his company, is focused on finding innovations in treating obesity. Hibernation itself is an adaptation to seasonal food shortages, extreme cold and snow. Millions of years of evolution has produced genetic adaptations that make fluctuating weight and obesity benign for bears. Corbit figures maybe scientists can figure out how to do that for humans.

A Science article by Sara Reardon says the mysteries of bear metabolism during hibernation could give doctors the ability to slow down the metabolism of accident victims, thereby extending the time when treatment is most effective. Findings could also help extend the preservation of organs for donation. Understanding how bear brains continue to function with low oxygen, and the mechanisms by which sleeping bears conserve their muscle and bone mass during months of inactivity could be useful in managing long term space travel.

Tags:  buscell  complexity matters  medicine  nature 

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“Crack Baby” Predictions Were Wrong

Posted By Prucia Buscell, Thursday, August 15, 2013

A neonatologist who led a long term study of babies exposed to crack cocaine in utero has reached a conclusion she and her colleagues did not expect: poverty harms children more than pre-natal cocaine use by their mothers. And among the cocaine-exposed, there are some kids who flourished, apparently because they experienced nurturing and lasting relationships with adults despite family poverty and addiction.

Remember the horrifying "crack baby” stories in the 1980s and 1990s? The nation’s health specialists and social pundits voiced dire warnings of a generation of children doomed to deficient intelligence and physical disability and deformity. TV, magazines and newspapers spread fearful predictions of damaged babies growing into a huge population of defective children and adults that would overwhelm social services and cost taxpayers billions. One newspaper columnist envisioned a "human plague almost too horrible to imagine." A prominent college president even suggested "crack babies won’t ever achieve the intellectual development to have consciousness of God."

Cheap smokable crack cocaine poured into cities across the country in the 1980s. A study in 1989 found that one in six newborns in Philadelphia hospitals had mothers who tested positive for cocaine. Hallam Hurt, MD, neonatology chair at Einstein Medical Center, organized a study of 224 babies born at Einstein between 1989 and 1992, half of whom had prenatal cocaine exposure, and half of whom had not. All the babies were from low income mostly African American families. All were full term or nearly full term, and all their mothers were serious users, with an average of 99 days of crack use during their pregnancies. Federal funds and contribution from the Einstein Society allowed the study to continue nearly 25 years. The research is described in an NPR RadioTimes discussion and in a Philly.com story by Susan FitzGerald.

Each child’s development was evaluated at six months, then regularly until early adulthood. Dr. Hurt, who moved her team to Children’s Hospital of Philadelphia in 2003 and is now a professor of pediatrics at the University of Pennsylvania, found virtually no differences between the children who had been exposed to cocaine and those who had not. She and colleagues did find that both groups lagged behind middle class kids the same age. So what influence besides cocaine was at work? The team discovered poverty was "the elephant in the room.”

"Finding that poverty is a bigger factor than drug use is a really tough finding,” Dr. Hurt said in the NPR discussion. "It’s much simpler to say that the drug is the problem.” It wasn’t a popular finding either, she said, because poverty is more complex and much harder to address, as are the cumulative effects of exposure to violence and deprivation that leave kids with post traumatic stress, more anxiety, lower self esteem, and less resilience.

"We began to hear stories when kids came in for testing,” Dr. Hurt said. "We’d hear about kids seeing their mother chased by someone with a knife.” Measuring exposure to violence, the team found that by age seven, 11 percent of children had seen someone killed; 81 percent had seen someone arrested, 74 percent had heard gunshots, 35 percent had seen someone shot, and 19 percent had seen a dead body outside.

An article in the journal Pediatrics in May described a study led by University of Maryland researcher Maureen Black, PhD. Evaluations of more than 5,000 children between the ages of 11 and 17 whose mothers had used cocaine during pregnancy found most developmental measures within normal ranges. That study too concluded the impact of violence and social environment outweighed cocaine exposure. Updated findings carry messages for medical professionals and the media.

A New York Times Retro report on the crack baby scare notes that the stereotype of bad drug abusing mothers, who often lost their children or got arrested, and the florid headlines, fit cultural prejudices of the time. Neither Dr. Hurt nor any other expert suggests it’s OK to use cocaine during pregnancy. But Dr. Claire Coles of Emory University says in a Times Vimeo that the hysteria was harmful, and that most actual damage was associated with prematurity, which cocaine use can influence, and alcohol. Prestigious journals as well as popular media hyped the story. Paul Raeburn, writing for the Knight Science blog Tracker, reflects now on a 1987 story of his quoting medical experts on crack babies, and wishes he had been more skeptical.

A college senior studying animal husbandry and business told Radio Times of her family’s strengths, values and the good grades she and her siblings earned despite her mother’s prenatal and continuing cocaine addiction. Listen to Radio Times here.

Tags:  buscell  complexity matters  culture  health  medicine 

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The Nocebo—The Placebo’s Evil Twin

Posted By Prucia Buscell, Thursday, July 25, 2013
Updated: Tuesday, July 30, 2013

Honesty is harder when the truth risks harm.

People taking sugar pills and other faux medications with inert ingredients for such symptoms as pain, dizziness, headache, and depressed mood often experience relief. The placebo effect is well known. The placebo’s evil twin is the nocebo—it comes from a Latin word meaning I will harm—and it has recently gotten more attention from researchers. The Harvard Mental Health Letter reports 20 percent of patients taking sugar pills in clinical drug trials spontaneously report unpleasant side effects—and even more describe unpleasant effects if they are asked.

Expectations matter. If we expect help, we may feel better. If we expect distress we may feel it. And these physical manifestations are real, not imaginary. The Harvard letter reports on an experiment in which volunteers were told a mild electric current would be passed through their heads and that they might experience headaches. There was no current, but two thirds of the volunteers got headaches.

A New Yorker story by Gareth Cook reports that people involved in clinical drug trials often experience the symptoms they are warned about even when they are taking placebos. In research on fibromyalgia treatments, the story says, eleven percent of the people taking sugar pills dropped out of the trial because of debilitating side effects.

People also experience the nocebo effect as a result of disasters and scary information, alarming news and rumor. After the 1995 saran gas attack in a Tokyo subway, many people who had actually not been exposed to the nerve gas suffered the highly publicized symptoms of dizziness and nausea. A New York Times story by Paul Enck and Winifred Hauser tells of a participant in a clinical trial for an antidepressant drug who attempted suicide by swallowing 26 pills. The person’s blood pressure plunged dangerously even though the pills swallowed were harmless.

Sometimes the same treatment can be both placebo and nocebo. The Harvard letter tells of volunteers who experienced discomfort when told an injection contained an allergen, and relief when told an injection would neutralize the symptom. In both cases the injection contained only salt water.

Informed consent is a powerful doctrine that obligates physicians to tell patients all the risks of treatments. But what if all that information is detrimental to the patient? A Boston Globe story by Chris Berdik reports some reflections by doctors, all of whom urge honesty combined with the kind of thoughtful and skilled communication that takes some time with the patient. Dr. Luana Colloca, a researcher at NIH who studies placebos and nocebos, describes positive framing—you can say that two percent of the people on this treatment had nasty side effects, or that 98 percent did not. The Times story emphasizes that a doctor’s choice of words is important. The story quotes the cardiologist Dr. Bernard Lown who once said, "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal.”

Tags:  buscell  complexity matters  health  medicine 

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Into the Same Space as Death... With Grace...

Posted By Prucia Buscell, Thursday, July 18, 2013

Empathy and generosity of spirit take a battering in the exigencies of medical training, physician Danielle Ofri writes, and doctors and nurses have to learn to face the hard realities of death, dying and dead bodies with skill, grace and compassion.

"Where do we gain the fortitude to step into the same space as death and negotiate the unnerving complexities that eddy between our breaths?" she asks in a Slate magazine essay. "It’s not the type of thing you can Google."

Dr. Ofri, who has researched the joys, fears, stresses and conflicting messages young doctors get when they enter the clinical world, is author of the book What Doctors Feel: How Emotions Affect the Practice of Medicine. She is an associate professor of medicine at New York University School of Medicine, has cared for patients at Bellevue Hospital and is the editor-in-chief of the Bellevue Literary Review, which she says focuses on creative interpretations of medical challenges and vulnerabilities. Dr. Ofri believes patients and physicians need poetry and that in order to be wise caregivers, doctors and nurses need the creative skills people learn from studying the humanities. Sometimes, she observes, "it is the things we deem least practical that wield the most power."

Her Slate piece describes the work of Cuban American physician-poet Dr. Rafael Campo, an associate professor of medicine at Harvard, who recently won the Hippocrates Open International Prize for Poetry and Medicine for his poem "Morbidity and Mortality Rounds." Accepting the prize, Dr. Campo wrote, "Through my poem - about a dying patient - I was able to address the power of empathy to combat the distance we almost reflexively adopt toward our patients and confront our own shortcomings." In his interview with Dr. Ofri, he said "A good poem engulfs us," and its brevity and urgency demand "full participation of another in order to achieve completeness, to attain full meaning. In this way, it is not so different from providing the best, most compassionate care to our patients."

Dr. Campo’s prize winning poem begins:

Forgive me, body before me, for this.
Forgive me for my bumbling hands, unschooled
in how to touch: I meant to understand

what fever was, not love. Forgive me...

Read the full poem here.

The poetry of medicine has been collected and taught at several schools. A University of Illinois School of Medicine page compares iambic pentameter to the heart beat.

William Carlos Williams is one famous physician-poet who wrote about life, love, joy, decline, death and his experiences in Paterson, New Jersey, where he lived and worked. Near the end of his lengthy poem Asphodel, That Greeny Flower, are lines compressing an urgent need for the ephemeral power of poetry:

It is difficult
to get the news from poems
yet men die miserably every day
for lack
of what is found there.

Tags:  art  buscell  complexity matters  medicine 

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ALS Patients Testing Home-Brewed Drugs

Posted By Prucia Buscell, Thursday, March 28, 2013
Updated: Friday, March 29, 2013

Networking and internet research help patients become increasingly involved in treatment of their illnesses, and people with Lou Gehrig’s disease are providing dramatic examples of medical autonomy. Many are making themselves guinea pigs to test unofficial treatments.

Lou Gehrig’s disease, also known as ALS for amyotrophic lateral sclerosis, is a degenerative disease that damages nerve cells in the brain and spinal cord and leads to loss of muscle control and eventual immobility. Life expectancy after diagnosis is only two to five yeas, and there is no known cure.

"Do It Yourself Medicine,” a story in TheScientist.com by Jef Akst tells the story of Eric Valor, a 42-year-old with advanced ALS who helped set up an independent drug trial for himself and other ALS sufferers. Although he needs a ventilator to breathe and cannot move any part of his body except his eyes and some facial muscles, he managed to use his eyes to research the web for information about a new drug and set up a website where he and fellow experimenters could report their data. Clinical trials for a new ALS drug NP001 developed by Neuraltus Pharmaceuticals, were to begin in 2010, but Valor’s debilitated physical condition made him ineligible. Developers hope the drug might slow progression of the disease, so to show any impact Valor couldn’t just stop getting worse. He’d have to start getting better, something not proven with any ALS drug.

Based on their research, Valor and others thought the drug contained 50 percent sodium chlorite, a chemical available online for about $50 a quart. He asked his mother to inject a dilute solution into his feeding tube. More than two dozen patients have done the same, and shared their experiences and data. They used a site at PatientsLikeMe, a company cofounded in 2004 by three MIT engineers, Benjamin and James Heywood and Jeff Cole. The Heywood family had spent years searching for anything that would extend and improve the life of a third brother who had ALS, and the experience inspired creation of a health sharing platform. The goal is to help patients manage their own care, and change the way industry conducts research.

According to a Wall Street Journal story by Amy Docker Marcus, many ALS patients concoct their own drugs because they feel they don’t have time to wait for clinical trials and FDA approval. They are also reluctant to risk getting placebos rather than the real thing in a clinical trail. Some medical authorities worry about that approach. Marcus quotes Jonathan D. Glass, professor of neurology at Emory University School of Medicine, who suggests research needs the rigors and controls set by the medical establishment. He worries that guinea pigs could hurt themselves, adding, "Who knows what they’re actually making in their kitchens?”

Neurologist and researcher Richard Bedlack, who directs the Duke University ALS Clinic, thinks greater patient involvement is a good thing. "There’s a new model of medicine, in my opinion,” he told TheScientist. "Once upon a time we had a very paternalistic system where patients would come…and doctors would ask all the questions and give all the answers. In the past decade, things have really shifted, almost to the other side, where a lot of medicine is autonomous now.”

Results from the independent sodium chlorite trials are equivocal. While some self-dosers reported improvement, a report published by PatientsLikeMe investigators found a potentially negative effect. Neuraltus researchers last October announced its drug showed progress, and it seeks a big-pharma partner for a Phase 3 clinical trial. Valor, for one, would like early access to the drug, and he sees no conflict in being both patient and researcher. "I just treat myself as another lab rat,” he said.

Tags:  buscell  complexity matters  medicine  networks  research 

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If the Doctor Feels Your Pain, Will You Hurt Less?

Posted By Prucia Buscell, Thursday, December 20, 2012

Placebo treatments can have real physiological impact, changing heart rate, blood pressure, chemical reactions in the brain, and influencing how we experience depression, anxiety, fatigue, pain and even some Parkinson's symptoms. Researchers are beginning to learn why, and new findings shed light on the importance of doctor-patient interactions.

Ted Kaptchuk and colleagues at the Program in Placebo Studies and the Therapeutic Encounter (PiPS), the only multi-disciplinary institute devoted to studying placebos, are studying what makes an intervention work when there is no active drug ingredient involved. The researchers, all from the Harvard-affiliated hospitals that created PiPS, are identifying the mechanisms in our brains and bodies that produce the physiological responses. A story by Cara Feinberg in Harvard Magazine tells how Kaptchuk, an assistant professor of medicine at Harvard and an acupuncturist with a degree in Chinese medicine from an institute in Macao, has spent years studying the way people are affected placebos and their delivery. That includes the physical surroundings and the characteristics of the treatment room, the behavior of the doctor, and method of treatment, whether it comes in the form of a pill or needle.

It turns out the placebo effect is actually many effects woven together. For years, placebos have been studied in comparison with real drugs. New research compares different placebos delivered differently. In one study, Kaptchuk divided 270 subjects suffering arm pain into two groups. One group was told that their pain pills might cause nasty side effects, from which they then truly suffered. The other group received acupuncture, and they reported greater pain relief. The unusual element in this study was that both treatments were fake. The pills were cornstarch, and the faux acupuncture needles never punctured the skin. But people thought acupuncture might really help, and they thought those miserable pill side effects would happen.

In another study, Kaptchuk examined the role of doctor-patient interactions in placebo effects. A group of 262 patients with irritable bowel syndrome (IBS) were divided into three groups - one told they were awaiting treatment, one given fake acupuncture with little attention from the practitioner, and a third showered with a doctor's attention as they were given fake acupuncture. The well-tended group experienced the greatest relief. Russell Phillips, director of the Center for Primary Care at Harvard Medical School, says the research points to the importance of the "ritual of medicine" in patient care, and he says that's one finding from the research that doctors can use immediately in their practices.

Kaptchuk doesn't recommend placebos for infections and tumors and he doesn't suggest placebo treatments are ready for clinical application. His interest in the placebo effect was sparked years ago when his acupuncture patients experienced relief even before he started treating them, and he suspected his interactions with them were having something to do with that. His recent researched, published in PlosOne, showed that even patients who knew they were getting placebo IBS treatment experienced twice as much relief as a control group of IBS patients who were not treated. Neuro-imaging of patients' brains has shown that some placebo treatments activate the same brain chemicals that influence sensations of pleasure and reward. The story reports neuroscientist Fabrizio Benedetti from the University of Turin found changes in the electric and metabolic activity in many regions of the brains of depressed patients who received placebos. Researchers have also discovered a genetic component in the susceptibility to placebos, which can be important in designing real drug trials.

No one has fully studied the role that "ritual of medicine" plays in patient care and healing, and Kaptchuk and his team are providing insights on that. The team recently devised an experiment in which fMRIs of physicians brains were recorded as they treated patients.

"Doctors give subtle clues to their patients that neither maybe aware of," Kaptchuk said in the Harvard Magazine story. "They are a key ingredient to the ritual of medicine." Ultimately, he added, the goal is to "transform the art of medicine into the science of care." Read the Harvard Magazine story here.

Tags:  buscell  complexity matters  medicine  neuroscience 

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On The Edge Nursing in the Age of Complexity-3rd Annual Conference on Complexity and Nursing

Posted By Prucia Buscell, Sunday, July 12, 2009
Updated: Tuesday, February 15, 2011
Marjorie Wiggins, Vice President of Nursing at Maine Medical Center, a 650-bed hospital, recalls being in the emergency room on a busy night when patients seemed to be arriving by the dozens. The waiting room was filed. Nurses were unable able to move admitted patients. The emergency department might have to be shut down and patients might have to be diverted to another hospital. Yet records were showing 12 empty beds. What happened? All the housekeepers went to dinner at the same time to give a shower for one member of the staff.

Housekeepers returned to work, prepared rooms, and the threatened shut down and diversion were avoided. But the incident illustrates the extraordinary interdependence of all players in complex modern healthcare systems. One principle of complexity is nonlinearity—small things, like an unusual dinner hour, can have very large effects. Ms. Wiggins discussed the challenge of change and new roles for nurses in today's turbulent healthcare environment. She was one of the presenters at the July 12 -14 Plexus Institute conference at St. Joseph's College in Standish, Maine.

While conventional models have emphasized the role of experts, the partnership model adopted by Maine Medical Center emphasizes the strength of all agents and the mutual relationships of all involved in patient care. The idea, she explained, is that while the nurse as professional caregiver is the expert in some clinical information, "You, the patient, are the expert in you, your family, and your resources."

The concept has created many changes in practice. For instance, nurses traditionally prepared patient information reports for the next shift in a small room behind the nurses’ station. Under the partnership model, the shift change information is delivered at bedside, in the presence of patients and family members, and often with contributions from multiple medical providers. Patient safety checks often are done at the same time. The results, said Ms. Wiggins, include improved patient satisfaction and knowledge. In addition, careful and respectful language to patients and among staff is practiced and becomes habitual.

Studies have shown that patients often do not understand their medical conditions and medication, and patients who are not prepared to manage their own care are often readmitted to the hospital, Ms. Wiggins said. Preventable readmissions within 30 days of discharge waste billions of dollars every year. Using a redesigned discharge process, nurses double time spent preparing patients for discharge from eight to 16 minutes. Families are present when possible, and nurses explain medication, provide devices such as a pill box or alarm when necessary, and help uninsured patients find ways to get their medications. Another change allows families to be present, if the patient so desires, during "codes"--the emergencies when patients lives are in danger. "Dying is part of the life process," Ms. Wiggins observes, "but we often don't bring families in." For those fearing litigation, she added, law suits actually decrease when families are present, because they see that providers did all possible for their loved one.

Ms. Wiggins also described the new role of clinical nurse leaders (CNLs), master's degree level nurses who follow the most vulnerable patients through their entire hospital stays, keeping track of care and treatment during their interactions with countless people as they are moved from one department to another in a hospital. She said CNLs have improved patient care by seeing that patients get what they need, and they have saved money by identifying patterns that show some procedures and practices that don't help patients can be eliminated.

Claire Lindberg, professor at The College of New Jersey School of Nursing presented a brief primer on Complexity Science. She emphasized the interdisciplinary nature of the science, which has influenced scholarship in biology, economics physics, the social sciences, anthropology, management and mathematics, as well as nursing. Complexity is not one theory, she said, but many. Dr. Lindberg briefly described complex adaptive systems and complex responsive processes, as well as such central complexity concepts as self organization, emergence, and distributed control. For fuller treatment of this material, see the chapter she wrote with Curt Lindberg in On the Edge, Nursing in the Age of Complexity, edited by Claire Lindberg, Curt Lindberg and Sue Nash.

Bruce West, chief scientist in the Mathematical and Information Directorate of the Army Research Office, talked about the history of ideas, the roots of complexity science, and the vital importance of understanding variability. One of his recent papers, Why Six Sigma Science is Oxymoronic, argues that eliminating variability is counterproductive in research environments and in human systems generally. The mathematician Carl Friedrich Gauss (1777 – 1855) developed the law of averages that became the bedrock of all statistics we learned in school, Dr. West said, "and it is wrong.” At the end of the 19th Century, the economist and philosopher Vilfredo Pareto asked new questions and looked at data in a new way. He discovered the power law distribution of income, and his work introduced a world view more consistent with the principles of complexity science. Mathematical and averages that create a "normal” distribution curve work fairly well with a subject like human height, which has restricted intervals within a fairly small range. An "average" adult of five feet nine inches tall won't meet another adult twice his height, Dr. West explained. But he could easily meet someone with five times his income. (If Bill Gates were in a room with five minimum wage workers, the average of their incomes would be meaningless.) Income distribution, consumer behavior, weather systems and any system where outliers can dominate requires an understanding of power laws.

Dr. West gave several examples of how averages can distort reality. For instance, the "average” scientist has 3.2 published citations a year. But 35 percent of scientists have no citation, and 90 percent publish less than the average. The scientist who has 3.2 citations is actually in the top four percent for published citations.

Sixty years ago scientists began developing revolutionary ideas about the organization of living networks, he explained, and recent advances in complexity science have dealt mathematics of complex networks. He said complex systems are most robust when they are confronting problems they have evolved to solve. He spoke of, habituation, negative entropy, how two complex systems might influence each other, and the need for more scientific exploration of complexity science. The "take home” message, he advised conference goers, is that the best way to influence complex networks is not direct force or dominant authority. The best influence can be delicate and direct, he said, but the influence must match the network in complexity.

Dr. West has written scores of papers, journal articles and books. His book Where Medicine Went Wrong explores how misuse of averages in human physiology have delayed understanding the role of variability in healthy human systems. Lack of variability, he has asserted, leads to the morgue.

Tags:  buscell  complexity matters  medicine 

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Sixth Annual Unite For Sight Conference: Insights and Innovations in Public Health

Posted By Prucia Buscell, Friday, May 15, 2009
Updated: Tuesday, February 15, 2011
Goals for a dignified and decent life on our planet have been enunciated three times in the last 60 years, and timetables and accountability are the only hope of achieving them, in the view of Jeffrey Sachs, an economist, professor and director of the Earth Institute at Columbia University.

In 1948, the Universal Declaration of Human Rights had profound significance around the world as people tried to recover from the ravages of World War II, Sachs said. In 1978, the Declaration of Alma-Ata proclaimed health as a fundamental human right. In 2000 the UN Millennium Development Goals constituted an international agreement to reduce extreme poverty, disease and hunger by the year 2015.

The goals have not been met, Sachs said, but the wisdom of the documents is still alive, and like all great documents they need to be renewed and refreshed by each new generation.

"The goals declared at the start of the new millennium were full of hope and renewal,” Sachs said, asserting that security, safety, health, and educational opportunity, as well as freedom from conflict and preventable disease, are basic human rights. Rather than defining poverty in terms of dollars, he added, the document recognizes that extreme deprivation is multi-dimensional and needs to be addressed in a multi-dimensional way.

It is inexcusable that nine million children die before their fifth birthdays, when nearly all of those deaths are caused by extreme poverty, Sachs declared, adding it is a disgrace that children die of malaria for lack of a $5 bed net, that women and infants die because of unsafe childbirth, and that pandemic, parasitic, infectious and controllable diseases cause suffering, blindness and death.

"We need to keep these goals alive, and hold leaders accountable. That is our most important tool,” Sachs said. "We need international leadership. The new world is multi-national, and any solution needs to be cooperative….We are networked. The joy of our time is that we can cooperate in ways we couldn’t even think about in the last century.”

Corporations, businesses, nongovernmental organization, universities, scientists, civil society and individuals can collaborate and create partnerships to find solutions, he said, adding that he sees himself "as a plumber, making connections across these areas, finding ways to make the pipes fit.”

Sachs was a keynote speaker at the Unite For Sight sixth annual Global Health Conference at Yale University April 18-19, 2009. Unite For Sight is a nonprofit organization founded to empower communities worldwide to improve eye health and eliminate preventable blindness. The conference drew more than 2,200 participants from 50 states and 55 countries and a multitude of disciplines, to exchange ideas in all areas of public health and international development. Presenters included physicians, nurses, professors, organizational development practitioners and workers and specialists from dozens of public health-related fields. The following summaries represent just a few of the presentations and discussions at this extraordinary event.

Idealism is Not Enough

Nicholas Kristof tells a cautionary tale about cassava farming in Nigeria.

He recalls that he and his wife worked on a farm where women were raising cassava they ate and sold. Their cassava bed had a low yield, so they welcomed the opportunity for a new variety of the plant that yielded five times more crop. But they didn’t have the time or equipment to harvest it all. Further, the cassava plants absorb mercury and arsenic in areas where it remains in the ground from earlier gold mining operations, and the plant itself has naturally occurring chemicals that trigger production of cyanide. So the increased processing was polluting the ground water. The crop, however, was making money, and men decided they should be in charge of a cash crop. So they took over the operation, and the women were left with nothing.

"Idealism is not enough,” Kristof said. "You need grass roots understanding. There is a danger of making things sound too easy. Ideas are easy. Acting on them is a difficult. And you need to learn form your mistakes.”

Kristof, the Pulitzer Prize winning New York Times columnist who has written stories about human suffering and courage in remote trouble spots all over the world, urges would-be activists, "When you think you know what’s happening, back off. Travel in grass roots areas, find a cause larger than yourself, and get out of your comfort zone. You have to be bewildered.”

Kristof addressed the Unite For Sight conference last month at Yale. People are sometimes dubious about whether aid interventions work, he said, but they are necessary and they can help. See his May 13 column "What A Little Vitamin A Can Do” to combat unnecessary blindness among people in Africa.

Grass roots efforts tend to work best, he said. Great effort has been expended since 1970 to reduce female genital cutting in Afghanistan, he said, but conferences and new laws have had little impact. What helped a great deal was getting girls to school. Politics also may not be helpful. In combating AIDS, he noted, conservatives want abstinence and liberals want condoms, but the most effective approach may be something else. Girls in school who have learned the AIDS rate among middle-aged men are less likely to become involved with "sugar daddies,” despite the economic pressures to find financial help from older men. Kristof was one of several presenters who observed that when girls are educated and women have more social influence, poverty declines. More money is spent on children and small businesses and less on alcohol, prostitution and other vices.

Years ago, Kristof said, a New Yorker donated $100 to educate bright girls in a Chinese village he had written about. The bank erred, and gave the village $10,000. On a return visit 15 years later, Kristof found girls’ education and scholarships continuing, and many more educated young women holding good jobs, starting businesses, and educating their siblings.

Infectious and Chronic Diseases: Today’s Health Threats

Susan Blumenthal, MD, a former US Assistant Surgeon General who is a professor at Georgetown and Tufts University Schools of Medicine, spoke of trends and changes, not all reflecting progress. In 1969, she said, the US Surgeon General declared the battle against infectious disease had been won. Today, she said, the greatest health threats world wide are infectious disease and chronic disease.

Since 1972, she said, more than 32 new infectious diseases have emerged, and 1,500 people die every hour world wide from infectious disease. When people and animals live in close contact, pathogens flourish, and modernization and international travel facilitates dissemination. Climate change and extreme temperatures also foster emergence of new diseases that are water borne, air borne, and carried by rodents and insects. She added massive forest cutting promotes lymes disease in humans.

"We need public health policy that focuses on chronic disease,” she said. "We need to combat childhood obesity: 24 percent of our kids are over weight, and diabetes is becoming epidemic.” Inactivity, which contributes to obesity, impacts every organ system in the body. She added that one fifth of American children are shorter than children of a decade earlier. Published reports have documented that Americans are no longer the tallest people the world.

Disease and "Socioemergence”

A collection of interacting economic, political and environmental processes over several decades may have facilitated the movement of the viruses, Simian Immunodeficiency Virus SIV and Human Immunodeficiency Virus HIV, from nonhumans to humans. Rebecca Hardin, PhD, an assistant professor at University of Michigan’s School of Natural Resources and Environment has studied "socioemergence,” the political and cultural dimensions of emergent viral diseases in Africa’s equatorial rain forest. From 1890 to 1930, she said, the area was under brutal colonial control, with forced labor drawn from small villages for logging and road building. Because the environment does not lend itself to raising cattle, workers were fed wild game. In later decades increased hunting and a growing trade in wild game meat was a threat to African wildlife in the Congo Basin, where the populations of chimpanzees and other primates plunged. Continued road construction from remote areas and human migration increased environmental pressures. Researchers found high HIV prevalence among women in commercial logging areas, and theorized that their vulnerability was related to the social and economic networks created by the industry. The Bushmeat Crisis Task Force website says wild game commercialization is a human as well as natural tragedy: loss of animals means endangered livelihoods and food insecurity for indigenous and rural populations most dependent on wildlife in their diet, and bushmeat consumption is increasingly linked to deadly diseases like HIV/AIDS, Ebola, and Foot and Mouth disease.

Mosquitoes and Malaria

Malaria is a preventable and curable disease that kills a million people a year, most of them children in Africa. Marcelo Jacobs-Lorena, PhD, a malaria researcher and professor in the department of Molecular Microbiology and Immunology at the Johns Hopkins School of Public Health, is seeking ways to increase the arsenal of weapons against mosquitoes. Mosquitoes bite an infected person, then pass the malaria germ to the next person they bite. Bed nets offer some protection for people sleeping. Insecticides bring resistance, Dr. Jacobs-Lorena said, and as soon as all the mosquitoes in an environmental niche are killed, more will come to fill the niche. A malaria vaccine does not yet exist. "We will never conquer malaria with a single approach,” he said. "We will have to do multiple things.”

Dr. Jacobs-Lorena’s research involves genetically modifying mosquitoes so that they will be resistant to the pathogen and unable to transmit it. That has been achieved, he said, and the next step, still being researched, is to spread the resistant gene to the rest of the mosquito population.

"Let the people Lead"

Pamela Lynam, MD, is country director for JHPIEGO in Kenya. (That’s pronounced Ja-pie-go-, and its one word, not an acronym.) In her Unite For Sight presentation she stressed letting people lead the way toward health in urban slums. By 2030, she said, three of every five people on earth will be living in cities, and 95 percent of urban growth is in the developing world. One third of all urbanites world wide live in slums, and 72 percent of African urbanites are slum dwellers.

The characteristics of slums, she said, include poor quality health care, lack of access to a hospital, lack of access to public services, good drinking water, and sanitation. "You’ve heard of the flying toilets of Nairobi? People use plastic bags and then throw them,” she said. "Sixty percent of the people live on five percent of the land. And officially, they are not there, so they have no rights where they live. No one has to supply them with water, electricity, or anything else.” Such conditions promote distrust between communities and health services that do exist, she said, with real issues of insecurity and neglect. Breakdown of traditional social structures in urban slums mean large numbers of HIV deaths, children given to neighbors, violence, and very sick patients.

The traditional approach to aid, she said, has been to have experts tell people what they need. The better approach, used by JHPIEGO and many others, is to let people define their needs, and have aid directed towards fulfilling the needs. For example, she said, in one large slum near Nairobi, an aid organization offered to bring people clean water, and was surprised to find what they really wanted. "People said that’s fine, we do want clean water,” Dr. Lynam said, "but first we’d like covered bus stops, because we get soaked waiting for buses to go to work.”

The community-owned JHPIEGO intervention included anti-rape training, peer education, a village health committee, and a community theater. A community garden is generating small income and better nutrition. A self-defense group made a map of their own community showing places where people can get medical help and counseling, and its members have helped victims of rape and other crimes file police reports so that suspects are charged. They have also traveled to other communities to help others address their local needs.

"Great things happen when people start to respect and appreciate each other,” Dr. Lynam said. "The key is having people come up with their own solutions, and building trust, which takes time and patience, as well as enthusiasm and energy. You have to have a local staff. Consumers do know their own health challenges, and the results are sustainable because they come from all stakeholders.”

Dr. Lynam added that monitoring and evaluating aid programs is a very big challenge that carries with it the need for flexibility from policy makers and donors.

Women as Change Agents

Educated, empowered women are society’s change agents and the key to community health, said Jill Lester, president and CEO of The Hunger Project, a non profit that fights poverty not by direct aid, but by mobilizing women and forming partnerships with government. The organization operates in eight countries, using an "epicenter strategy”, in which clusters of villages that have up to 20,000 people work together to improve health, education, sanitation, or start small businesses. "If a woman can earn enough income so that her family goes from one to two meals a day, it changes her relationship with her husband,” Ms. Lester says. "The whole family changes if the mother has enough money for her family to eat.” She described a group of women in Senegal used a small loan to begin manufacturing a vitamin supplement for children using millet and nuts. In the process they learned skills in nutrition, hygiene, marketing and finance. A women who was illiterate a year ago now takes pride in being able to read her Bible, have soap and water in her house, and handle money without being cheated.

Destruction and Building Back Better

The Chinese got it right, Neil Boothby says: Crisis does represent both danger and opportunity. The aftermath of the devastating Indian Ocean tsunami that struck just before Christmas 2004, killing more than a quarter of a million people, also brought some beneficial legal and social changes.

Boothby is a professor and director of the Program on Forced Migration and Health at Columbia’s Mailman School of Public Health, addressed a session entitled The Epidemiology of Human Rights. He has studied efforts to protect children and families in war and disaster, and described several positive changes that developed from viewing emergency responses through a human rights-based lens. For one thing, he said, the tsunami was a tipping point for cessation at the time of civil war in Sri Lanka and Indonesia In Aceh, an emergency response framework resulted in establishment of family tracing and legal changes to protect children. New laws banned children from leaving the country alone so that child kidnapping and trafficking was greatly reduced. Police patrolled bus stations and created special desks in police stations for women and children. Before the new laws, only eight percent of children accused of crimes had lawyers, so a child who stole a piece of fruit would receive the same treatment as one who committed a felony. After the change, 71 percent of accused youngsters were represented, and the rudiments of a juvenile justice system was begun. In addition, 82 percent of children who were separated from their families in the disaster were placed with families or reconnected with relatives as a result of a family search program. Under the old system, orphanages would recruit and pay families for bright children with good academic records. A large Muslim nonprofit organization that formerly supported orphanages is reexamining its policies.

In Sri Lanka, a proliferation of orphanages came to be viewed as a secondary cause of family separation. Government and non-government agencies have started finding ways to reduce institutionalization of children, and to create safe recreational space where large numbers of children can be reached with basic social supports. Social spending has been increased in Sri Lanka and Indonesia since the tsunami.

Violence Against Women

Marie Skinnider, MD, Health Advisor to Medecins Sans Frontieres/ Doctors Without Borders, Canada, described the "consequences of gender-based violence in Papua New Guinea,” which has one of the world’s highest rates of domestic and sexual violence. One of her patients, in the first trimester of pregnancy, was gang raped while walking across a field in mid-afternoon. She had returned to her parents’ home because of domestic violence, and it appeared her husband had arranged the attack as revenge for her leaving him. Dr. Skinnider cited national survey data showing 67 percent of wives say they have been beaten by their husbands, and 60 percent of men say they have participated in gang rape at least once. The violence, she said, is generated and reinforced by the low standing of women in society: women are regarded as property of their husbands, and there are traditions of bride price and polygamy as well as a history of compensation and retribution attained at the expense of women. These social forces contribute to men being pressured by their peers to control women in their homes. Many women do not feel empowered to seek medical help, Dr. Skinnider said, and lack of transportation also prevents many women from going to health clinics.

Liberation Medicine in Education and Action Toward Health For All

Lanny Smith, MD is Professor of Medicine in the residency program of primary care and social medicine at Montefiore Medical Center, Albert Einstein College of Medicine in The Bronx, New York. He sees patients from the Highbridge and Morrisania sections in the Bronx, communities that are predominantly Hispanic and African American and that have extremely high poverty rates. He is also assistant director of the Human Rights Clinic for Victims of Torture and founder and president of Doctors for Global Health. He explains that liberation medicine has its roots in theology, psychology, ethics, education and liberation movements. The clinic design is inter- and multi-disciplinary, community-oriented and bottom-up, risk-taking, compassionate, and uses a praxis—practice in action—model. Online resources include Social Medicine and the People’s Health Movement. In a discussion after his presentation, he stressed the importance of careful listening and action learning. He cited Daniel Levin, who was acting assistant US Attorney General when he voluntarily endured waterboarding to decide for himself whether it constituted torture. He decided it did and later lost his government job.

Tags:  buscell  change  complexity matters  innovation  leadership  medicine 

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Superbugs and Antibiotics: A Deadly Dance

Posted By Prucia Buscell, Thursday, April 16, 2009
Updated: Tuesday, February 15, 2011
Clostridium difficile, a contagious and potentially deadly pathogen, isn’t just increasingly resistant to antibiotics. Its ability to cause serious infection is often triggered by antibiotic treatment.

An article in the Cleveland Clinic Journal of Medicine describes the bacterium, also known as C-diff, as a gram positive, spore forming bacillus that was first linked to disease in 1978 when it was identified as the cause of antibiotic-associated diarrhea and colitis. The February 2006 article, by Rebecca Sunshine, MD and L. Clifford McDonald, MD, says that more than 90 percent of healthcare associated C-diff cases occur after a patient has received antibiotic treatment for some other illness. The story is posted in the website of the federal Centers for Disease Control and Prevention.

Treatments with antibiotics are likely to disturb the bacteria that normally live in the digestive tract and colon. If a person’s exposure to C-diff coincides with that that disruption, the C-diff bacteria flourishes and releases toxins that are harmful to humans.

An April 14 story in The New York Times by Tara Parker Pope reports that health authorities estimate C-diff causes 350,000 infections each year in hospitals alone, with tens of thousands more in nursing homes, and that 15,000 to 20,000 people die annually from the infection. C-diff spores are hardy and live on environmental surfaces and people’s hands and clothing. They are not killed by alcohol based hand sanitizers and hospital cleaning agents. It takes bleach to kill them, which increases the difficulty of eradicating them.
A national prevalence study of C-diff conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) indicated 13 of every 1,000 patients in US healthcare institutions are infected or colonized with C-diff. Based on that rate, on any given day at least 7,178 patients are infected or colonized, at a cost that could range from $17.6 million to $51.5 million. The APIC study, released in November 2008, reported the C-diff incidences rate is between 6.5 and 20 times greater than previous incidence estimates indicated. The Times story notes C-diff now rivals MRSA as one of the top emerging disease threats to humans.

While C-diff has become increasingly virulent and increasingly resistant to antibiotics, recent research findings may lead to better treatment. A March 1, 2009 story in ScienceDailyreports that C-diff manufactures different toxins, and that researchers may have focused on the wrong one. Dr. Dale Gerding, a co-author of the study, published in the journal Nature, explained that while researchers have focused on Toxin A, recent research shows the real culprit is Toxin B. Gerding and colleagues found that the organism was fully virulent and caused disease when Toxin A was knocked out, but did not cause disease when Toxin B was eliminated. Researchers think understanding the relative importance of the two toxins could help pave the way for new methods to combat deadly C-diff infections.

Tags:  buscell  complexity matters  infection  medicine 

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