Flu season 2012-2013 could be bad

The CDC influenza surveillance system indicates that seasonal flu (H3N2) has gotten off to an earlier start than usual, and the attack rates are higher than usual. Collaborating labs are reporting steadily increasing numbers of isolates. There is only one reported case of a novel virus, indicating that genetic shift has not occurred. The ILI (influenza like illness) surveillance system indicates very high activity in Texas and in some of the southeastern states. See:


for CDC’s “Fluview”. 

The actual trends have been presaged by similar increases in search term inquiries in Google Flu Trends, which has been shown to predict actual flu activity–and precede surveillance data by weeks.

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Medical geography: a better name needed

The traditional “medical geography” has been replaced in discussions in the field of geography by “health geography.” Neither describe the field adequately. To me, the importance of medical geography is one of perspective and of methodology: a view of health and disease from the perspective of spatial patterns, and of human-environment relationships. “Medical” refers more to diagnosis and treatment. “Health geography” connotes, to me, a de-emphasis of disease, while most research in epidemiology and related areas deals with disease. “Disease geography” de-emphasizes health. So “epidemiologic geography”? “Geography of health and disease”? Please leave suggestions or comments.

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New SARS-like virus identified

I am back again after a long interval during which I had spine surgery. It was my first experience with an operation. I have seen over 500 of them from the OR side for a project on anesthesia and pain, but had yet to experience anesthesia myself. It was very interesting, really. A very smooth induction, and a very smooth emergence without nausea and vomiting–both pretty common post-anesthesia, but less so with some of the agents that are now being used. It is ironic that in the midst of a long standing project and interest in pain, I had the “privilege” of experience both. I find that most of my ideas come from experience.

My first seminar of the year on medical geography begins today, and I am excited to meet the new graduate students (17)

The subject of today’s posting is the new SARS-like coronavirus that has been identified in two patients: one in Saudi Arabia who died, and another in the UK. It is difficult to ascertain what the significance of this newly identified virus is. Are these patients just two of many who have contracted the virus, and it was not identified previously? Are these isolated cases? Is this the beginning of an epidemic? Only time will tell.

The rapid identification of the virus demonstrates the importance of new technologies for identifying the genomes of viruses and other pathogens. Identifying genotype can now occur quickly using DNA/RNA amplification techniques, and this allows placement of the virus on a phylogenetic tree, which is a statistical and graphical technique for ascertaining similarities between viruses.
See the following website for an excellent glossary:

This virus is not *SARS*. There are many coronaviruses, with renewed interest since the SARS outbreak. Some of these can cause respiratory symptoms, and others gastrointestinal symptoms.

Only time will tell whether this particular virus will be consequential for human health. It is impossible to tell from only two cases.

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Are social determinants of health actually determinants?

There has obviously been a tremendous proliferation of research on what has long been labeled “social determinants of health.” The wording, however, is unfortunate. “Determinants” suggests determinism–a mechanistic set of influences that do not allow for the possible, for the stochastic, for the undetermined. The problem with “social determinants of health” is that it is too–deterministic. This is an irony. We cannot treat social factors such as locus of control, inequality, and structural violence as though they are deterministic variables in simple Newtonian mechanics. The irony is great. I now use “social influences on health” as a simple substitute. We need new words. Language can determine how we think.

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Public Health: Responsibility to whom?

In clinical medicine, responsibility is to the individual patient. I have often thought that in public health, our responsibility is to the population–to the group, the collective, the strange amalgam of “society.” As somebody put it, “the responsibility of physicians is to the patient. Our patients are all of society.” Many go into public health from either planned or actual medical careers because of the realization that effective change begins with more than the patient. There are all sorts of theoretical and very practical problems that arise from this dichotomy–including the very definition of ethic’s ‘beneficence’–a pillar of medical ethics. In public health, there are frequently divergent views of what specific acts and changes are beneficent, and to whom. This takes us into the whole realm of social justice–distributive justice–the ‘who benefits?’ and at whose expense? And what is society? And what is the relationship between individuals and society? These are deeply social and philosophical issues.


I have been thinking about this a great deal and am embarking on a long term project on the juxtaposition of individual rights and collective rights in public health, and when and how they can conflict. Vaccination, motor cycle helmet laws, environmental tobacco smoke, the health plan now before the Supreme Court, all are examples of this. I began thinking of this a long time ago when I first got into TB research and realized the immense potential ethical conflicts of forced quarantine and even medication for somebody with MDR-TB, for example–a person not willing or able to take medication, and therefore serve as incubators for selection of further resistant organisms. So boom….


This brings me full circle to when I was finishing my clinical and policy ethics fellowship in the late 1980s–3 years, funded by Kellogg. Issues of ethics and moral action usually don’t just disappear. Over the next 2 years, I’ll be trying to tackle some of these issues, and will be writing about them here from time to time.

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Jim Kim and his nomination to president, World Bank

Last week, Jim Kim (Jim Yong Kim) was nominated by Pres. Obama to serve as President, World Bank. This is a brilliant nomination. Before his Macarthur fellowship (incorrectly known as the “genius fellowship”), he was a Kellogg National Fellow, and we share the latter in common.

Jim has the unusual credentials of being a physician, having a PhD in medical anthropology as well as his MD, and service as President, Dartmouth College. He was co-founder with Paul Farmer of Partners in Health (PIH) as described in Tracy Kidder’s book, “Mountains Beyond Mountains”. Jim also served as head of the HIV division at the World Health Organization, where he developed the 3 x 5 program.

JIm has been criticized as lacking a background in finance. However, he will the entire staff of the Bank to advise him in this area, and Jim should be seen as a leader–a visionary leader–who also knows how things work on the ground. Leadership demands a broad perspective that includes ethics, social policy and organization, ability to develop a vision and to motivate people to share this vision. Jim will excel at this. The World Bank is basically an international development organization. Jim has spent his career working in this area. He values social equity, is well aware of global and local disparities in health, wealth, and power, and of the power of the World Bank itself to invest in policy as much as programs. With the IMF, the World Bank developed its structural adjustment policies, which even staffers at the Bank admit to being a failure. These policies required investment in economically productive activities–frequently industrial development, construction of transportation networks, and so on. This forced many to most of the recipient nations to move both attention and investment away from social services, including public health, and health services. Though the Bank has moved away from this policy because of its social consequences, many still believe in this as a way for regions to develop. This will not happen with Jim.

Jim’s orientation will move the Bank from its emphasis only on investment to a position as a progressive leader in international development, emphasizing social investments as well as directly productive activities. We should have no illusion, though. A leader can only go so far unless there is buy-in from employees, constituencies, and stakeholders. If such consensus develops, then Dr. Kim’s appointment could represent a progressive landmark in setting a progressive social agenda for needy nations.

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Contagion as a teaching tool

I am planning on showing “Contagion” today in my undergraduate disease ecology class. As my previous blog entry indicated, i think that the concepts that are illustrated in this excellent film include: disease spread and its elementary math; routes of contagion and the possibility of airborne viruses spreading quickly internationally, and locally; human impacts of infectious disease; and containment, prevention, surveillance, and control measures. I think that these concepts come alive in the film, and when students see the film, they will immediately see the relevance for our own society,

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“Contagion”-movie with Matt Damon et al

We saw “Contagion” last night–as an official function of my position with the American Society of Tropical Medicine and Hygiene (see astmh.org—and note that students can join and receive a top infectious disease journal for $5.00 per year). The film was excellent in all respects. It is more of a chronicle of a hypothetical event than a film with many subplots, with the setting (an outbreak) only providing a stage for a story about a conflict, or a relationship, or….? This film is scientifically accurate, and the movie is surprisingly tight. The concept of the basic reproductive rate (R0) is explained perfectly, and using everyday terminology. The acting was excellent. Ian Lipkin, a high school classmate and now an epidemiologist at Columbia, as well as a virologist and neurologist, was on the set during filming, to make sure that the technical details, including lab procedure, were correct. It is very difficult to really criticize the film. As Dr. Lipkin said in an interview, this may be a wake up call. I add: the scenarios in the film are entirely possible. Some would say even probable–though I won’t go that far. Go see the film, and if possible, see the IMAX version. Think about it. Learn. But do not say or think, “it can’t happen here.” It can. And I hope that we–the public health infrastructure; government units; everyday citizens–are prepared.

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Contagion; malaria vaccine

I am eagerly awaiting “Contagion”, starring Matt Damon, among others. It had two excellent science consultants–my high school classmate Dr. Ian Lipkin, who directs a center at Columbia (Mailman School of Public Health) and is a virologist and neurologist by training–but has also become an epidemiologist. He speaks highly of it. Laurie Garrett, the well known public health journalist, says that they got the science right this time.

I’ve been asked to review the film for the American Society of Tropical Medicine and Hygiene. I edit the online publications–really, the contents of the web related things–but my article will be in the newsletter. I’ll let you know what I think of the movie after tomorrow night.

On another front, there is no malaria vaccine that has been released for one of the major causes of mortality and morbidity in the world. Several are in Phase 3 clinical trials, and the first vaccine will be released before 2011. That may be nice for travelers, but how will the vaccine reach the people in endemic areas–the real sufferers of malaria?.GlaxoSmithKline will release their new RTS,S vaccine. A novel idea that shows promise has been written up in Science. The vaccine uses mosquitoes themselves (well, highly fragmented–a derivative) as a bioreactor. Really though, the vaccine is derived from the dissected salivary glands of infected anophelines, using the sporozoite stage of the parasite. It did not look like a good vaccine in early trials, but a recent study showed that if it is administered intravenously, it now shows much better efficacy in animal models. So, stand by! It reminds me of the contemporary use of leeches for stimulation of blood circulation in reattached fingers, toes, and other appendages, as well as the use of maggots to deride wounds–especially useful in diabetic ulcers and infections. While in the operating room, I asked one of the hand surgeons how he wrote up orders for maggots in an admissions note. At one of the hospitals where I spend much time, that is simple. “Use maggots per protocol” is the standard order. The hospital inpatient pharmacy has them in stock, and keeps them viable.
So, back to writing “in the news” for the trop med society.

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Assorted observations

The sun is setting on a warmish day in Seattle, and the fact that there was sun and that I can say “warmish” portends better weather ahead. Having just caught up on several issues of The Lancet, I reaffirm that it is, for me, the most interesting journal that I get.
Of the many items of interest in the June 11-17 issue, several resonated.

In 2010, there was an increase in corporate philanthropy of $2 billion. Half of that increase was by pharmaceutic companies in the form of both medication donations (presumably to developing countries), and monetary donations. In the midst of many deserved attacks on the industry, I am reminded that some pharmaceutical companies have made sizable. donations. Best known is the donation, mostly to African counties, of ivermectin by Merck. Ivermectin is used to treat hookworm, onchocerciasis, and other parasitic diseases. Hookworm is the most common cause of both mild and severe childhood anemia, and ivermectin is highly effective. Onchocerciasis, nickname “river blindness,” is one of the most prominent causes of blindness in countries where it is endemic, and the WHO, NGOs, and charities, in cooperation with local health agencies, have made concerted efforts to eliminate oncho. GIS, couple with remote sensing, have been instrumental in these efforts, because these tools point to high risk areas and with this, targeted intervention can take place. In addition, GIS is crucial in accurate prediction of where oncho will be found in the future.

Another brief article on HIV in Mississippi demonstrates that nearly 50% of the individuals who are HIV positive do not receive antiretroviral therapy, and, notably, this is a rate comparable to that found in Ethiopia. Accessibility to health care in that state is very poor. About 40% of the population lack sufficient access to family physicians and other primary care clinicians. These, and other themes, are highlighted in a report by Human Rights Watch titled “Rights at Risk.”

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