Read this brief commentary in the Lancet by James Pfeiffer and Rachel Chapman on health systems strengthening (or lack thereof) in Mozambique. They write,
“The “golden age” of global health aid, as some have called it, was not a golden age of health system building. So after 10 years and millions of dollars, on the day we visited that health centre there was still only one nurse who could provide 7 minutes each to dozens of pregnant women waiting for hours, with leaking roofs, broken filing cabinets, and no activistas (since the funding had dried up)—not because the money was stolen or lost by the government, but because the health system itself received very little of it. Instead, aid funds built a massive NGO infrastructure that will dissipate as soon as donors tire of the effort.”
This is consistent with my own experience. When we analyze these global health “interventions” we must ask if they are locally owned and operated. Are they truly integrated into the health system? Are they sustainable? All too often, the answer is no.
Your grandmother is probably taking a medication to lower her cholesterol. Who funded the researchers who performed the clinical trials of the drug? Does it matter? There has been a growing debate about conflicts of interest in medical journals. Read Lisa Rosenbaum’s three part series (1, 2, 3) and NEJM Editor Jeffrey Drazen’s accompanying editorial. Then, read the response of former NEJM editors Robert Steinbrook, Jerome Kassirer, and Marcia Angell published in the BMJ. This is an important debate.
When we physicians hear the term “retrovirus,” we instinctively think of HIV. That is understandable. HIV/AIDS has infected and killed tens of millions of people worldwide. But there are other retroviruses out there. One such virus is called Human T-lymphotropic virus type 1, or HTLV-1. HTLV-1 was the first cancer-causing retrovirus to be discovered, in 1980, by Robert Gallo and colleagues. HTLV-1 causes a dreadful, rare disease called adult T-cell leukemia/lymphoma (which I have only seen once as a physician). That patient was left debilitated and unable to communicate. HTLV-1 is found around the world and 5-10 million people are infected. It apparently originated from a primate retrovirus called simian T-lymphotropic virus type 1 (STLV-1). STLV-1 infects many species of apes and monkeys. HTLV-1 is thought to have originated from STLV-1 because the viruses have similar genetic sequences. Interestingly, HTLV-1 is very prevalent in some areas of the world, like Japan, where there is virtually no contact between people and primates. In those areas, it seems to spread via mother-to child or sexual transmission. In areas of Sub-Saharan Africa such as Cameroon, however, the situation is markedly different. In rural Cameroon, many hunters collect and consume bush-meat from apes and monkeys and that may lead to HTLV-1 transmission. The authors of a recent study in Clinical Infectious Diseases set out to investigate the risk factors for HTLV-1 acquisition in humans via interspecies transmission of STLV-1. The researchers studied 269 individuals (mostly men) living in the southern Cameroonian rainforest. Most lived in the general vacinity of Lomie, seen on the map below. The investigators compared individuals who were bitten by a gorilla, chimpanzee, or small monkey to those who had not been bitten. Interestingly, they found that individuals with severe bites (particularly bites by gorillas) were more likely to be infected with HTLV-1. Their results suggested ongoing direct transmission of STLV-1 in humans through severe bites during hunting activities. More studies are now being undertaken in hunters. What are the implications of this study?
In the context of HIV/AIDS (also a retrovirus of zoonotic origin), Ebola in West Africa, MERS-Coronavirus in the Middle East, and H7N9 influenza in China, there is an increasing recognition of the importance of the transmission of microbes between animals and humans. There is a concept called “One Health” which recognizes that the health of humans is connected to the health of animals and the environment. Unfortunately, as far as I am aware, “One Health” are barely taught in medical schools. That needs to change, quickly. Habitats are being disrupted all around the world and disease transmission is occurring as a result.
I have taken care of many HIV-infected gay men over the years. Some died from the complications of advanced AIDS. I think those preventable deaths were largely due to stigma, fear, and discrimination which led to delayed diagnoses of HIV. Today I am pondering Ireland’s surprising vote to legalize gay marriage. A major victory, this will hopefully reduce homophobia. If the Irish can change, why can’t we all?
I just finished reading Oliver Sacks’s memoir, On the Move, and decided to write a quick blog review of this exceptional book. (If you want to read a professional book review, I suggest Michiko Kakutani’s in the New York Times or Will Self’s in the Guardian).
Sacks surprises the loyal readers of Awakenings, The Man who Mistook his Wife for a Hat, and An Anthropologist on Mars with extreme tales from his youth. For example, he had a penchant for powerlifting/bodybuilding, amphetamines, hitchhiking with truckers (he goes by his middle name of “Wolf,”) and motorcycling through rural California. The peaceful-appearing neurologist even comes off as as frightening at one point, when a car full of teenagers tries to run him off the road. Sacks, 260 pounds, pursues them on his motorcycle brandishing a club, “like the mad colonel astride the bomb in the final scene of Dr. Strangelove.”
Sacks loves taking care of patients, but struggles to fit in and develop a career in medicine. He is fired from his job at Beth Abraham Hospital. In his early years, despite publishing several well-received books, he has no faculty appointment in a department of neurology. “I am a gypsy, and survive— rather marginally and precariously— on odd jobs here and there,” he writes to one medical student.
Swimming is a theme of the book. In the water, some of his best ideas develop:
“The greatest joy of all was swimming in the placid lake, where there might be an occasional fisherman lounging in a rowboat but no motorboats or jet skis to threaten the unwary swimmer. The Lake Jeff Hotel was past its prime, and its elaborate swimming platform and rafts and pavilions were completely deserted and quietly rotting. Swimming timelessly, without fear or fret, relaxed me and got my brain going. Thoughts and images, sometimes whole paragraphs, would start to swim through my mind, and I had to land every so often to pour them onto a yellow pad I kept on a picnic table by the side of the lake. I had such a sense of urgency sometimes that I did not have time to dry myself but rushed wet and dripping to the pad.”
It could be argued that writing is actually the love of Sacks’s life (he kept over 1000 journals)
“I am a storyteller, for better and for worse. I suspect that a feeling for stories, for narrative, is a universal human disposition, going with our powers of language, consciousness of self, and autobiographical memory. The act of writing, when it goes well, gives me a pleasure, a joy, unlike any other. It takes me to another place— irrespective of my subject— where I am totally absorbed and oblivious to distracting thoughts, worries, preoccupations, or indeed the passage of time. In those rare, heavenly states of mind, I may write nonstop until I can no longer see the paper. Only then do I realize that evening has come and that I have been writing all day.”
Sacks touches on one of the central criticisms of his work, the accusation (in my opinion, unfounded) that he has taken advantage of his patients for his literary career. How was it possible for Sacks to “write about these patients and even film them, yet continue to be seen by them as a trustworthy physician, not as someone who had exploited or betrayed them.”
Sacks doesn’t answer the question directly, but I come away from “On The Move” trusting that he had his patients’ best interests at heart. This is an important issue for we physicians who want to write about our work. (This theme was also explored by Dr. Anna Reisman in an essay in The Atlantic.)
The bravest and most surprising part of Sacks’s book are the discussions of his sexuality. He describes his mother’s furious reaction when she learns that he is gay.
“You are an abomination,” she said. “I wish you had never been born.”
Sacks withdrew from his mother but felt guilty about it the rest of his life. He lost his virginity in Amsterdam while drunk (it is unclear but appears that he may have been raped).
Sacks then developed a relationship at the age of 20 with a man named Richard Selig:
“We would go on long walks together, talking about poetry and science. Richard loved to hear me wax enthusiastic about chemistry and biology, and I lost my shyness when I did so. While I knew that I was in love with Richard, I was very apprehensive of admitting this; my mother’s words about “abomination” had made me feel that I must not say what I was. But, mysteriously, wonderfully, being in love, and in love with a being like Richard, was a source of joy and pride to me, and one day, with my heart in my mouth, I told Richard that I was in love with him, not knowing how he would react. He hugged me, gripped my shoulders, and said, “I know. I am not that way, but I appreciate your love and love you too, in my own way.” I did not feel rebuffed or brokenhearted. He had said what he had to say in the most sensitive way, and our friendship continued, made easier now by my relinquishing certain painful and hopeless longings.”
At times while reading this book, I felt sorry for Sacks’s isolation. He lives far from his family in England and has no partner or children. In addition, as the memoir goes along, Sacks’s parents, siblings, and close friends die off, one-by-one. But happily, Sacks finds new love at the age of 75, with a writer named Billy Hayes. It is a lovely way to end this powerful memoir:
“We often swim together, at home or abroad. We sometimes read our works in progress to each other, but mostly, like any other couple, we talk about what we are reading, we watch old movies on television, we watch the sunset together or share sandwiches for lunch. We have a tranquil, many-dimensional sharing of lives— a great and unexpected gift in my old age, after a lifetime of keeping at a distance.”
Happy that our new article is online… if you don’t have access, and want to read it, email me and I’ll send you a copy.
A 37 year-old woman (G3P1) presented at 8 weeks gestation with 3 weeks of fever, cough and malaise.
Fever in early pregnancy is often due to common infections such as those due to respiratory viruses and urinary pathogens. Viral infections such as Epstein Barr Virus (EBV), Cytomegalovirus (CMV), or Human Immunodeficiency Virus (HIV) leading to mononucleosis or a mononucleosis-like illness are high on the differential diagnosis of this young patient with weeks of high fevers and nonspecific symptoms…