Sunday, March 27, 2016

Ebola, WHO and the timidity of some infectious diseases experts to criticise those with power

This is slightly adapted from a blogpost published in BODHI, one of the NGOs I co-founded in 1989. That is called Ebola, WHO and the failures of a market based approach to global health.

The importance of the "milieu" (the social and environmental, or "eco-social") context

In 2012 I wrote a paper called "Infectious disease emergence and global change: thinking systemically in a shrinking world" in the inaugural issue of Infectious Diseases of Poverty (impact factor now 4.1). It has been moderately successful; cited 24 times to date, and for several years it was the most viewed article in the journal (and it might still be). That paper attempted to make several controversial points. One was that the risk of a globally catastrophic influenza outbreak has been grossly exaggerated. But the most important point was that the global health community needs to pay far more attention to the "milieu", the "terrain" in which infectious diseases thrive, a point about populations analogous to that made concerning the personal milieu, the individual immune system, by the Claude Bernard, who rivalled Pasteur as the most famous French health scientist in the 19th century. I suggested that there are forms of social immunity, not just determined by "herd" immunity (conferred by vaccination) but by health literacy, poverty, health systems and environmental conditions.

In 2015 I gave an invited talk at an infectious diseases conference in Spain, which I called Poverty, demography and infectious disease. This again stressed the milieu. The opening paragraph of my abstract read:

"Generations of slash and burn neoliberal, almost laissez faire development policies, with only rhetorical nods to global conservation and equity, continue to erode not only many environmental determinants of health, but also many factors that underpin social and health development. Here are three warnings to all who will listen that we live in One World with One Health."  My three warnings concerned (a) Ebola; (b) slowed poor development even in affluent Indian children, speculatively linked to the inadequacy of the sanitation system, in turn related to discrimination against the poor, and (c) how "Planetary Overload" could produce a future milieu in which public health systems fail and old diseases (e.g. TB, plague) return.
The political correctness of leading infectious diseases experts

Unfortunately, very few people in global public health seem to be in sympathy with my main point. This perception has been strengthened by my review (forthcoming for Faculty 1000 Global Health) of a recently published report concerning the Ebola epidemic in West Africa, which is still ongoing (as of March 2016). This long article is called Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola".

Its lead author is Dr Susan Moon, from the Harvard Global Health Institute. This paper is highly critical of WHO's slow response to the appalling and frightening tragedy of Ebola in West Africa, but there seems no criticism of other big players in global health, such as the Bill and Melinda Gates Foundation, the Clinton Foundation (indeed, Chelsea Clinton is a co-author) nor, indeed, of Médecins Sans Frontières‎ (who are also represented in the authors). Worse, there is no mention of neoliberalism (or any synonym for it, such as market-based approaches) but also no criticism of vertical health programs (i.e. interventions focusing on single diseases, at the expense of  broader health systems).

The crisis of funding for WHO

In 2002, the budget of WHO was reported to be less than that spent on advertising by two cola companies (Coca Cola and PepsiCo) (1). Since then the WHO budget may have fallen even more, as evidenced by quotes (in the Lancet paper) such as: "in the wake of the global financial crisis (2008) when WHO laid off more than a tenth of its headquarters staff, outbreak response capacity was deeply and disproportionately cut." "Decades of reducing assessed contributions in real terms has starved the organisation of resources."

The Lancet article includes extensive recommendations for how WHO might be strengthened, mainly by narrowing its focus and trying to wrest a different form of funding. But, again, there is no criticism of the international milieu which determines this funding.

The paper recommends that a global strategy be developed to invest in, monitor, and sustain core national health capacities. However, the onus seems then to be largely placed on WHO to do this ("WHO should convene governments and other major stakeholders within 6 months to begin developing a clear global strategy to ensure that governments invest domestically in building core capacities and to mobilise adequate external support to supplement efforts in poorer countries.")

We cannot just focus on firefighters: we need to reduce the risk of catastrophic fires

But the broader challenge of promoting development in low-income settings appears to have been overlooked in this paper. Firefighters are needed, but so is fire prevention. London banned thatched roofs following its Great Fire (1666).

WHO cannot do everything. There is far too little recognition that market forces, untramelled, combined with laissez-faire, environmental policies and population growth generate the milieux in which Ebola and other pandemics thrive (the point I made in my 2012 paper mentioned above.) This blindspot is also evident in a paper written by Bill Gates about Ebola.

This difference can also be seen as that between Bernie Sanders and Hilary Clinton. Clinton and other supporters of neoliberalism hold most power, and appear to sincerely believe in their own rhetoric; they know best. But many younger Democrat  supporters, who strongly favour Sanders, recognise the failure of conventional policies to give hope to the poor and the young. Donald Trump's support is driven by some similar factors; especially the realisation that so-called free markets are failing the inner-cities. Trump's isolationism is likely to further erode support for WHO, and the U.N. However I am uncertain Trump's policies will be that much worse for other determinants of global health than of Hilary and Bill Gates. However, at least, Melinda Gates has some awareness of the risk of unrestrained population growth.

1. Lang, T., Rayner, G.; E., K. The food industry, diet, physical activity and health: A review of reported commitments and practice of 25 of the world’s largest food companies. Report to the World Health Organization; City University Centre for Food Policy, London UK: 2006.

Thursday, March 24, 2016

The "war on terror" that will not end while we continue to make the same errors

I just read a report about the inquest into the death of Numan Haider, the troubled 18 year Afghani-Australian, shot in September 2014 by a policeman who he had just stabbed.

Prof Greg Barton says Numan's (Islamist) radicalisation was very fast, and I accept that. However, there seems to me, on reading this, that there was ample evidence for those close to Numan to be very concerned indeed. As adolescents mature, they can change rapidly; I personally don't find Numan's story surprising (apart from its miserable end). Rapid changes in thought processes are very common in adolescence, if not towards Islamist radicalisation then certainly to other forms of radicalisation. If rapid Islamist radicalisation is currently rare that may well change in the future.

How not to establish rapport

The police, it is reported, tried to establish "rapport" with Numan on the day he was killed. The way they are reported as attempting this (if true) is sadly naive, almost unbelievable, even  though I think the idea of trying for more rapport is excellent.

I remember when I was 18; if I was asked to report to a police station I would have felt extremely uncomfortable - it's hardly neutral territory to establish "rapport" is it? Instead, they could have suggested meeting for a kebab, or something like that, and worn plain clothes.

The "war on terror" that will not end while we continue to make the same errors

As for the wider, ever deepening series of terrorist tragedies in Europe, Turkey and elsewhere: I first published on these issues in 2000. My opinion then was that global inequality is so high that privileged populations should expect a backlash. I argued then, and I have argued many times since, that reducing inequalities are the best way to ensure the sustainability of civilisation. I hear and read occasional echoes of that view from Muslims, but such opinions, uttered by non-Muslims, are virtually never heard on mainstream media, and not much in academia, either. Paul and Ann Ehrlich's book  "One with Nineveh" is a notable exception. An essay by Thomas Piketty puts an interesting twist on this, but I believe his points as reported (inequality in the Middle East) are only a minor contributing  cause. (Note Piketty's blog is French, my comments are based on a commentary.)

While we in the rich countries continue to support the use of drones and other forms of extreme violence, all too often killing civilians, and even striking an MSF hospital in Afghanistan, we cannot expect victims to consider us as benign. They will try to strike back and they will attract sympathisers. We need to at least move in the direction of a fairer world, not an intensifying fortress world.

Democracy, dharma and the long struggle

I am giving a talk tomorrow at Parliament House, in Canberra, to commemorate the 125th birth of Dr Ambedkar, in a meeting called "The Celebration of Social Justice and Empowerment - The Legacy of Dr BR Ambedkar". This is organised by the Dr Ambedkar International Mission, Australia 

My talk is posted here, and my slides here.

In summary, my talk traces some of the struggle for greater democracy, including the French Revolution, Peterloo (Manchester, 1819), the Chartists and the Suffragettes. I mention Emily Davidson, a suffragette who had endured more than 50 forced feedings and who had been in prison many times. She was trampled by a horse during the Derby before the English king. 

Dr Ambedkar is part of that great lineage for greater social justice, in  a struggle that is very far from over.

Monday, March 7, 2016

Open Letter to Media Watch concerning their attack on Catalyst and Dr Maryanne Demasi

This letter was originally signed with four of my colleagues, all academics (i.e. 5 in total); it was sent to Media Watch on March 7, 2016.

To ABC staff at Media Watch

We are writing as a scientists (one a parent of children of the generation born into wi-fi) with expertise in medicine, public health, epidemiology, environmental studies and the “Precautionary Principle” to express concern about the tone and content of the broadcast of Media Watch on February 23, 2016, concerning the Catalyst programme, presented by Dr Maryanne Demasi on Feb 16, 2016. This broadcast concerned the safety of mobile phones and radio-frequency radiation (including “wi-fi”).

Media Watch used phrases such as “supposed dangers of wi-fi and mobile phones”, “Demasi’s so-called ‘investigation’, “scorned in this way”, “Demasi’s program was shockingly one-sided” and “the scientific consensus weighs heavily in the opposite direction”. We bring together our expertise to make the case (below) that such claims are patently wrong, in so doing adding to and supporting Dr Demasi’s own defence.

As stated in the Catalyst programme, by Dr Bruce Armstrong, Emeritus Professor of Public Health at the University of Sydney, the International Agency for Research on Cancer (IARC) in 2011 classified radiofrequency radiation as a Group 2B possible human carcinogen. Prof Armstrong also stated that more recent “studies do suggest rather more strongly than the body of evidence available to IARC at the time of its evaluation that there is an association between heavy mobile phone use and brain tumours.” Furthermore, as Catalyst also stated, “mobile phone manufacturers themselves are aware of the potential risks which is why they recently put warnings in each device.”

We believe that to promote the public good, science needs an informed media. The issues raised by Catalyst in Demasi’s investigation are highly complex and uncertain, and there is insufficient space in the letter format here to review the scientific considerations involved.

Instead, we write in the hope that this letter will bring perspective in its support of exactly what Demasi produced and aired, leading to a more nuanced consideration by your programme, Media Watch, of the “Precautionary Principle”. This term, coined a few decades ago, restates ancient wisdom expressed in sayings such as “play it safe” or “an ounce of prevention is worth a pound of cure”, or a “stitch in time saves nine”. But, of course, as also long recognised, one can have too much caution leading to “s(he) who hesitates is lost”. This is the conundrum for those of us working at the interface of research and policy.

In our view, there are good arguments to promote the use of mobile phones and wi-fi, but there are also well-documented safety concerns. We recognise, at the moment, that social consensus in Australia accepts that the benefits of mobile phones and wi-fi exceed their risks, although there are insufficient data to conduct a meaningful risk-benefit evaluation. Catalyst provided a valuable service in not only reminding the public of these risks, but of describing several practical ways to lower them, including reduced exposure of the head to mobile phone use (eg a hands-free kit, speaker phone use) reduced body contact during mobile phone carriage, and the thoughtful placement of routers with the additional suggestion to turn them off during sleep.

Contrary to the assertion in Media Watch, our view is that programmes such as Catalyst should not necessarily follow formulae that give equal time to the dominant view, often sponsored by vested interests, especially when it is based on limited relatively early data. In scientific papers (other than reviews) this is rarely the case. Scientists seek to advance knowledge. Hypotheses are tested and literature interpreted in ways that explore our theories. Over time, good science discards false theories and approaches truth. Rather than balance, science seeks knowledge. Catalyst is a mix of science and media; we did not find its presentation to be unfair, but refreshing and a valued public service.

In this case, Catalyst provided a forum for the expression of the activist scientist, Dr Devra Davis, who, like us, advocates judicious use of the precautionary principle.

Finally, we note that evidence for widespread public concern about the issues raised here by Catalyst is also shown in many of the 256 comments on your website (as of March 1, 2016), the vast majority of which also called for more appreciation of the precautionary principle (albeit using a variety of synonyms).

We congratulate Dr Demasi for both the insights conveyed and the accuracy of her message vis á vis the state of the art in radio-frequency radiation health effects. It is an example, in our view, of responsible science journalism in the public interest.

Yours sincerely

Professor Colin D Butler BMed, BMedSci(Hons), DTM&H, MSc(epidemiology), PhD (epidemiology and population health)
Faculty of Health and Health Research Institute, University of Canberra, Australia;, Canberra
Visiting Fellow, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
Founding co-chair: Health-Earth
Co-Founder: BODHI and BODHI Australia

Associate Professor Mark Diesendorf  BSc (Hons), PhD
Interdisciplinary Environmental Studies
School of Biological, Earth and Environmental Sciences UNSW
Australia Sydney NSW 2052 Australia


Dr Murray May BSc (Hons), DipEd, MEd, PhD
Visiting Fellow, School of Physical Environmental and Mathematical Sciences,
UNSW Canberra

Em Professor Colin L Soskolne PhD
University of Alberta;
Adjunct Professor, University of Canberra
Fellow, American College of Epidemiology;
Fellow, Collegium Ramazzini Chair, International Joint Policy Committee of the Societies of Epidemiology (IJPC-SE)

Plus one colleague to be confirmed

PS As of today (May 16, 2016) our letter has not been acknowledged.

As of today (Jan 21, 2018) still no acknowledgement. The BMJ has been reviewing our article for almost 7 months. No decision as yet.