Thursday, 23 October 2014

Bernadel Quartet

http://www.bernadelquartet.com/

IMG_1939.JPG Bernadel Quartet

 

 

These boys and girls are good. Having them play three yards away is a privilege: each finger moving in vivid synchrony with the cascading sound in a gracious room by the river, all London forgotten in stately Haydn’s String Quartet No 55 and the more vivid and Slavic Shostakovich String Quartet No1 1. Then a quiet drink with the 21 other members of the audience, and finally Beethoven String Quartet No 7, at which the world must bow the knee, knowing that creation of that sort comes but once.

When Robert Graves went before the examiners as a young man one Don leant forward and said accusingly: “You have preferred some poets to others”. When four excellent young musicians play so well together I should simply enjoin you to follow the Bernadel Quartet. Do so. Nonetheless, although you will enjoy them all, I think you will find yourself watching violinist William Melvin.

And so to bed.

A demented government plan

As you will have noted in previous posts, I intend to write without fear or favour about mental prowess, and in that spirit can only describe as stupid a government plan to pay General Practitioners £55 for the next 6 months for every diagnosis of dementia they make.  First and foremost, getting a diagnosis of dementia can damage the life chances of elderly patients.  Second, dementia is not currently a treatable condition. Third, doctors cannot diagnose the condition accurately. Fourth, a proper assessment of dementia requires a base rate psychological assessment and then a re-test 6 months or more later. Fifth, a GP ought to be allowed to exercise some professional judgment without being suborned to meet the Flavour of the Month Five Year Plan.

So, to what do we owe this stupidity? The reasons given are that the Powers That Be have determined that dementia is under-diagnosed, and therefore family doctors need an incentive to label people properly, rather like pouring concrete walls to make rivers run in tidy straight lines. One of the things this silly policy intends is that doctors should “visit care homes to assess very elderly people who have not previously been checked for dementia”. What fools. How will this pointless paper exercise assist the brain function of the elderly? In the better homes they are already being given tasks and experiences to keep them mentally active (more in hope than because of established efficacy) and in the poorer homes they would do those exercises if they could afford to hire the staff.

Prof Sir Simon Wessely, who can always be counted on to make sensible remarks despite being President of the Royal College of Psychiatrists and a Knight of the Realm said “"at the moment the evidence favours either improving social care, or investing in research to find new treatments that actually modify the course of the disease. Until that happens I can see little point in this initiative.” By rights, that ought to stop the nonsense in its tracks, but here is a little further explanation.

When you try to diagnose dementia, you come up against g (general intelligence). It is simply inescapable. To get advance warning of memory problems you have to test memory. Because all mental abilities are correlated in a positive manifold, a bright person with memory problems will often still have a better memory than a duller person without memory problems. If you want any accuracy you have to do a full intelligence test and a full set of memory tests. By looking at both types of performance you can hazard a guess as to whether current memory abilities are worse than would be expected, given the estimated lifetime intelligence level of the person concerned. To improve on that initial opinion, you treat it only as a baseline, and test the person again after at least another 6 months, when practice effects should have faded, and the condition may have progressed. You draw the line of slope, and make some predictions about the rate of decline, distinguishing between the age related norm and the faster decline that may be part of dementia.

Of course, all this takes time, so standard NHS policy is often restricted to doing a one time screening test, coupled sometimes with a brain scan. The latter is pretty to look at, but of surprisingly little diagnostic help. Most of the observable changes are those seen in people of that age, and the correlation between the scan and real life capability is weak.  Nonetheless, a doctor then signs a form and bingo, your chances of getting into a pleasant nursing home are reduced to almost zero.

An elderly friend, of high ability and inquisitive mind, with failing physical health, selected a nearby nursing home, not far from his flat, which would keep him in touch with his friends and his old haunts. He had previously mentioned to his hospital doctors that he was worried about his memory, and so was given a screening test. On this slender basis he was diagnosed with dementia. The nursing home turned him down, on the basis that they would have taken him, given his presentation at interview, but that they could not take on someone with a dementia diagnosis. They were implacable when, late in the process, I found out what had happened, studied the psychological report, and pointed out that this conclusion was premature, to say the least. After some discussion he is now in his flat, with staff visiting daily, and the arrangement seems to be working for the time being. His memory is still good, his physical state rather frail. Should things get worse, he will not be able to go to his preferred nursing home.

Even if dementia could be diagnosed with a high level of accuracy (perhaps using annual symbol-digit subtest scores) diagnosis without an effective treatment is a baleful gift. Expectations are reduced, friends drift away, and normal decline becomes abnormal disease.

Of course, it is very likely that every single person associated with this stupid policy is probably well intentioned and perfectly capable of solving difficult intellectual problems in other contexts, and also kind to children and animals. However, some collective process seems to have drained the intellect out of them. Come to think of it, perhaps the policy was formulated in a moment of abstraction brought about by poor concentration and failing memory. Perhaps they all drifted into the conference room at the Dept of Health, forgot why they had come into that particular room, signed a document they found there because it seemed the sort of thing they had always done, and then tried to make their way down the maze of corridors to the room they half-recognised as their own office. I hope they will be treated kindly, kept warm and well fed,  and that absolutely no-one will stoop to denouncing them for £55 a head.

Wednesday, 22 October 2014

Lefties and the media

 

Pew Research have been looking at Liberals (lefties) and Conservatives (righties) and noting what media they consume in the USA. To my mind, the main finding is that the media are dominated by lefties. As I have explained, on leaving college the righties go into business, do the heavy lifting, make the money and pay taxes; and the lefties go into education and public service, and scribble the theory. 

 

image

http://www.journalism.org/2014/10/21/political-polarization-media-habits/

When readers are asked to say which of the most notable 36 US news sources they follow, no fewer than 28 are trusted by liberals to express their point of view. The headline that Pew should have used is: “78% of US Media Socialist”. So rich is the array of Left inclined propaganda sheets that Lefties can pick and choose their brand of communism from 4 main outlets: CNN, MSNBC, NPR, NYT. In contrast, Conservatives cluster round the outpost of Fascism which is Fox News. They distrust 24 of the same notable 36 news sources. I regret that, as a BBC consumer, I cannot tell you much about any of these US offerings, but The Guardian is recognisably to the Left, and bills itself as such. The Economist is a bit surprising, because business publications tend to the right, but it is certainly far to the Left on intelligence.

I suppose that, from another perspective, US liberals could say that they are truly Liberal, and watch a range of outlets, including Fox News, while Conservatives, as the name implies, watch virtually nothing else but that preferred provider. To put matters in context, although viewers prefer particular news outlets, they are exposed to a wider range, even though they may not concentrate upon them, so it is not a case of complete tunnel vision.

Of even more psychological interest is that US Lefties are more likely than Righties to dump friends who do not hold to their political opinions. This is strange, and suggests that a strict “purity” or “solidarity” measure is being applied on the left. Expulsion from the party was certainly a Bolshevik control mechanism: declaring that former persons were now un-persons, which in modern times translates to un-friending and un-following errant comrades. Conservatives tend to congregate round those who hold similar views, so perhaps they select more carefully, and don’t have to eject many left-leaning souls.

One thing the hard left and the hard right have in common (as Eysenck noted) is that they take a tough-minded approach to politics: they think that action matters, pay money to political parties, organise, keep up with the news, and vote.

On a transatlantic note, I had no idea so many Liberal Americans watched the BBC and read The Economist.

The sample on which the survey is based seems to be representative. I see that the top third of Americans earn more than $75,000 a year, and that only 66% of all US citizens are now classified as White.

I cannot find any mention of the amount of time people spend consuming news, It is possible that Lefties devote more time to news because being connected in that way is more part of their core self perceptions “I ought to know where people are being oppressed” while Righties might feel “I don’t want to hear about other people’s problems, unless the present a threat to me”. If this is true to any extent it might explain why lefties consume so many different sources of news.

However, if Lefties really are brighter, then if follows that they will write more, read more, sample more opinions, and have more influence. They will dominate the intellectual landscape, and establish hegemony. My old party card should be knocking about somewhere.

http://drjamesthompson.blogspot.co.uk/2014/10/are-lefties-clever-or-just-grasping.html

Sadly, the Pew research does not give any intelligence estimates, not even a short Wordsum vocabulary test. This would give us additional data to check whether Lefties really are brighter than everyone else. If Pew has got intelligence estimates for their respondents, please let me know.

For the moment, this is the summary. Lefties find 78% of news outlets to their taste, presumably because the content is provided by Lefties in the first place. They shop around, mostly within the range of political views they accept, but also move out of that range. Lefties prefer their own kind but go further afield. They are more likely to dump politically deviant friends. Solidarity trumps friendship.

Righties find only about 20% of news outlets to their taste, and distrust most of the rest. They have gathered round the campfire of Fox News, and don’t stray far from it. Righties prefer their own kind, and mostly mix only with them. They are less likely to dump friends because of political differences.

 

Disclaimers: Most of my recent TV interviews have been on the BBC, a few on CNN. No money changes hands. Years ago I got paid for an article in The Guardian. Indeed, The Guardian once asked me to write a letter to the Editor about a clinical services matter, which they published just in time to cause embarrassment at the Conservative Party Conference, resulting in a former Conservative Prime Minister, Ted Heath, ensuring that more funding was available for British “human shields” who had been held by Saddam Hussein.  Years later, going into a BBC TV studio on a different news story I chanced to meet him and thanked him for his intervention, saying he probably didn’t remember it. To my surprise Heath stopped in his tracks, nodded in approval, and expostulated “and they are still suffering”.

Tuesday, 21 October 2014

Ebola: I don’t do policy, but…..

I know there are other subjects which require attention, but sorting out Ebola should have priority, because implementing a sensible policy could save lives. Every day counts when controlling an outbreak. I claim I don’t do policy, but I have a modest suggestion, which may simply show you why I should not be trusted with policy making.

What if we invited all the key government officials of Liberia, Sierra Leone, and Guinea to an all-expenses paid conference in some African location, say a luxurious Cape Town beach hotel, assuring them that for every day they spent at the conference their carnal and material desires would be fully satisfied, and in addition they would receive a generous per diem payment through the usual obscure channels, and also that they would never be taken to The Hague to answer to any tribunal.

Then, in their absence, we could hand over Ebola management in those countries to Medecins Sans Frontieres, assuring them that they have the lead role and full command over such resources as those countries have available, with no need to consult the World Health Organisation unless they wanted to, and that their money will come from charitable donations only. They might need a large police force and a cadre of health workers. They can bring in Nigeria and Senegal if they wish. Westerners can help, but only if they agree that in the case of getting infected they will be treated in local facilities with their African colleagues. Flights are banned until the outbreak is over, or until there is a reliable quick test for the virus. The new management is told that to fulfil their side of the bargain they must stamp out the outbreak in 210 days, which is ten times the presumed incubation period. That is, no new cases after 19 May 2015. They can use quarantine, isolation, tracing, tracking, and incineration of bodies and contaminated property. Failure means that they have to apologise to WHO, sack all their PR people, and keep quiet for 5 years.

One would expect that, given the welcome change of country management, the owners of Microsoft and Facebook would step up their already generous donations and channel them directly to MSF. However, if you have severe doubts about the quality of Microsoft software, and bemusement at the purpose of Facebook, and thus would not like these organisations to dominate the proceedings, then you could send the new MSF medical powers a pair of rubber gloves.

http://www.msf.org/donate

Monday, 20 October 2014

Wall Street Journal: Ebola a busted stock?

 

The Wall Street Journal is a reassuringly capitalist newspaper, and they have a reassuring article about Ebola by a distinguished epidemiologist, the talented Dr Larry Brilliant. There is much to commend in the article, based on his experience of the treatment and containment of smallpox and other infectious diseases. However, there are some points worth debating.

Dr Brilliant begins with a vivid description of an awful smallpox outbreak in 1974 in India. Yet, as he reassuringly points out, 6 years later smallpox had been eradicated. However, his article does not reiterate the obvious point that a vaccine for smallpox had been made available by Jenner in 1798. A commonplace in much of the world, (I still have my Uruguayan vaccination certificate somewhere) it had not been given to everyone in the world, and when mass vaccination achieved global herd immunity the last cases were tracked down. On 26 October 1977 a health worker dealt with the very last case, a moving moment in medical history. (I can remember the team being given an award at a medical conference I attended in the 80s).

Dr Brilliant says: The signs are optimistic that we will have an Ebola vaccine soon—hopefully in months. Even in its absence, we still have good tools. To fight Ebola, our tools are early detection, innovative diagnostics, isolation, epidemiologic tracing of contacts and good clinical care.

I did not know we would have an Ebola vaccine so soon. Hope so. At the moment we don’t have one, so our policies must be based on there being no vaccine. Isolation is important (though often not being achieved). Tracing of contacts appears to have been achieved in Nigeria and Senegal, but not elsewhere in West Africa. Good clinical care is also often not being achieved, and invasive clinical interventions might not be a good idea if they cover health workers in large viral loads of fluids.

Early detection: First, we must find new outbreaks faster. The current Ebola outbreak, initially misdiagnosed as cholera, had a head start of four to six months, enough to account for most of its unprecedented size.

Agreed. However, at the moment we have a big outbreak, and must deal with that.

Second, we need two kinds of technological innovations in diagnosis: one for the airports and points of entry, and one for the field and hospitals. For passengers and visitors, we need a rapid finger stick test that delivers results within minutes while a passenger is held at an airport.

Agreed. However, we don’t have one yet.

The second diagnostic breakthrough we need is for the hospital….tests that immediately diagnose if Ebola is present and suggest the best medical plan. The technology is also coming soon.

Agreed. However, we don’t have one yet.

Third, we need to learn from the past successes of smallpox, polio and Guinea worm how to contain an outbreak. In the smallpox program, we used rewards of a few dollars to stimulate reports of disease, a rumor register and searches and visits to temples and mosques, along with two billion house calls in India alone. When a case was found, we initiated complete isolation, including paying for a guard from the community to prevent anyone from entering or leaving the home. At times, WHO even paid for and sent meals to smallpox patients so they had no incentive to leave the house. If a patient still managed to leave a village, we notified next of kin and any place that person might be going, as well as health authorities. Along with vaccinating residents around each infected house, we monitored every infected village and patient for six weeks after each case.

Strongly agreed. I wish West African governments had followed these policies. The paid guard outside the isolated case’s home makes great sense. That policy would have saved lives in Guinea/Sierra Leone/Liberia. Implementing those sorts of policies has, as far as I know, not been agreed in West Africa. They have not handled the outbreak well.

Now, with mobile technologies, cloud computing and participatory epidemiology, we can make this a much more efficient process. Specifically, we need a modern, digital contact tracking system. Then travelers would answer questions about any symptoms and take their temperature, perhaps with their phone.

Agreed. I had suggested that last point myself, and am pleased to see it supported by an expert.

Fourth, we need improved coordination among public health systems, particularly across borders. The West Africa outbreak has put out in the open what many in the public health community have long feared: that fundamental impediments in the funding and structure of the WHO hamstring it at moments like this. There is no cavalry coming from Geneva when it comes to pandemics, no entity with a fully prepared SWAT team to tackle an outbreak. The WHO is not entirely to blame, but rather its member states, who have politicized the organization while also cutting funding.

Agreed. However, the national and international health authorities have not yet achieved that level of performance.

So far I have been agreeing that, once new technology is in place, things will be much easier than they are now, when the outbreak in not yet under control in West Africa.

Dr Brilliant says: Our real enemy is a hybrid of the virus of Ebola and the virus of fear. As the famous World War II British poster reads, we need to keep calm and carry on.

Here I have a point of disagreement. Fear need not be our enemy, and can be protective. Fear stops us walking into danger. The thoughtful approach is to balance alarm against too much calm. In the Second World War the authorities did not want the public to spend the night in the underground tube stations. They feared that they would never come out again. The great British public simply bought a ticket late at night, and camped down on the platforms with a thermos of tea and some blankets. The authorities capitulated. Citizens spent the night underground and came up to work in the day, and lives were saved during the Blitz.

Far from really panicking, all Western nations are carrying on with their lives at the moment, (not staying at home and hoarding food) but they are also trying to understand the risks and the best protective strategies to adopt. At this point most citizens would very probably like to see Ebola cases isolated, and a guard placed on their houses. Dr Brilliant makes an important point that this ought to be part of the armoury of disease control. It is right to be alarmed if the virus is carried to new territories. Why take risks just at the moment regarding travel, when better diagnostics may be available soon, thus making sure that the virus is not carried far afield? Better wait for a brief finger-prick test to become available than tracing hundreds of worried contacts.

Interestingly, Dr Brilliant does not mention another virus, HIV. Arising in modern times, even with all the armoury of diagnostics and pharmacological innovation at hand, it has killed 30 million, and infected another 36 million so far (rising by 2.5 million a year) all of whom are dependent on expensive medication for survival (one order of magnitude higher than an uninfected patient), and might well become infectious again if that treatment lapsed. It keeps spreading, but antiretroviral treatment seems to have reassured the public that the threat is over. In many ways current perceptions of Ebola mirror the perception of HIV decades ago, though not in the way that the authorities imagine. Far from panic, there is alarm that yet another virus will spread when it could have been contained in the early stages by strict measures of control. It looks as if an opportunity is being missed, and that saddens and alarms people, as it should.

On a brighter note, if Dr Brilliant’s policy advice about isolating cases in a guarded house can be implemented, that could make a major contribution to the control of Ebola. It will increase prompt human and financial costs in the hope of a future benefit, an example of deferred gratification: the public health equivalent of the famous “marshmallow test”.

Finally, on a more general note: none of us deserve to die because our personal or collective errors have given the virus an easy ride. Infectious diseases certainly test our intelligence and our personality, and collectively test the morality of the societies which we have created. Some governments will do their best to protect us. Others will do their best to protect themselves. Governments can be well organised and humane, or incompetent, indifferent, over-confident, untruthful and corrupt.  No deaths have to happen, nor is any purpose served by them. Nonetheless, many of us will have died stupidly if we are outwitted by a virus which is easy to control.

Sunday, 19 October 2014

Ebola: equal opportunity pestilence

A long time ago I decided to look at human error in the context of the risks of nuclear war. I read the published literature, including the US Congressional Record, and the work done by James Reason and others on the psychological underpinnings of mistakes. I was aware of journalistic accounts about nuclear accidents, drug-taking nuclear guards and the like, but did not give them much space. Eventually I was invited to a Pugwash Conference in Geneva, an East-West summit forum where I met US intelligence experts, Russian generals, think tank researchers and interested scientists. Chatting with senior figures about accidents they initially gave me to understand that everything was under control, but as the weekend progressed many told me that if I wanted to know what was going on then the alarmist journalistic accounts were probably closer to the reality than the official accounts I had been reading.

The official story on Ebola was that, nasty as it was, it would be controlled. Now, late in the day, courtesy of Associated Press, we have been given the internal WHO view as to why it was not controlled in West Africa. It said the heads of WHO country offices in Africa are 'politically motivated appointments' made by the WHO regional director for Africa, Dr. Luis Sambo, who does not answer to the agency's chief in Geneva, Dr. Margaret Chan.

Dr. Peter Piot, the co-discoverer of the Ebola virus, agreed that WHO acted far too slowly, largely because of its Africa operation. 'It's the regional office in Africa that's the front line. And they didn't do anything. That office is really not competent,' Dr Piot said. “What should be [the] WHO’s strongest regional office because of the enormity of the health challenges, is actually the weakest technically, and full of political appointees.” He also questioned why it took WHO five months and 1,000 deaths before it declared Ebola an international health emergency in August. 'I called for a state of emergency to be declared in July and for military operations to be deployed,' Dr Piot said.

In late April, during a teleconference on Ebola among infectious disease experts that included WHO, Doctors Without Borders and the U.S. Centers for Disease Control and Prevention, questions were apparently raised about the performance of WHO experts, as not all of them bothered to send Ebola reports to WHO headquarters.

WHO said it was 'particularly alarming' that the head of its Guinea office refused to help get visas for an expert Ebola team to come in and $500,000 in aid was blocked by administrative hurdles.

On 3 April, MSF first warned WHO about the outbreak, saying it was unusual because far from being in a forest village it was in an urban centre on the border of three countries, thus making control difficult because of different bureaucracies and a reluctance to admit to the Ebola infection because of the economic consequences. WHO responded by saying the numbers were still small. A dispute then broke out on social media between MSF and the WHO’s spokesman, who insisted it was all under control.

So, the West African national organisations screwed up. However, Nigeria and Senegal seem to have done well, so we need to do a discriminant function analysis sometime soon. The key patient is always Patient Zero. Nigeria seems to have had a sharp diagnostician, and sufficient toughness among key health workers to face down threats from the Liberian embassy. Nonetheless they lost 8 citizens because they tried to help an uncooperative infected Liberian diplomat. However, they have saved their fellow citizens, so far. A success story.

Next, the USA. Before launching into lamentation, we need to do a mini meta-analysis. The USA has been tested by an Ebola carrier who did not tell the truth about having been in contact with Ebola. This is the real test for the Western world. Not everyone fills in forms correctly. The US response has not been brilliant, but it might improve as they move their cases to specialist centres. What is clear is that one case can put 2 lives at risk even in supposedly competent hospitals. It can also damage the equanimity of many citizens, who are put at risk. Having worked on the Camelford water pollution case in the UK, I know that these health scares can be a source of medium term, low grade worry, even when the health authorities do their best to be reassuring.

Spain has less excuse for its record. They knew the returning priests had the disease, but did a poor job of protecting their medical staff. Britain handled its one case well, in a super-specialised unit. (He wants to go back, imagining that his having caught Ebola in the first place is an additional qualification). Germany and other European countries have handled their pre-booked cases well, in the sense of no further infections. These figures from the BBC may be a little out of date, but the overall Western death rate is 4, with 6 recovered, and 7 in treatment. It is much better than the African experience of 70% death rate, but it is a bit early to say that the fancy drugs, blood transfusions, and close contact nursing are winning the day. The death rate might turn out to be 4 out of 17, which would be very good. Currently it seems likely that all the infected new cases might survive.

image

So, we do not have a good estimate of how many new infections will be caused in the West by each unannounced Ebola carrier, but 2 per case seems likely, in line with the African estimate. There is evidence from Ng and Cowling (2014) that the virus lasts longer in cooler and moister climates, which might be relevant in the US and Spanish cases.

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20892

What now for the Western response to Ebola. Health services have not always made life easy for whistle blowers. On the contrary, the UK experience is that they can be ostracised. The airline industry was on top of this years ago. They allow pilots to admit errors anonymously, which means they can confess a mistake which acts as a warning to other pilots, and gives guidance to systems engineers as to what needs to be improved. We should have a similar system for health workers (and for car drivers, no doubt).

http://www.chirp.co.uk/

Above all, estimates of human-to-human transmission of any virus need to take into account human foolishness. For every “public awareness” health campaign predicated on average intelligence and average public spiritedness we have to apply a realism coefficient: an allowance for human error in following protocols, plus selfishness, indifference, egotism, deluded altruism and occasionally downright malevolence. Human stupidity is infection’s fifth column. From the viewpoint of any virus, we serve as useful fools. The stupider the human carriers, the higher the eventual human cost. So, every measure of the infectiousness of a disease is also a measure of our intelligence. Adjust the Ro calculations for the IQ calculations.

Finally, what are we to make of the view that the key to solving Ebola is to rush to Africa with trained staff and resources, in order to put out the fire at the source? From a global point of view, given the ubiquity of the wide body jet and the apparent political imperative to keep borders open at all costs, Ebola is being given a free ride, as if it were only fair that it should take hold across the planet: an equal opportunity pestilence. In that sense, going to Africa is an understandable policy, simply because it is the one way left to control the disease. However, health colonialism runs up against some contradictions. If local governments block the prompt rollout of resources, or refuse to publish the true death rates, or fail to pay their health workers, how should the Western health colonialist respond? Should these powers edge towards to imposing good governance, or should they try to battle to bail out the ship of failed nations while corrupt and incompetent local strongmen keep drilling holes in the hull of the sinking ship?

This probably a problem Western government should leave to the Chinese Politburo, who have taken over the colonialist mantle in Africa. 

Leading indicator: watch how many Chinese in Africa get Ebola. If all threats are the ultimate IQ tests, then the Chinese should have a low rate of infection. Equally, the virus should be controlled easily if and when it reaches the Chinese mainland.

Friday, 17 October 2014

Special offer to readers


Here is a little item I thought you might enjoy for the weekend. Three researchers want bright people to contribute raw genetic data for a study on high intelligence, by which they mean IQ at least 2.5 SDs above average. By my, admittedly shaky,  calculations that means an IQ of 138 and higher. As a general guide, in 1000 Europeans only 6 will be as bright. If we can spread the net to 100,000 Europeans we can expect 565. These numbers will be higher or lower according to ancestry, but intellect of that stature is uncommon. Naturally, the authors regard the readers of this blog as a likely source of suitable candidates, and in this assumption they show great perspicacity. All you have to do is send in your IQ results and your results from the 23andMe test to Davide Piffer. Please give them a hand, including doing some recruiting for them.

For your guidance, I will not be participating. Sunday papers, a little gardening and other important weekend matters preclude my attendance. However, I know that you will be stepping into the breach.

This research is conducted by Davide Piffer (Italy), Emil Kirkegaard (Denmark) and Bertram Gilfoyle (Norway).

We seek to identify genes that have an effect on general intelligence in humans. For that reason we need raw genome data from high IQ individuals.

The preliminary phase of our project (analyzing genomes from two scientists) has produced brilliant results and for this reason we want to follow up with genomes from more high IQ individuals.

Many people have already taken the 23andMe test, which enables its users to download raw data file. We’re looking for genomes from individuals whose IQ is at least 2.5 SDs above average.

The results of this study will be published on a pre-print, open access server (e.g. biorXiv, PeerJ) and will be available to everybody, in the true spirit of free science and scientific inquiry. Subsequently we may decide to follow up with a submission to a peer-reviewed scientific journal (e.g. PlosOne, Nature, etc.). Names of participants will not be disclosed (unless expressely requested by you or any other potential participant).

Genome files will be anonymous (a random code will be assigned) and will not be published. Please send genome raw data file (.zip) along with IQ score to: pifferdavide@gmail.com

Ancestry information (e.g. nationality and ethnicity) is needed (e.g. White American; Italian; German, etc.) to correctly match genomes to their reference population.If you have any questions, do not hesitate to contact us at the above email address. For the financial support of this study, a crowd-funding campaign is launched.

Best Regards,

Davide Piffer (Italy)
Emil Kirkegaard (Denmark)
Bertram Gilfoyle (Norway)

Wednesday, 15 October 2014

Ebola quarantine under-estimate?

http://currents.plos.org/outbreaks/article/on-the-quarantine-period-for-ebola-virus/

An interesting paper by Charles Haas suggests that calculating the quarantine period for Ebola at 21 days may result in a 0.2% up to 12% chance of release of the virus.

The precise origin of this assessment (21 days) is unclear, however it is possibly based on the study of the either the 1976 Zaire outbreak11 or 2000 Uganda outbreak12 both of which reported (without detailed analysis) a maximum observed incubation time of 21 days.

The WHO Response Team17 has just published an incubation time distribution based on the first 9 months of the West Africa outbreak (total of 4010 confirmed and probable cases with usable data). They reported a mean incubation period of 11.4 days with an upper 95th percentile of 21 days — and they were able to fit the data to a gamma distribution.

image

For greater security, Haas argues, a quarantine period of 31 days is preferable. However, all quarantines run up against a trade-off:

image

So, we need to look at the cost of enforcing quarantine (Police wages plus cost of food and medical supplies plus loss of earnings for quarantined person) as opposed to the costs of treating contacts who may get infected, and the costs of lives that are lost. Time to call in the accountants.

Ebola: Errata

I need to correct three errors I have made.

Error 1

For some months I have been saying, based on expert advice from various trusted expert sources, that the Ebola virus would be easily contained in Western countries, particularly in Western hospitals. I now recognise that this was an error. Sorry.

It turns out that nurses at Texas Health Presbyterian Hospital in Dallas, according to the director of the National Nurses Union RoseAnn DeMoro, were given inadequate protective clothing; conflicting guidance about treatment protocols; were closely involved in dealing with the patient’s infected projectile vomit and explosive diarrhoea; and worked in rooms where soiled materials were piled up to the ceilings.  All this despite receiving many official directives from the CDC about how Ebola should be handled. It is said that 72 hospital workers may have come into contact with patient zero at some stage.

The nurses' statement (given anonymously, which is probably the best way to find out the truth in these fraught circumstances)  alleged that when Duncan  (US patient zero) was brought to Texas Health Presbyterian Hospital by ambulance with Ebola-like symptoms, he was “left for several hours, not in isolation, in an area” where up to seven other patients were. “Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities,” they alleged. Duncan's lab samples were sent through the usual hospital tube system “without being specifically sealed and hand-delivered. The result is that the entire tube system … was potentially contaminated,” they said.

48 contacts in the community are being monitored for exposure. Health workers were not part of this group, because it was assumed they were not exposed. Another health worker has tested positive for the virus (announced today), so we have 2 hospital worker infections arising from the index case. This is stupidity of the highest order, and the management of the hospital need to explain themselves quickly. The union representative may be exaggerating, but she doubts that any US hospital is able to deal safely with Ebola at the moment.

Error 2

I said that HIV was easier to spread than Ebola because you can transmit HIV through sex while still looking healthy. I forgot that Ebola can remain in sperm for 60 days, and in one case probably up to 90 days, such that the 30% who survive Ebola  will be in reasonably healthy looking condition and might have unprotected sex. So, in calculating the spread of Ebola we should factor in some sexually transmitted infections.

Error 3

I retained the idea that, in the case of widespread global spread of Ebola, the Authorities had a Plan B somewhere, in which the conventional narrative about disease control would come into question, and stricter quarantine would be recognised as the one option that works, given strict enforcement. Privately, I assumed this might be found somewhere in the World Health Organisation. Now Dr Bruce Aylward, the WHO Assistant Director-General of WHO's work in polio eradication and humanitarian response, is quoted as saying that the 70 per cent death rate made Ebola "a high mortality disease" in any circumstance. The WHO target is to isolate 70 per cent of cases and provide treatment as soon as possible over the next two month in an effort to reverse outbreak, he said. "It would be horrifically unethical to say that we're just going to isolate people," he said, noting that new strategies like handing out protective equipment to families and setting up very basic clinics was a priority.

His comment on ethics seems to hinge on the concept that it would be wrong to “just isolate people”, in that they ought to be isolated (I presume) but provided with protective equipment. That is fine, but the phrase “horrifically unethical” reveals a one-sided approach to ethics. I assume that Dr Aylward would concede that it would be “horrifically unethical” to let infected persons spread the disease by coming into close contact with others. Therefore, ethics must balance the needs of infected persons against the need of other people not to become infected.

A reminder

If the World Health Organisation is in favour of handing out protective equipment to families and setting up very basic clinics it is now coming round to saying in public what just about anyone pointed out much earlier, as I did on 5th August:

If treatment is really unlikely to help victims, then in a big outbreak it might best to avoid attempts at close contact nursing, and rely on quarantine and subsequent disinfection as the best way to save more lives. Perhaps hydration packs distributed to homes under quarantine would be best, but that is for public health specialists to judge.

So, I have quickly corrected 3 errors, and drawn attention to a prior, modest suggestion for Ebola management.

If you detect any further errors in the way that experts are dealing with Ebola, please let me know of them as they arise, daily.

Tuesday, 14 October 2014

Ebola in 2040: will stigma save us?

 

One of the few perks of being a psychologist in a medical school (apart from occasionally running to a colleague to check a personal health matter) was talking to researchers about the real state of knowledge in any particular field.

The Middlesex Hospital Medical School, which started in 1746 and was subsumed into UCL in 1987, had a great talent for developing new services. In a very minor way I added to that trend by setting up, with two other colleagues, a national referral centre for post-traumatic stress disorder, which is still in operation as an NHS clinic.

However, of much greater importance was the clap clinic. At a time when the usual appellation was Venereal Disease, two clinicians got together and decided, over a glass of champagne, to move it from the dark basement to the full daylight. In 1964 Duncan Catterall established the first Chair of Genito-urinary Medicine at the Middlesex Hospital Medical School, and so when the first symptoms of a strange sexually transmitted disease showed up in the very early 80s, James Pringle House started seeing the first cases and was at the forefront of European research. I went to seminars, talked to colleagues, and sometimes met the guest speakers for a canteen lunch. The greater the expert, the quicker they were to admit that no-one knew what the hell was going on.

To my dismay, the public management of the disease quickly veered away from traditional public health concerns, and became a political battlefield. At the WHO headquarters in Geneva senior colleagues muttered that they had been criticised for saying the virus came from Africa: a colonialist perspective, they were told. Even years later, those who worked in the field in London talked sadly, and privately, of the difficulties they encountered with giving straightforward health warnings. I wanted to design a simple poster to illustrate the relative risks, but it got no further than a large page in my filing cabinet. Such, dear readers, were the difficulties of quickly disseminating an opinion before blogging became available.

It was clear to researchers that blood was the key vector of transmission (contaminated blood transfusions had a 90% chance of resulting in the recipient getting HIV), so that shared needle drug injecting and to a lesser extent anal intercourse without condoms were high risk activities, but public broadcasts talked vaguely about icebergs, and suggested everyone was at risk. I did some research on public perceptions of risk at that time, and AIDS figured high in the public mind. The common folk knew that it was a “gay plague” but the expert emphasis seemed to be on getting heterosexuals to use condoms. The great and the good were interviewed and asked to say the word “condom” on camera which they valiantly did. The correct way of putting on a condom was demonstrated on television, using a cucumber. This led to some worried calls about whether one could catch AIDS from a cucumber.

However, it was generally agreed that the UK government had done “rather well” and had got on top of the crisis. Now, with Ebola in the news, I thought it worthwhile looking at the current situation for the HIV virus in the UK, 30 years on from the first outbreak. This might give us a possible scenario for imagining what Ebola might look like in terms of prevalence.

In fact, the UK response to HIV seems to have been at the European average. Statistics vary in different parts of the world, but I imagine that European statistics have a modicum of accuracy. Finland, Germany, Malta, Norway (and Cuba, see below) did very well (0.1 %); Denmark, Greece, Netherlands and Sweden and Israel pretty well (0.2%) and Belgium, Iceland, Ireland, Luxemburg and the United Kingdom were average (0.3%). Austria, France, Italy, Spain, Switzerland were a bit worse (0.4 %) and Portugal very much worse (0.7%). Of course, these are not sub-Saharan African levels (as high as 25% in Swaziland and Botswana) but given that the governments knew what was coming, and had resources available, they are not stellar achievements.

Greg Cochran mentioned the case of Cuba, which had forewarning of the virus in the US and two years to prepare for their first case.

http://westhunt.wordpress.com/2014/09/28/forty-days/

They quarantined patients for 8 weeks of health education, tracked contacts in a very determined way, and used their relative isolation to put public health before private liberty, an approach which comes naturally to the regime. Their resultant prevalence of roughly 0.1% is one-sixth the rate of the United States, one-twentieth of nearby Haiti.

http://news.bbc.co.uk/1/hi/in_depth/sci_tech/2003/denver_2003/2770631.stm

http://www.nytimes.com/2012/05/08/health/a-regimes-tight-grip-lessons-from-cuba-in-aids-control.html?pagewanted=all&_r=0

HIV probably moved from monkeys to humans before the 1950s, although the first cases were recognised in 1981 in the US. About 100,000 people in the UK are infected, mostly homosexuals, and heterosexuals from sub-Saharan Africa. More than 20 per cent of them do not know it, and are several times more likely to transmit the virus to their partners than those who have a diagnosis. Half of the newly diagnosed cases in the UK seek medical help when they are in the late stages of disease. In 2012, there were 6,360 new diagnoses of HIV, which is 17 a day in case you find that more dramatic. In England the local authorities with the highest prevalence of diagnosed infections are London, Brighton and Hove, Salford, Manchester, Blackpool and Luton, and in Scotland, Edinburgh. Treatment with antiretroviral drugs reduces the risk of transmission by more than 90 per cent. The cost of these drugs is said to be £20,000 a year and given the current almost normal life spans of HIV patients, 20 years of medication seems a prudent minimum for budgeting purposes. The money spent per capita on NHS services in England was £1,979 in 2011, so each patient with HIV consumed at least 10 times the resources of an average patient every single year.

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http://www.avert.org/uk-hiv-aids-statistics.htm

A possible explanation for the apparently lacklustre performance of the UK may be that many of the cases are imported: that is, brought in by Black Africans infected in Africa. Looking at the demographics of the UK in 2011 that shows that 55,730,000 persons are classified as White and 1,905,000 are classified as Black or Black British. Looking at the HIV figures (this is broad brush, because I have omitted the “mixed” groups) the HIV rates per 100,000 are as follows:

Whites: 93 per 100,000

Blacks: 2015 per 100,000

So, the rate seems to be 21 times higher among Africans. The fact that so many Africans have come to the UK cannot be blamed on the quality of UK public health warnings aimed at changing the behaviour of the local population. The White rate is exactly comparable with the best European nations at 0.1%

Nonetheless, considering that about 36 million people in the world are infected by HIV and that 30 million have died, the management of HIV is hardly a global success story. Does this give us any help in looking ahead to the prevalence of the Ebola virus in 30 years’ time? Prediction will depend on whether treatments or vaccinations become available, but my impression, no more than that, is that the spread of the virus should be much slower, very much slower. HIV can be passed on whilst the carrier still looks good for sex, and sex is fun, so HIV gets an easy ride. Ebola can only be passed on (if the experts are right) when the carrier is looking pretty ill and unattractive, and dealing with ill people is a duty, and not much fun. Furthermore, Ebola is so virulent at the moment that immediate death rates are high. With simple precautions it should be contained. Even when “protocols” fail, the reproduction rate of the virus in human carriers should be low. Despite all the worrying news, it should be a simple matter to avoid the spread of the disease.

On a more speculative note, perhaps we shall be saved by stigma. By fearing all people who look as if they are ill with Ebola, stigmatising them and avoiding all contact with them, definitely not putting ourselves at risk by helping them, particularly not touching them when they are dying or dead, the virus will die out. So, in one corner we have the virus, in the other corner the uncertain public, caught in an awkward tussle between altruism and abject fear. Ebola has its best chance of spreading in societies which don’t believe it exists (like in parts of Africa), and to a lesser extent in those which don’t believe that, given the virus does exist, the absolute priority is to change our behaviour quickly (parts of the wealthy West). Informed opinion ought to be right, but with every failure of both treatment and containment in Western hospitals public belief is eroded.

Although it goes against altruistic instincts, futile attempts at interventionist treatments may be making matters worse.