The Mysteries of the Mind

By Claire Meek
Posted: May 18, 2012

I was in London recently and, pleasingly, was running a little ahead of schedule. I therefore spent a fascinating hour wandering around the latest exhibition in the Wellcome Trust building ‘Brains: Mind as Matter’*. The exhibition charts the history of humanity’s quest to understand and describe the brain, ‘the most complex entity in the known universe’.

Image Credit: dierk schaefer

In antiquity, apparently, the brain was considered a less useful organ than the heart and liver. However, by Roman times, the brain was believed to be the seat of the mind and the soul, and its activities were thought to occur in the ventricles, rather than the brain tissue itself. Interest in the brain grew throughout the Middle Ages, and for many centuries thereafter, having a large brain was considered an asset.  Indeed, popular culture in the 18th century held that humans were different from animals as we evolved from a large-brained ancestor. The Piltdown remains, discovered in 1912, were purported to confirm this, but were later shown to be an elaborate hoax.

The importance of having a large brain continued to interest many in Victorian times and led to the practice of preserving the cerebral matter of particularly intelligent or villainous individuals to permit future study. The exhibition includes the preserved brain tissue of serial murderer William Burke  and an influential American suffragist, Helen Hamilton Gardner,  who argued that the female brain was not “demonstrably different from that of a man under the same conditions and with the same opportunities for development”.  Charles Babbage who invented the first computer, also bequeathed his brain to permit further study.

Image Credit: J E Theriot

Public interest in the brain prompted the birth of anthropometry, and the less useful pseudoscience of phrenology – the study of the contours and shape of the human skull to derive information about an individual’s personality and emotions. Despite the limitations of this approach, it introduced an important concept: that cerebral functions were localised to certain areas of the brain. Head measurements were also used to justify racial and gender-related stereotypes. There is a fascinating poster in the exhibition explaining that although women have smaller brains than men, many are just as intelligent and should not be refused the vote based on smaller head size alone.

I found this exhibition to be enjoyable and stimulating with many thought-provoking pieces from across the world. It is also an illuminating study of how medicine and science have tried to grapple with the inexplicable. The mixture of half-truths believed about brains throughout the centuries reminds me that our knowledge today, while hopefully more accurate, is still not infallible.

 

* More details can be found at www.wellcomecollection.org/Brains or from the book accompanying the exhibition – ‘Brains: the mind as matter’, Kwint M, Wingate R. Wellcome Collection, 2012.

http://www.guardian.co.uk/culture/2012/apr/13/mind-as-matter-brains-wellcome

http://www.independent.co.uk/arts-entertainment/art/reviews/brains-the-mind-as-matter-wellcome-collection-london-7605935.html

http://www.reuters.com/article/2012/03/27/us-brains-exhibition-idUSBRE82Q0PT20120327

 

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Have management papers ever changed practice in healthcare?

By PLoS Guest Blogger
Posted: May 17, 2012

Guest blogger Trish Greenhalgh takes on a Twitter challenge

 

Sir Muir Gray, of evidence-based medicine fame, is a man who speaks his mind – often in 140 characters or fewer. “Show me a paper by a management academic,” he Tweeted, “that has changed the way we deliver health services” [and, implicitly, improved patient outcomes].

 

Part of me agreed with him, but I’m married to a management academic (“Oops sorry, better man than me,” Muir backpedalled), who helped me rise to Muir’s challenge.

 

We kicked off with a paper almost every clinician has heard of:

Image Credit: Julie Rybarczyk

Kaplan and Norton’s ‘balanced scorecard’, published in Harvard Business Review in 1992 and cited over 8000 times since [1]. The scorecard was aimed at company directors who wanted some quick (and, one is tempted to suggest, dirty) metrics to monitor what their customers thought of them and where they should direct their efforts for the future. It has certainly changed practice (many healthcare organisations use it), but we were not overly sold on its transferability to the healthcare setting.

 

In danger of winning the point but losing the principle, we tried to think of papers in management journals (which consist mainly of studies undertaken on US private-sector, product-oriented firms) whose findings had been applied to public sector, service-oriented organisations in the UK in a way that improved patient-relevant outcomes. We pretty much drew a blank.

 

One paper – Ramiller and Pentland’s critique of ‘variables centred’ organisational research [2] – gave a clue as to why.  Abstracted variance models aimed at producing generalisable truths about how organisations behave may appear scientific and rational (and promise findings that could be ‘rolled out’ to new settings), but in reality may have limited value since they divert the focus away from people taking action. These authors argue for a case study approach to complex change, in which human actors and action remain in frame, and the link between ‘input’ and ‘outcome’ is made using here-and-now narrative rather than abstracted, logicodeductive reasoning.

 

Talking of the narrative form in organisational research, there are a number of classics in this genre, including

 

  • Weick on sensemaking. Staff need to make collective sense of organisational life; encouraging this sensemaking process is key to successful change efforts [3].

 

  • Tsoukas [4] and Brown and Duguid [5] on organisational knowledge. Knowledge is embodied, socially developed and – to a metaphor originally coined by Wittgenstein – “rides along the rails laid down by shared practice”. This view of knowledge has been applied by Gabbay and le May in their brilliant work on ‘mindlines’ in health professionals [6].

 

  • Van de Ven on the longitudinal case study method for organisational innovation [7]. However carefully you plan, innovation in healthcare organisations is invariably a messy, non-linear process that takes years rather than months and is characterised by shocks and setbacks. Again, don’t expect to document predictable and reproducible links between inputs and outcomes. My team’s systematic review of diffusion of innovations in healthcare drew heavily on Van de Ven’s empirical studies [8].

 

  • Feldman and Pentland on organisational routines [9]. Routines are recurring patterns of interpersonal interaction that confer stability in an organisation but which also offer scope for change (when human actors choose to enact the routine differently). My team used this approach to surface the sophisticated ‘hidden work’ of receptionists in assuring medication safety in healthcare [10].

 

Incidentally, for a feisty argument over whether ‘variables-centred’ or ‘actor-centred’ paradigms are more robust, see Pfeffer’s Academy of Management Annual lecture from 1993 [11] and Van Maanen’s insouciant response [12].

 

We found many papers we wished had changed practice but probably hadn’t. For example:

 

  • Fulop’s team showed pretty decisively that hospital mergers don’t save money [13].
  • Currie and Guah predicted (accurately) the failure of England’s ill-fated £12.7 billion National Programme for Information Technology if policymakers continued to ignore stakeholders’ conflicting institutional baggage [14].

 

Image Credit: Adrian Boliston

Do healthcare policymakers take any notice of academic papers which warn that current approaches are unwise? My team didn’t think so. We drew on Tsoukas’ model of organisational knowledge to explain why [15].

 

A number of management papers emphasised the complex and context-bound nature of organisational phenomena. For example:

 

  • Hawe and colleagues theorised complex interventions as events in complex systems [16]
  • Lanham et al considered healthcare teams as complex systems and quality as an emergent property of those systems [17]
  • Bate and colleagues looked at social movements as a force for change [18]. These movements – from feminism to the Arab Spring – work by linking an emerging identity (being part of the movement says something about who we are) with collective action (movements organise and do things). But they are inherently non-linear and cannot be ‘controlled’.

 

The topic of leadership is done to death in healthcare journals but most management academics have little interest in it, perhaps because it’s an example of a variable that has been abstracted from the person who has it!  But one paper – on the subtle approach of ‘tempered radicalism’ by Myserson and Scully – made it onto our list [19].

 

I’ve been avoiding Muir Gray recently. Whilst the exercise of attempting to “find a paper by a management academic that had changed practice and benefited patients” produced many insights into why organisational change in healthcare is difficult and unpredictable, the links between these papers and hard outcomes in healthcare were usually tenuous. If I were being pedantic, I would suggest that this is because Muir’s question implies a deterministic link between inputs (academic papers) and outcomes (patient benefits) whereas most of the literature listed above is theoretically incommensurable with such a link. But I suspect I should concede defeat and go buy him a drink. Or at least, give his book – on how to get it right when building healthcare systems – a gentle plug [20].

 

Acknowledgment: This blog is based on a discussion on Twitter and includes
various papers suggested by my followers.

 

Trish Greenhalgh is Professor of Primary Health Care at Barts and the
London School of Medicine and Dentistry, London, UK, and also a general
practitioner in north London.

 

1.         Kaplan RS, Norton DP: The balanced scorecard–measures that drive performance. Harvard Business Review 1993, Jan-Feb:71-147.

2.         Ramiller N, Pentland B: Management implications in information systems research: the untold story. Journal of the Association for Information Systems 2009, 10(6):474-494.

3.         Weick KE: Sensemaking in organizations. Thousand Oaks, CA:    : Sage; 1995.

4.         Tsoukas H: What is organisational knowledge. Journal of Management Studies 2001, 38(7):973-993.

5.         Brown JS, Duguid P: Knowledge and organization: A social practice perspective. Organization Science 2001, 12(2):198-213.

6.         Gabbay J, le May A: Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004, 329(7473):1013.

7.         Van de Ven AH: Central probelms in the management of innovation. Management Science 1986, 32(5):590-607.

8.         Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organisations: systematic literature review and recommendations for future research. Milbank Q 2004, 82  581-629.

9.         Feldman MS, Pentland BT: Reconceptualizing organizational routines as a source of flexibility and change. Administrative Science Quarterly 2003, 48:94-118.

10.       Swinglehurst D, Greenhalgh T, Russell J, Myall M: Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. BMJ 2011, 343:d6788.

11.       Pfeffer J: Barriers to the advance of organizational science: paradigm development as a dependent variable Academy of Management Review 1993, 18(4):599-620.

12.       Van Maanen J: Style as Theory. Organizational Science 1995, 6:133-143.

13.       Fulop N, Protopsaltis G, Hutchings A, King A, Allen P, Normand C, Walters R: Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. BMJ 2002, 325(7358):246.

14.       Currie WL, Guah MW: Conflicting institutional logics: a national programme for IT in the organisational field of healthcare. Journal of Information Technology 2007, 22:235-247.

15.       Greenhalgh T, Russell J, Ashcroft RE, Parsons W: Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History. Milbank Q 2011, 89(4):533-563.

16.       Hawe P, Shiell A, Riley T: Theorising interventions as events in systems. American journal of community psychology 2009, 43(3-4):267-276.

17.       Lanham HJ, McDaniel RR, Jr., Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting P: How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Joint Commission journal on quality and patient safety / Joint Commission Resources 2009, 35(9):457-466.

18.       Bate P, Robert G, Bevan H: The next phase of healthcare improvement: what can we learn from social movements? Quality & safety in health care 2004, 13(1):62-66.

19.       Myerson DE, Scully MA: Tempered radicalism and the politics of ambivalence and change. Organization Science 1985, 6(5):585-600.

20.       Gray JAM: How to build healthcare systems. Offox Press Ltd: Oxford; 2011.

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Maternal Mortality Falling – But Still Too High

By PLoS Guest Blogger
Posted: May 16, 2012

Today’s new estimates of maternal mortality from the United Nations’ Maternal Mortality Estimation Inter-Agency Group (MMEIG) are good news – but not good enough. All the evidence points to more than a quarter of a million of women still dying as a consequence of pregnancy and childbirth every year – that’s around one every two minutes. We know that adequate logistics and medical care can, in principle, prevent almost all of these deaths. In Scandinavia, rates are down to under 1 in 10,000 births, but for the world as a whole they remain around 20 per 10,000 births, and in some countries maternal deaths still occur in 1% of births – totally unacceptable for the 21st century.

Why do we need to have estimates of these important figures? The answer is that the details, on a world-wide basis, are simply unknown. PLoS Medicine published an interesting series on the pros and cons of global estimates. WHO, on their Twitter feed today, wisely pointed out “not even the best modelling can give us the real figures. Hence, WHO calls for stronger registration of births, deaths, causes of death.” Nevertheless, the inadequate progress on maternal deaths – and the almost inevitable global failure to reach the 75% reduction in maternal mortality called for by Millennium Development Goal 5 (MDG5) by 2015, is all too real, whatever estimation techniques are used.

When new sets of global estimates are published, first attention naturally goes to the headline results – 287,000 maternal deaths during 2010 in today’s report. But such estimates also contain a wealth of detail. One of the trickiest issues in estimating maternal mortality is modelling the interactions between pregnancy and HIV/AIDS in terms of causing women’s deaths, particularly in areas such as southern Africa where HIV/AIDS infections occur at high rates. Women with HIV are less likely to be pregnant in the first place, but being pregnant and HIV positive may represent an increased risk. There’s a whole appendix on the mathematics of this in the new estimates – but the fact remains that there are difficulties and uncertainties in making any such estimates.

There is a risk involved for every woman who gets pregnant. But the global community has the knowledge and resources to manage those risks and minimise adverse consequences. Why can’t we stop mothers dying?

Peter Byass is Professor of Global Health at Umeå University in Sweden and Director of the Umeå Centre for Global Health Research. He is a member of the PLoS Medicine Editorial Board and of the Technical Advisory Group to the UN Maternal Mortality Estimation Inter-Agency Group.

e-mail: peter.byass@epiph.umu.se Twitter: @UCGHR

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This Week in PLoS Medicine: Pregnancy in DART trial; Health & pharmaceutical R&D

By Michael Morris
Posted: May 16, 2012

Image Credit: lilivanili

Three new articled published this week in PLoS Medicine, including two magazine pieces on R&D:

Diana Gibb and colleagues investigate the effect of in utero tenofovir exposure by analysing the pregnancy and infant outcomes of HIV-infected women enrolled in the DART trial.

As part of a cluster of articles leading up to the 2012 World Health Report and critically reflecting on the theme of “no health without research,” Suerie Moon and colleagues argue for a global health R&D treaty to improve innovation in new medicines and strengthening affordability, sustainable financing, efficiency in innovation, and equitable health-centered governance.

John-Arne Røttingen and Claudia Chamas, chairs of the the Consultative Expert Working Group on Research and Development (CEWG), summarize their recent report recommending to the World Health Assembly that a global health R&D convention be developed.

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This Week in PLoS Medicine: Co-proxamol deaths; Aid & govt spending; HIV & TB in prisons

By Michael Morris
Posted: May 9, 2012

Image Credit: Charles Williams

Three new articles published this week in PLoS Medicine:

A time-series study conducted by Keith Hawton and colleagues reports on the links between withdrawal of the analgesic co-proxamol and subsequent prescribing and deaths associated with analgesic poisoning.

Rajaie Batniji and Eran Bendavid dispute recent suggestions that health aid to developing countries leads to a displacement of government spending and instead argue that current evidence about aid displacement cannot be used to guide policy.

Katherine Todrys and Joseph Amon argue for criminal justice system reforms in sub-Saharan Africa to reduce HIV and TB transmission in prisons and to guarantee detainees’ human rights and health.

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Poop Excavated from Old Latrines Finds New Life

By Maggie Brown, MS, ELS
Posted: May 8, 2012

What good is human excrement? For most of us, it’s something to be flushed away, washed off, and certainly not discussed in polite company. Yet many millions of people around the world live with “unimproved” sanitation facilities or none at all (i.e., “open defecation”). It’s a huge problem for both human and ecosystem health, and efforts at improvement generally focus on disposal methods that protect people and the environment from contamination. End of story.

Outhouse

Outhouses in student's tourist tent base in Jawornik, Beskid Niski, Poland. Image by Tomasz Kuran (aka Meteor2017), Wikimedia. CC-BY agreement.

However, that doesn’t have to be the end of it. If you have a garden, you know that cow and horse manures are wonderful soil amendments. But have you ever considered human manure? DIY is very hip right now, and what could be better than DIY compost for your DIY vegetable garden?

If you find this a little repulsive, that’s ok. Most people are not very comfortable with poo, and with good reason – it can and does transmit disease, very efficiently. About 1.5 million children around the world each year get sick or die from diarrheal diseases specifically due to poor sanitation, and improved sanitation can reduce the incidence of diarrheal diseases by more than 35% (Source: US CDC).

But consider this: correctly aged and composted (and there are very feasible, safe, and effective ways to do this), human feces and urine make excellent fertilizer, and many cultures reuse their “waste” for just that purpose. And – bear with me here – this can take care of at least two important problems at one go: waste handling and agriculture. What’s not to love?

Recently a small nonprofit organization called SOIL (Sustainable Organic Integrated Livelihoods) kicked off a series of informal reports on a project they’re doing in Africa (in collaboration with others such as National Geographic Emerging Explorers, SELF, and others) promoting improved sanitation and, specifically, reuse of human waste. For example, they dug up the contents of old, unused latrines to mine the contents for local agriculture. Upon excavating their first latrine – at a grammar school in Benin – they reported, “The pit, once filled with fresh human wastes, was now a chamber of rich black soil, a color and consistency that was in stark contrast to the dry red dust of northern Benin.” They removed the entire contents for a garden they planted with corn. In another wonderful post, they report on their experience promoting a “magic toilet” to the women of a small rural community.

Proof positive that there’s plenty to love about poop.

For more on this topic:

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Short-Term Surgical Mission: A Vehicle for Sustainable Surgical Care Delivery?

By PLoS Guest Blogger
Posted: May 4, 2012

Guest bloggers Gita Mody, JaBaris Swain and Maurice Musoni discuss sustainable surgical care delivery and their experience in Rwanda with Team Heart.

Sustainable models for delivery of both Emergency and Essential surgical care and specialty surgical care are needed to eliminate global disparities in health. The most cost-effective, feasible, and replicable methods to implement the complex systems needed to provide surgery are still debated. However, to quote ophthalmologist and founder of the Himalayan Cataract Project Dr Geoffrey Tabin at the recent Extreme Affordability Conference held by the Center for Global Surgery at the University of Utah, “high quality [surgical] care is the key to sustainability.”  Some would argue that traditional short-term missions, which are often caricatured as a visiting team parachuting into a foreign environment, providing clinical care for a few short days or weeks, and exiting never to be seen again, are a poor return on the investment.  But, can short-term missions be structured in such a way to become components of a high-quality, sustainable plan?

In our experience, they can. Team Heart represents such an effort, with the aim of establishing a self-sustaining cardiac surgical program in Kigali, Rwanda. Since 2007, Team Heart has worked with King Faisal Hospital, a 140-bed referral hospital in Kigali, to provide sophisticated cardiac surgical intervention for critically ill patients suffering from the consequences of advanced rheumatic heart disease. Team Heart encompasses collaborative partnerships with the Rwanda Heart Foundation, the Rwanda Ministry of Health, and a group of committed volunteers from several Harvard-affiliated academic medical centers, many of whom return year after year.

Throughout the Team Heart mission, opportunities for knowledge transfer and skill expansion are abundant. Both Rwandan and American trainees are actively involved in pre- and postoperative patient care, operative management, and team logistics. The trainees work closely with Rwandan faculty members to review complicated cases and collaborate on comprehensive, multi-disciplinary plans for the patients. Daily bedside teaching rounds emphasizing physical exam and diagnosis, opportunities to first-assist in the operating theatre, and hands-on fundamentals of echocardiography are just a few examples of learning opportunities.  One Rwandan trainee, inspired during his involvement in the mission over the several years, is now being sponsored by Team Heart to complete a fellowship in South Africa such that he can return to lead a cardiothoracic program in Rwanda.

Members of Team Heart also remain committed to providing high quality patient care and utilizing proven systems improvement tools, which are nimbly adapted to the available Rwandan resources and infrastructure.  In the debrief session after the last mission, care delivery innovations imported from Boston teaching hospitals such as the Intensive Care Unit record keeping forms and the surgical safety checklist were selected to be incorporated into the daily operations of the host hospital. The mission, by demonstrating the feasibility of specialty surgical service delivery at the host hospital, has both inspired and prepared the local health care administration to undertake building its own cardiac surgery program.  For example, ancillary services including the blood bank and laboratory noted that by participating in the mission, they have acquired insight on how to restructure their departments going forward.  So, indeed, herein lies one example of a surgical mission that is leading to a lasting and safe care delivery system.

Another model of sustainable surgical care delivery is the incorporation of short- term visits of surgeons into longitudinal community-based health care activities.  Operation Smile, an international volunteer organization that performs reconstructive surgery missions around the world, is piloting deployment of its volunteers in overlapping rotations to provide continuous plastic surgery services at Butaro Hospital, a 150-bed rural district hospital in northern Rwanda supported by Partners In Health.  The overall objective of the rotations is to go beyond direct clinical care delivery and provide mentorship and training such that the roles of visitors including operating theatre and ward nurses, surgeons, and anesthesiologists can be effectively transitioned to local staff.  The process of integrating short-term visitors into the hospital’s daily schedule requires patience and flexibility by all parties, but the impact of these missions is anticipated to far exceed the number of surgeries completed.

How to measure the impact of short-term surgical missions was the subject of discussion at a recent Academic Global Surgery journal club session held at the Brigham and Women’s Hospital Center for Surgery and Public Health.  While short-term missions that involve surgical residents have demonstrated positive impact on the core educational and professional competencies of North American trainees, future studies are needed to demonstrate their long-term impact on global surgical care delivery by local and visiting residents. Furthermore, cost-benefit analyses including the clinical effectiveness, skill transfer, and quality improvements resulting from these missions must be conducted. In the meantime, the Team Heart and Operation Smile missions represent invaluable exposure for surgical residents, both Rwandan and American, to mentors committed to training the next generation of global health leaders.

Gita Mody and JaBaris Swain are general surgery residents at the Brigham and Women’s Hospital and Arthur Tracy Cabot Research fellows at the Center for Surgery and Public Health.  They were both recipients of the Team Heart Stanley Rawn Travel Award for the 2012 mission, and Dr Mody serves as a surgical consultant for Partners In Health. Maurice Musoni is a surgical postgraduate at King Faisal Hospital in Kigali, Rwanda and will begin training at the University of Witwatersrand, South Africa, in General and Cardiothoracic Surgery this year.

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Conflict and Open Access: A Tale of Two Conferences

By Medsin
Posted: May 2, 2012

For medical students interested in advocacy, action and debate, the last weekend of Easter provided all three in buckets at two of the biggest conferences on the UK Medical Student calendar.  The BMA Medical Students Conference and the Medsin Conference ‘CONFLICTED’ left all who attended feeling excited that WE CAN DO MORE!

The BMA's national conference

In Nottingham, medical student representatives from all over the UK attended the BMA Medical Students Conference, commencing with a rousing and thought provoking speech from Clare Gerada, Chair of the Royal College of General Practitioners, on where we go now with the Health and Social Care reforms in the UK.  Although many important and well-considered motions were debated, it was pertinent that, in the same week that the Wellcome Trust announced that all their research would now be Open Access, the Medical Students Conference voted unanimously to support the Student Statement on Open Access as outlined by the Right to Research Coalition. It is really exciting that Medical Students are bringing this issue to the wider profession, and students can, in the coming months, lobby their universities and the government to make research accessible to all.  Any students interested in getting more involved, please do get in touch for information about forthcoming work on Open Access, including a forthcoming conference organized by the Right to Research Coalition in July.

BMA co-chairs and Medsin National Coordinators L-R Elly Pilavachi (BMA), Dan Knights (Medsin), Marion Matheson (BMA), Felicity Jones (Medsin)

A bit further south at King’s College London, Medsin’s CONFLICTED conference was also a vibrant and exciting weekend.  From the moment Dr Robin Coupland launched into his opening speech, it was clear CONFLICTED was going to pose some challenging issues, and that these were issues that the Medsin network were not only prepared to grapple with, but also take beyond the conference, and take action on. The weekend provided ample opportunity for engagement, focused as it was around the themes of conflict, health, and humanitarian aid, and the four plenaries set their complex interaction in sharp relief.  Newcomers and experienced Medsin-ers alike were fully engaged with the issues discussed, as evidenced by the quality and quantity of questions both during and between plenary sessions and workshops.

Medsin’s CONFLICTED conference

And Medsin not only engaged, but also took action. Hundreds of attendees signed postcards against the arms trade, and petitions and letters to their MPs on multiple related issues, and a large group headed to the Millennium bridge to put their Hands Up for Healthcare Workers, as part of Merlin’s campaign on the issue. 

Many signed up to one of Medsin’s amazing activities; topic-specific groups, such as Student Stop Aids, or Healthy Planet (working on climate change).

All-in-all the weekend provided delegates with insight into many aspects of global health inequity, and the opportunity to take forward specific issues such as the Hands Up for Healthcare Workers campaign, which has now been officially launched within Medsin. The next conference, focusing on Maternal & Child Health, will take place on the 20-21st October in Warwick.

All of the plenary sessions and the keynote address were professionally filmed by Kwatsi and are available online here!

It is clear that at both conferences, making contact with students from all over the UK was as important as the topics themselves. The issues can seem insurmountable, and one can feel unsure where to start.  Learning how to work on these issues together, like a jigsaw puzzle, will serve us well in tackling the inequalities we seek to address, as well as in our careers as doctors.

Links:

www.medsin.org/blogs

www.bma.org.uk

Felicity Jones

Karin Purshouse


Felicity Jones is a fourth year medical student at King’s College London. She is currently Joint National Coordinator of Medsin-UK, along with Dan Knights. Follow her on twitter: @faejones.

Karin Purshouse is a final year medical student at Newcastle University and was Chair of the British Medical Association’s Medical Students Committee (BMA MSC) 2010-11.  She has been involved with Sexpression and Medsin since 2006, and was part of the Medsin-UK delegation to the International Federation of Medical Student Associations (IFMSA) August Meeting 2011.

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This Week in PLoS Medicine: BMI & ischemic heart disease; Nigerian midwives

By Michael Morris
Posted: May 1, 2012

Image Credit: Melvin “Buddy” Baker

Two new articles published this week in PLoS Medicine:

A Mendelian randomization analysis conducted by Børge G. Nordestgaard and colleagues using data from observational studies supports a causal relationship between body mass index and risk for ischemic heart disease.

Seye Abimbola and colleagues describe and evaluate their program in Nigeria of recruiting midwives to rural areas to provide skilled attendance at birth, which is much poorer than in urban areas.

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Sugar: A Popular Poison?

By Claire Meek
Posted: April 30, 2012

Yesterday, for me, marked the true end of the Easter festivities as I solemnly finished the last of my Easter eggs. I now have cupboards stocked with useful things like beetroots and bread, radishes and rice, but there is a sad sparsity of sugary snacks.

Image Credit: Adam Selwood

I read an interesting book about sugar recently (Sugar: A Bittersweet History by Elizabeth Abbott), which has forced me to evaluate my attitudes towards it. I wonder whether it could be considered an example of a Paracelsian poison (where the dose of a substance determines whether it is a toxin or a medicine). In the past, sugar was considered a medicinal agent, known for altering ‘the humours’ and for its soothing properties. I remain somewhat unconvinced of the medicinal benefits of sugar, but certainly it has a role in treating hypoglycaemia, and is used widely to make medicines palatable, especially for children.

The toxic value of sugar is now well established, as a major cause of dental caries, insulin resistance and type 2 diabetes mellitus. However, it has taken many centuries of sugar consumption for society to begin to acknowledge its dangers. Although sugar was available in small quantities in Europe from the 13th century, consumption began in earnest in the 15th and 16th centuries. This followed the discovery and cultivation of sugar cane (Saccharum officinarum) in the New World by European explorers such as Christopher Columbus. At home, affluent Europeans developed a taste for this luxury import and soon lucrative trade routes were established between Europe and the Caribbean sugar islands. In time, much of the agricultural land in the new territories was used for growing sugar cane alone. This crop was demanding on soil nutrients and the harvesting of the sugar was tedious, painful and often dangerous. Slavery was introduced, providing the labour source to supply Europe’s greed for sugar, but it also fractured societies and families, causing incalculable hardship and innumerable loss of life.  North American populations also developed a love of sugar and began to import and cultivate ‘the noble cane’.

In Europe, sugar consumption was initially restricted to the rich.

Image Credit: Kevin Jones

Indeed, Queen Elizabeth I reputedly had poor dentition due to her love of sugar. Over time however, prices fell and the normal working classes also had some access to sugar.  At this time, the health consequences of sugar were hotly debated. A few voices raised concerns about the risks of sugar over-consumption, but these voices were often silenced by others who had strong financial interests in maintaining the demand for sugar. Slavery also became a topic of dispute and gradually public opinion turned against it, culminating in the abolition of slavery in England in 1833, and throughout the British Empire in 1834.

Now, most European populations source sugar from locally-grown sugar beet, with fewer adverse consequences on the agricultural, ecological and societal aspects of our world. However, the cost of ignoring health concerns due to financial gain is a lesson which holds true for every generation. Despite the evidence of the dangers of excessive sugar, we give sweets and chocolates to children and enjoy them ourselves as adults. Perhaps we need to develop a more sober attitude to this, the most tempting of toxins.

Recommended reading:

Abbott E. Sugar: a bittersweet history. Duckworth & Overlook, 2009. This is a fascinating book.

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