Monthly Archives: October 2014

Re-envisioning Ebola, including updated story about Nigeria from Kas Nwuke

Arlene Ash, Professor and Division Chief, Biostatistics and Health Services Research, at UMass Medical School, has compiled a useful series of original thoughts, emails, and links about Ebola which I am broadcasting and reposting on my blog site here.

This posting repeats some of the information already posted in my earlier blog:

Ebola is being contained in Nigeria

The original article by Kas Nwuke is now linked (with permission) as a pdf and includes linked references on my web site. (It is 6 pages – updated to include two pages of references.)

Containing Ebola: A success story from an “unexpected” place?

From Arlene Ash:

Friends and Colleagues,

Here’s what I [Arlene Ash] sent previously with some updates.

I now have Mead Over’s permission to circulate his text that is included below, plus sharing the link to his Twitter log: @MeadOver.

Also, I have added the text from yesterday’s NYT editorial “Cuba’s Impressive Role on Ebola,” since non-subscribers may not be able to get it themselves on-line.  The full text, with links and commentary, is very interesting, and I think important.

These are, indeed, extraordinary times – and, I firmly believe, they offer an extraordinary opportunity to discard old, dysfunctional paradigms – if only we can seize it.

Arlene

_

Last weekend I [Arlene Ash] wrote:

Re-envisioning Ebola as an opportunity

Friends, If you like this idea as well as I do, perhaps you can help make it “go viral.”

  •  I believe it would be cheaper to stop Ebola in Africa than to try to seal our borders against it as it spreads unchecked.
  • I believe that taking a leadership role in stopping Ebola would do a great deal for our self-esteem as a nation, and for our regard in the world.
  • I believe that cost-effectiveness calculations could make a strong case for a “war on Ebola” as the best kind of war that we could wage. I propose we could do more to combat ISIS and protect America by working with the world community to prevent the spread of Ebola in Africa than by any level of commitment of troops and weapons to the enflamed Middle East.

I want America to re-envision Ebola as an opportunity to demonstrate what great things we can do when we bend ourselves to the task.

Of course we are all busy, but perhaps it takes only a little help from many people to spread a really good idea.

Thought for the day. Please grow it and pass it along.

_

I got back some very interesting feedback which I would like to share:

From Randy Ellis (a success story in Nigeria, with lessons for the rest of the world):

Amid so much negative and scary news about Ebola, this research paper on the experience of Nigeria where it has not spread widely after arriving by airplane gives great hope. I recommend it if you have time (It is 6 pages).

Containing Ebola: A success story from an “unexpected” place? [Now linked instead of attached as a pdf]

The author, Kasirim Nwuke  is a BU Ph.D. Here is his bio from one web site.

http://www.elearning-africa.com/profiles/profile_popup.php?address_id=595692&lang=4

_

Then a follow-on from Mead Over, author of a World Bank report (Twitter log  @MeadOver):

This is indeed a good story with details that go beyond the information our World Bank report (in the box on page 29) on the efforts of Senegal and Nigeria that I co-authored on October 7 and blogged on Friday:

http://www.cgdev.org/blog/understanding-world-banks-estimate-economic-damage-ebola-west-africa

http://documents.worldbank.org/curated/en/2014/10/20270083/economic-impact-2014-ebola-epidemic-short-medium-term-estimates-west-africa

The box on page 29 of the WB report was requested by JYK after he sat next to Goodluck Jonathan at the UNGA meeting last week and President Jonathan told him that 1,000 Nigerian public health workers were involved in the contact tracing including almost 300 Nigerian doctors.  This is remarkable not only for the level of effort, but also in comparison to Liberia, Sierra Leone and Guinea each of which had fewer than 100 doctors before the crisis.  In Nigeria I have heard that the polio eradication workers are the ones who were redeployed to do the Ebola contact tracing.  Other countries don’t have the polio program because they don’t have polio.  So even a relatively wealthy country like Ghana may have trouble emulating Nigeria’s success.

I like the point made in the article that Nigeria showed courage in announcing the danger far and wide and rolling out a massive public health effort to contain it.  This was before the rest of the world was taking the epidemic as seriously as they are today, and thus the measures could well have been opposed by economic interests.  (Parallel to HIV:  In the early days of the HIV epidemic, business interests in Thailand opposed the admission that HIV was a problem.  In “Confronting AIDS” we attribute Thailand’s energetic and remarkably successful “100% condom program” partly to the fact that the country was under a military dictatorship for 6 months and the “benevolent dictator” saw the wisdom of opposing the economic interests in order to start that program.)

When I spoke on Ebola at American University the other evening, one of the other panelists was an anthropologist who had recently returned from Sierra Leone.  She also reported the “Ebola handshake” and other “self-isolation behavior from that country.  Epidemiologists are hoping that such behavior, developing in response to the news and the public information campaign, will reduce the reproductive rate of the epidemic.  But we have not seen a deceleration in Liberia or Sierra Leone yet.

Another implication of the author’s account and of the Nigerian and Senegalese public health expenditure amounts reported in the box of the World Bank report is that several West African countries are increasing government spending in response to the outbreak (as is the US).  Our World Bank report does not include the possible stimulus effect of this spending on national economies.  This spending may offset some of the reduction in aggregate demand due to aversion behavior, and thus reduce the economic impact below our estimates.  However, as I say at the end of my blog, unless the epidemic begins to decelerate soon, our “High Ebola” estimate may fall short of estimating the total impact.  And I hope that when Charles Kenny and I join CDC and others in asserting this is still a small problem inside the US, we are not being overly optimistic.  As here:

https://www.youtube.com/watch?v=_jCWkDYwN2g; https://www.youtube.com/watch?v=113kLL3pZQQ

One frustrating aspect of the report by Kasirim Nwuke is the lack of references or hyperlinks [AA: they are now attached in a separate file.]  Even our World Bank report did better.  I agree totally with his conclusion that Nigeria is not yet “safe”.  Each day is another roll of the dice.  In one sense, Nigeria was lucky that they detected the first case on entry.  Next time they may not be so lucky.

_

In response, Kas Nwuke KNwuke@uneca.org wrote (on 10/18/14):

Going through the materials, I have come to know that Nigeria’s preparations started much earlier. It started once the outbreak in Guinea and reached full steam after the July ECOWAS Heads of State Summit.  That Summit discussed Ebola in the sub-region and resolved that member States of ECOWAS should be prepared to contain it.  Nigeria according to the Health Minister made, after the Summit, the very first financial donation of $3.5 million US to the three countries.  Back home, the Health Minister briefed the Commissioners for Health in the 36 States of the Federation and asked for increased vigilance.

 

You will find this additional information in the references.

 

In my essay, I had given the number of Nigerians who have volunteered to go to Liberia and Sierra Leone as 200.  I have since learned that the number is actually 591.  In addition, Nigeria is also providing crash courses to health personnel from the three most affected countries.

 

I am sure that lots more will be written about Nigeria experience.  I hope that the lesson can be of value to resource constrained countries on how to handle/tackle epidemics in the future.

 

(I must with regret inform you that Nigeria’s election politics has now entered the Ebola debate.  Rivers State and Lagos State are controlled by the opposition.  Electioneering campaign for next year’s election has started and the ruling PDP and the opposition APC is each seeking to claim credit for the success in containing the spread of Ebola.  The Rivers State Governor has just disclosed – see the hyperlink – that the state spent N1.106 billion – more than $6 million – to tackle Ebola.)

 

With best wishes,

 

Kas

Also, some inspiring information about a UMass colleague (Steven Hatch) now in Liberia:

http://www.nytimes.com/2014/10/17/world/africa/pursuing-a-calling-that-leads-to-west-africa.html

http://www.nytimes.com/2014/10/17/world/africa/ebola-liberia-west-africa-epidemic.html

and a NYT “conspicuous success story” about Senegal, that points to the so far very positive Nigerian experience as well.

Also,

NYT, October 19 Op-Ed: “Cuba’s Impressive Role on Ebola” (http://www.nytimes.com/2014/10/20/opinion/cubas-impressive-role-on-ebola.html?_r=0)

Cuba is an impoverished island that remains largely cut off from the world and lies about 4,500 miles from the West African nations where Ebola is spreading at an alarming rate. Yet, having pledged to deploy hundreds of medical professionals to the front lines of the pandemic, Cuba stands to play the most robust role among the nations seeking to contain the virus.

Cuba’s contribution is doubtlessly meant at least in part to bolster its beleaguered international standing. Nonetheless, it should be lauded and emulated.

The global panic over Ebola has not brought forth an adequate response from the nations with the most to offer. While the United States and several other wealthy countries have been happy to pledge funds, only Cuba and a few nongovernmental organizations are offering what is most needed: medical professionals in the field.

The Cuban health sector is aware of the risks of taking on dangerous missions. Cuban doctors assumed the lead role in treating cholera patients in the aftermath of Haiti’s earthquake in 2010. Some returned home sick, and then the island had its first outbreak of cholera in a century. An outbreak of Ebola on the island could pose a far more dangerous risk and increase the odds of a rapid spread in the Western Hemisphere.

Cuba has a long tradition of dispatching doctors and nurses to disaster areas abroad. In the aftermath of Hurricane Katrina in 2005, the Cuban government created a quick-reaction medical corps and offered to send doctors to New Orleans. The United States, unsurprisingly, didn’t take Havana up on that offer. Yet officials in Washington seemed thrilled to learn in recent weeks that Cuba had activated the medical teams for missions in Sierra Leone, Liberia and Guinea.

With technical support from the World Health Organization, the Cuban government trained 460 doctors and nurses on the stringent precautions that must be taken to treat people with the highly contagious virus. The first group of 165 professionals arrived in Sierra Leone in recent days. José Luis Di Fabio, the World Health Organization’s representative in Havana, said Cuban medics were uniquely suited for the mission because many had already worked in Africa. “Cuba has very competent medical professionals,” said Mr. Di Fabio, who is Uruguayan. Mr. Di Fabio said Cuba’s efforts to aid in health emergencies abroad are stymied by the embargo the United States imposes on the island, which struggles to acquire modern equipment and keep medical shelves adequately stocked.

In a column published over the weekend in Cuba’s state-run newspaper, Granma, Fidel Castro argued that the United States and Cuba must put aside their differences, if only temporarily, to combat a deadly scourge. He’s absolutely right.

 

Ebola is being contained in Nigeria

Amid so much negative and scary news about Ebola, this research paper on the experience of Nigeria where it has not spread widely after arriving by airplane gives great hope. I recommend it if you have time (It is 6 pages – updated to include references.).

Containing Ebola: A success story from an “unexpected” place?

The author, Kasirim Nwuke  is a BU Ph.D. Here is his bio from the elearning-aftrica web site.

http://www.elearning-africa.com/profiles/profile_popup.php?address_id=595692&lang=4

Kasirim Nwuke

Kasirim Nwuke is Chief, New Technologies and Innovation at the United Nations Economic Commission for Africa (ECA), Addis Ababa, Ethiopia. He has thought in a number at a number of higher education institutions in the United States of America including Tufts University, Medford, MA; Wellesley College, Wellesley, MA, and Northeastern University, Boston, MA. He been a Research Associate at Harvard University School of Public Health and the a Fellow in African Studies at the African Studies Centre, Boston University. He has held different positions at the United Nations Economic Commission for Africa and as Senior Economic Adviser to the Minister of Finance of the Federal Republic of Nigeria. Kasirim is the author (or lead author) of several research papers and reports and policy briefs on African economic development.  Among books to which he has been a contributing author is “AdricaDotEdu: IT Opportunities and Higher Education in Africa” Maria Beebe et al. Kasirim holds a PhD in Economics from Boston University, Boston, MA.

Former BU professor and World Bank senior economist Mead Over has also been blogging on ebola in west africa. Here is one of his recent blogs.

http://www.cgdev.org/blog/understanding-world-banks-estimate-economic-damage-ebola-west-africa

http://documents.worldbank.org/curated/en/2014/10/20270083/economic-impact-2014-ebola-epidemic-short-medium-term-estimates-west-africa

 

 

 

Important Reposting on Placebo surgery from TIE

I am forwarding this excellent TIE post since every health researcher and indeed every consumer should realize how serious the lack of evidence is on many common surgical procedures. Here are some quotes organized in a succinct way.

“2002… arthroscopic surgery for osteoarthritis of the knee … Those who had the actual procedures did no better than those who had the sham surgery. ” (We still spend $3 billion a year on this procedure)
“2005… percutaneous laser myocardial revascularization, …  didn’t improve angina better than a placebo”
“2003, 2009, 2009… vertebroplasty — treating back pain by injecting bone cement into fractured vertebrae … worked no better than faking the procedure.”
“2013 … arthroscopic procedures for tears of the meniscus cartilage in the knee… performed no better than sham surgery” (We do about 700,000 of them with direct costs of about $4 billion.)
“[2014] … systematic review of migraine prophylaxis [prevention], while 22 percent of patients had a positive response to placebo medications and 38 percent had a positive response to placebo acupuncture, 58 percent had a positive response to placebo surgery.
“2014… 53 randomized controlled trials that included placebo surgery as one option. In more than half of them … the effect of sham surgery was equivalent to that of the actual procedure.”

If you are getting surgery done, do your own research on it and ask questions!

 

——– Original Message ——–

Subject: “The Placebo Effect Doesn’t Apply Just to Pills” plus 1 more
Date: Thu, 9 Oct 2014 11:13:06 +0000
From: The Incidental Economist <tie@theincidentaleconomist.com>
To: <ellisrp@bu.edu>

“The Placebo Effect Doesn’t Apply Just to Pills” plus 1 more


The Placebo Effect Doesn’t Apply Just to PillsPosted: 09 Oct 2014 04:00 AM PDT

The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

For a drug to be approved by the Food and Drug Administration, it must prove itself better than a placebo, or fake drug. This is because of the “placebo effect,” in which patients often improve just because they think they are being treated with something. If we can’t compare a new drug with a placebo, we can’t be sure that the benefit seen from it is anything more than wishful thinking.

But when it comes to medical devices and surgery, the requirements aren’t the same. Placebos aren’t required. That is probably a mistake.

At the turn of this century, arthroscopic surgery for osteoarthritis of the knee was common. Basically, surgeons would clean out the knee usingarthroscopic devices. Another common procedure was lavage, in which a needle would inject saline into the knee to irrigate it. The thought was that these procedures would remove fragments of cartilage and calcium phosphate crystals that were causing inflammation. A number of studieshad shown that people who had these procedures improved more than people who did not.

However, a growing number of people were concerned that this was really no more than a placebo effect. And in 2002, a study was published thatproved it.

A total of 180 patients who had osteoarthritis of the knee were randomly assigned (with their consent) to one of three groups. The first had a standard arthroscopic procedure, and the second had lavage. The third, however, had sham surgery. They had an incision, and a procedure was faked so that they didn’t know that they actually had nothing done. Then the incision was closed.

The results were stunning. Those who had the actual procedures did no better than those who had the sham surgery. They all improved the same amount. The results were all in people’s heads.

Many who heard about the results were angry that this study occurred. They thought it was unethical that people received an incision, and most likely a scar, for no benefit. But, of course, the same was actually true for people who had arthroscopy or lavage: They received no benefit either. Moreover, the results did not make the procedure scarce. Years later, more than a half-million Americans still underwent arthroscopic surgery for osteoarthritis of the knee. They or their insurers spent about $3 billion that year on a procedure that was no better than a placebo.

Sham procedures for research aren’t new. As far back as 1959, the medical literature was reporting on small studies that showed that procedures like internal mammary artery ligation, a surgical procedure used to treat angina, were no better than a fake incision.

In 2005, a study was published in the Journal of the American College of Cardiology proving that percutaneous laser myocardial revascularization, in which a laser is threaded through blood vessels to cut tiny channels in the heart muscle, didn’t improve angina better than a placebo either. We continue to work backward and use placebo-controlled research to try to persuade people not to do procedures, rather than use it to prove conclusively that they work in the first place.

A study published in 2003, without a sham placebo control, showed that vertebroplasty — treating back pain by injecting bone cement into fractured vertebrae — worked better than no procedure at all. From 2001 through 2005, the number of Medicare beneficiaries who underwent vertebroplasty each year almost doubled, from 45 to 87 per 100,000. Some of them had the procedure performed more than once because they failed to achieve relief. In 2009, not one but two placebo-controlled studies were published proving that vertebroplasty for osteoporotic vertebral fractures worked no better than faking the procedure.

Over time, after the 2002 study showing that arthroscopic surgery didn’t work for osteoarthritis of the knee, the number of arthroscopic procedures performed for this condition did begin to go down. But at the same time, the number of arthroscopic procedures for tears of the meniscus cartilage in the knee began to go up fast. Soon, about 700,000 of them were being performed each year, with direct costs of about $4 billion. Less than a year ago, many were shocked when arthroscopic surgery for meniscal tearsperformed no better than sham surgery. This procedure was the most common orthopedic procedure performed in the United States.

The ethical issues aren’t easily dismissed. Theoretically, a sugar pill carries no risk, and a sham procedure does. This is especially true if the procedure requires anesthesia. The surgeon must go out of his or her way to fool the patient. Many would have difficulty doing that.

But we continue to ignore the real potential that many of our surgical procedures and medical devices aren’t doing much good — and might even be doing harm, since real surgery has been shown to pose more risks than sham surgery.

Rita Redberg, in a recent New England Journal of Medicine Perspectives article on sham controls in medical device trials, noted that in a recentsystematic review of migraine prophylaxis, while 22 percent of patients had a positive response to placebo medications and 38 percent had a positive response to placebo acupuncture, 58 percent had a positive response to placebo surgery. The placebo effect of procedures is not to be ignored.

Earlier this year, researchers published a systematic review of placebo controls in surgery. They searched the medical literature from its inception all the way through 2013. In all that time, they could find only 53 randomized controlled trials that included placebo surgery as one option. In more than half of them, though, the effect of sham surgery was equivalent to that of the actual procedure. The authors noted, though, that with the exception to the studies on osteoarthritis of the knee and internal mammary artery ligation noted above, “most of the trials did not result in a major change in practice.”

We have known about the dangers of ignoring the need for placebo controls in research on surgical procedures for some time. When the few studies that are performed are published, we ignore the results and their implications. Too often, this is costing us many, many billions of dollars a year, and potentially harming patients, for no apparent gain.

@aaronecarroll

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Placebo historyPosted: 09 Oct 2014 03:00 AM PDT

Here are my highlights from “Placebos and placebo effects in medicine: historical overview,” by Anton de Craen and colleagues. All are direct quotes.

  • In 1807 Thomas Jefferson, recording what he called the pious fraud, observed that ‘one of the most successful physicians I have ever known has assured me that he used more bread pills, drops of colored water, and powders of hickory ashes, than of all other medicines put together’. About a hundred years later, Richard Cabot, of Harvard Medical School, described how he ‘was brought up, as I suppose every physician is, to use placebo, bread pills, water subcutaneously, and other devices’.
  • The word placebo (Latin, ‘I shall please’) was first used in the 14th century. In that period, it referred to hired mourners at funerals. These individuals often began their wailings with Placebo Domino in regione vivorum, the ninth verse of psalm cxiv, which in the Latin Vulgate translation means ‘I shall please the Lord in the land of the living’. Here, the word placebo carries the connotation of depreciation and substitution, because professional mourners were often stand-ins for members of the family of the deceased.
  • In 1801, John Haygarth reported the results of what may have been the first placebo-controlled trial. A common remedy for many diseases at that time was to apply metallic rods, known as Perkins tractors, to the body. These rods were supposed to relieve symptoms through the electromagnetic influence of the metal. Haygarth treated five with imitation tractors made of wood and patients found that four gained relief. He used the metal tractors on the same five patients the following day and obtained identical results: four of five subjects reported relief.
  • In the 1785 New Medical Dictionary, placebo is described as ‘a commonplace method or medicine’. In 1811, the revised Quincy’s Lexicon-Medicum as ‘an epithet given to any medicine adapted defines placebo more to please than to benefit the patient’.
  • In the 1930s, several important papers were published with regard to the introduction of placebos in clinical research. [… Two] papers assessed the value of drugs used in the treatment of angina pectoris in cross-over experiments and deceptively administered placebos to the ‘no-treatment’ comparison group. […] In both trials the drugs were judged to exert no specific action that might be useful in the treatment of angina. Gold and colleagues tried to explain why inert interventions might work: their points included ‘confidence aroused in a treatment’, the ‘encouragement afforded a new and ‘a of medical by procedure’ change advisor’.
  • Placebo was a fraud and deception that had the ‘moral effect of a remedy given specially for the disease’, but placebos did not affect the natural course of disease; they were a priori excluded from having such an impact. Placebos were therapeutic duds to manage patients, or, as in the Flint investigation, a camouflage behind which to watch nature take its course.
  • In 1938, the word placebo was first applied in reference to the treatment given to concurrent controls in a trial.
  • The efficacy of cold vaccines was evaluated in several placebo-controlled trials. […] The conclusion [of one] reads ‘one of the most significant aspects of this study is the great reduction in the number of colds which the members of the control groups reported during the experimental period. In fact these results were as good as many of those reported in uncontrolled studies which recommended the use of cold vaccines’. The placebo effect was born.

@afrakt

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