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Archive for October, 2007

 Now, here’s an interesting study. It’ll soon be published in the November issue of the American Journal of Public Health. There’s a way of considering the amount of health benefit from an intervention. It’s to assess the number quality-adjusted life-year gains per dollar invested. That is, not just benefits in terms of greater life expectancy, but also a measure of quality of life in those years. It’s a cost benefit analysis so the economic payoff is measured by assessing how much the intervention costs so you can work out how much it would cost to get the benefit of the better, longer lives. These researchers claim to have found an intervention which brings greater payoffs in these terms than most other interventions. What amazing new drug is this? Or is it a life-style change?

Nope.

You’re going to be surprised.  It’s reducing class sizes at school!

The class size reduction was from 22 – 25 kids per class, down to 13 – 17. From kindergarten through to Grade 3. The better education, produced better educational outcomes leading to better, less hazardous jobs and the ability to move out of poorer housing etc. I won’t bother you with the details of the figures here (you can follow the link and read more yourself if you like). But what I think makes this study especially fascinating is thinking out of the box.

These days we hear endless claims for technological fixes – from wonder drugs, to vaccines, to new claims for possible genetic engineering. But, historically, the greatest improvements in the health of populations do not come from medical interventions, they come from things like improving water supplies, sanitation, reducing overcrowding and so on. There’s been an enormous movement towards looking at smaller and smaller parts over the last couple of hundred years – reductionism. In the future we’ll see the greatest health gains by focusing holistically, considering the environments and contexts in which individuals are embedded and studying what happens within these systems instead of exclusively studying what happens at molecular levels.

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Smart World starts by acknowledging the work of two others – Albert-Laszlo Barabasi and Andy Clark. I’ve just read Linked by Barabasi. (ISBN 0-452-28439-2) It’s a fascinating book about the rather young science of networks. I agree with the author, that understanding how networks are created and function is going to be absolutely key to our future direction in science.

A network, quite simply, is made up of nodes and links. One example is social networks. Think of a piece of paper with the names of several individuals on it and lines drawn between the names of people who know each other. It’s remarkable how quickly information can spread around such a network. Maybe you came across the movie “Six Degrees of Separation” – a story based on the premise that there are only an average of six links between any two human beings on the planet. Turns out that idea, which apparently came from a Hungarian short story, is pretty accurate. But there’s a twist…….sometimes the number of links is way less than six (even between people who don’t know each other). Other kinds of networks you are familiar with are the maps of flight routes you see published in airline magazines, the power grid, and, yes, our dear World Wide Web. In fact, everywhere you look, you’ll see networks. Everything is connected. Nothing exists in isolation.

To try and understand how networks develop and how they function, Barabasi takes you on a journey through the world of mathematicians, physicists, social scientists and engineers. It’s quite fascinating. In the process he describes a very clear evolution of this new science. Intially, complex networks were thought to be completely random. But randomly created networks produced by computer modeling turn out not look like real world networks. Real world networks don’t have random distribution of nodes. Some nodes are way more connected than others. Barabasi calls these hubs. Once you introduce the concept of hubs, the mathematical modeling of networks reveal what are known as “power laws” (this is a bit beyond me I’m afraid – maybe Phil can help explain these?) but, as I understand it, if you take a single quality or characteristic in nature, say, height of individual human beings, you’ll get a bell curve. Bell curves look symmetrical and they have steep sides ie there aren’t many “outliers”. Complex, natural networks however have node distributions which can’t be described by bell curves. Instead you get a small number of highly connected nodes (hubs) and a huge number of less connected ones. This characteristic produces incredibly resilient and fast networks.

Real life networks are highly resistant to damage and they adapt to change. You can take out lots of nodes and not make much difference to the functioning. To really damage them you have to go for the hubs. Take them out and you bring the system down catastrophically. So, the structure of networks provides both their greatest strength and their greatest weakness.

Barabasi gives masses of great examples, from epidemiological spread of viruses like HIV, to the functioning of international economic markets, to the spread of ideas throughout civilisations. But one of his most interesting analyses is his critique genetics.

How often do you read about “breakthroughs” in mapping the genetic “origins” of various diseases – all with the promise of predictive genetic tests and of treatments based on what is known as pharmacogenomics – finding which genetic precursors determine the responses to which particular drugs. He dismantles this reductionist view very effectively and promotes a network model instead – making what I find to be a convincing argument that the genetic bases of diseases won’t be found in mapping the genome but in mapping the networks of genes.

This shift in perspective is crucial. It drives us away from a reductionist consideration of elements and parts towards a holistic consideration of system function by understanding nodes and their connections. He even terms this “postgenomic biology”. I like it! However, it’s at this point that he suddenly disappoints. His chapter 13 is very odd. It’s entitled “Map of Life” and in it he takes this idea of postgenomic biology and applies it in a bizarrely reductionist way, predicting that the future of medicine will be in tests and highly individualised drugs based on eliciting these genetic maps. He thinks you won’t need consultations with doctors any more, just simple blood tests which will be computer analysed and targetted, tailored drugs will then be kind of published on demand and delivered to your door and, voila! you have your own special cure!  I’m sorry, but I don’t buy this. I mean, I believe that if we could produce a new generation of highly specific drugs rather than the blunderbust ones we use now that would be great, but what happened to this idea of the science of networks, and how they would change our understanding of everything? Suddenly Barabasi leaps into a reductionist model of disease and healing which is predicated on the idea that each individual is indeed an island. Hasn’t he just spent the rest of the book showing us the importance of mapping connections? Isn’t every individual in fact massively connected not only to other individuals but to all kinds of environments. Isn’t it impossible to understand an individual as context-free?

However, don’t let chapter 13 put you off. He really is onto something extremely important here. Once you start to think this way you see networks everywhere and you begin to understand the inescapable importance of connections, and, interestingly, of hubs. We’re at the beginning of this science and I think it’s pretty exciting.

Those of you who have read other posts on this blog will be familiar with my references to Deleuze. His philosophy of networks – he preferred the model of the rhizome – predates this scientific development and has probably been one of the important nodes from which this area of study has grown. You’ll also be familiar with the concept of the Complex Adaptive System which I believe is the best model we have so far for understanding human health and illness.

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Having just blogged about living with uncertainty, I stumbled across this –

Gilda

Gilda Radner, by the way, died in 1989, aged 42, from ovarian cancer.

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My daughter, Amy, sent me a link to this video (I think she “stumbled” upon it – I DO recommend “stumbling“!)

I think it is WONDERFUL.

I think this is a fabulous representation of how everything is connected. Whatever we do has consequences and impacts in unpredictable ways. This is actually a great example of why a complex system is so impossible to control – the characteristics of complex systems include networks of connections between things which means that a change in any part of the system changes the whole system; that outcomes are highly dependent on the starting conditions; that emergence occurs – new phenomena; and that every situation is unpredictable in the details.

Thank you Amy!

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Two things got me thinking about certainty, uncertainty and risk on the way to work today.

First off, as I started to descend the two flights of concrete steps to the low-level platform at Queen Street Station, I heard this disembodied voice of a Scotrail employee saying “Customers are reminded to take care on the stairs and use the handrail provided”. I realised that they’d installed an automatic system which would play this message repeatedly every time somebody stepped onto the staircase. AAAAAARRRGGGHHH! I felt like shouting! “Thankyou for reminding me! I was just about to throw myself recklessly head-first down your concrete steps cocking a snoot at your shiny metal handrail! I won’t do it now! You reminded me just in time!” Good grief! What next? What with hot water taps that have warnings that say “This water is hot” (!!! Really???!!) So, that was my first thought. What is all this about warnings of all the terrible things that might happen these days? A variation of this same theme is surely those government bods who reckon they can keep us safe from terrorism by confiscating toiletries and baby milk before people get on planes!

Then I get on the train (having successfully managed yet again to negotiate a whole flight of stairs without falling down!) and I pick up a copy of the free newspaper “Metro”. My eye is caught by a piece about genetic tests to predict what diseases we might get, and here’s this quote from a woman in England who has a family history of breast cancer and she’s saying how great it would be to have genetic tests that told us exactly what diseases we were going to get and goes on to express her preference for the development of tests that would tell you exactly when you are going to die too!

What do you think about that?

Would you like to have a test that would tell you exactly what disease you were going to get and your exact time and date of death? (Of course, no test in the world will ever predict the chances of you dying in an accident – make sure you pay attention to that Scotrail message when negotiating stairs!)

But, seriously, do we want such certainty? Do you?

In Reckoning With Risk, Gerd Gigerenzer, repeatedly returns to Benjamin Franklin’s aphorism

In this world nothing can be said to be certain, except death and taxes.

But this really is at the core of a tricky issue. As far as I’m aware, human beings are the only creatures endowed with an imagination capable of enabling them to imagine their own deaths. Psychologists say that all fears are, at source, ‘existential’ fears (the fear of death, of ending, of non-existence). This knowledge of this one certainty can make life difficult for people. Many people consult doctors because they are afraid that a symptom is a feature of a mortal disease. Many people are trapped in routines because they fear what might happen if they try something different, or stray into previously unexplored territory. We even have a certain type of “scientist” who seeks to present every one of their findings and opinions as the certain Truth, and there are goodness knows how many experts who reckon they know for sure what is best for us!

OK, I accept that I need security in life. We all do. If I really couldn’t reasonably expect to travel to work tomorrow why would I even set out? But these things are variables and probabilities. There really are no guarantees – well, except death and taxes (Benjamin was right again)

Tell me what you think.

How much do you want certainty? What kind of risks are you prepared to take?

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Blog Action Day

Here’s my contribution to Blog Action Day. A little movie of some of my photos showing how beautiful the environment is. I’ve set it to ‘I Saved The World Today’ by the Eurythmics. This is a world worth saving, and it’s down to you and me (the zombies aren’t going to do it!)

We adapt to the changes in the environment around us but we can interact more powerfully if we do it consciously.

To adapt consciously, first you have to become aware, then you have the opportunity to make choices. Having chosen, you can then act. So, take a few moments today to ask yourself how you might live a more aware life. Without awareness, you won’t even know what choices are available to you.

A life of conscious choices is a creative life. It’s a life of growth and development.

A growing life is a more engaged life, more connected, more interactive, more active.

I hope today you’ll start to think how to consciously ADAPT, CREATE and ENGAGE.

Bloggers Unite - Blog Action Day

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The easiest way to offend a patient is to fail to engage with their reality by projecting our assumptions, theories and realities upon them. – Brian Bloom. Meaningful Disease.

There’s an awful lot of arrogance around these days. So many people seem to assume they are the sole possessors of The Truth. In my own sphere of work, I frequently read pontifications from non-clinical “scientists” berating doctors and patients. The arrogance usually takes the form of a fairly abusive attack on anybody who claims a benefit from a therapy which the “scientist” doesn’t support. It’s a “Trust me I’m an expert” at best, and it’s “Just be quiet, I know better than you” at worst. Arrogance is never appealing.

My view is that a good scientist is a humble scientist and never claims to possess The Truth, never claims to know all that needs to be known about any subject.

A good doctor puts the patient first. As Brian Bloom says in the quotation at the beginning of this post, projecting their own assumptions or theories onto the patient is a failure to engage. A failure to engage is a failure to practice good medicine.

The balance of power has started to shift in the doctor-patient relationship. I’m glad. It’s time doctors cared about every patient they meet, put the patients’ agendas to the fore, and it’s time for us to reject one-size-fits-all treatments which actually never ever have fitted everyone.

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Darian Leader, co-author of Why do People Get Ill? has written an article about the proposal to expand CBT on the NHS in today’s Guardian. He points out that CBT (Cognitive Behavioural Therapy) has a high failure rate when considered over time. It is effective in the short term but many patients have either relapsed or developed other symptoms over an 18 month period. This is a common problem with a lot of medical care based on the very time-limited RCTs conducted for most treatments – in other words, whilst treatments can often be shown to do what they claim to do in the short term, very few several year long studies are conducted and pretty much almost NO whole of life ones which follow a life-course approach (please draw my attention to the right places if you know I’m wrong about this). This short-term-ist approach to health care keeps us all spinning round on the same hamster wheel. Until we tackle the harder questions of how to improve health, resilience, and the causes of disease, we’re going to be stuck with all these protocols of health care created on the back of short term solutions.

The issue of the problems with this current obsession with RCTs which are narrow in scope and short in duration is explored by Professor Paul Verhaeghe, Professor psychodiagnostics at Ghent University in his paper presented at Health4Life. There’s a twelve page pdf of his paper available at that link (It’s worth reading)

Darian Leader concludes –

Real mental health policy has to recognise that there are no easy answers, that human beings are complex and contradictory, and, most important, that we can never know in advance what will be best for a patient.

A true exploration of psychological suffering is perfectly possible in the framework of the NHS – if policymakers can think beyond mental hygiene and start listening to the patient.

How true! There are no easy answers. Human beings are complex and contradictory. It’s time to start listening to the patient.

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I search for life in dread deathin fearful disease for health,

in dark prison for liberty,

escape in a sealed room,

in a traitor, loyalty.

But my own fate from whom

I ne’er hope for the good

has with just heaven ruled

if the impossible I demand,

for me the possible is banned.

Know where this quote comes from?

What do you think about it?

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From Brian Broom’s Meaning-full Disease

Goethe showed science a new approach…..of seeing the whole world symbolised in a flower, an animal, a pebble, the human eye, the sun; and to construct the world from

this flower flower

this pebble pebble

that is to create anew and to investigate things not by analysing, but by placing them in the context of the whole.

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