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Science Tuesday - TB, Cigarettes, Language skills, and climate change
The Doctor's World: Rise of a Deadly TB Reveals a Global System in Crisis
By LAWRENCE K. ALTMAN, M.D., The New York Times, March 20, 2007
LOS ANGELES — The spread of a particularly virulent form of tuberculosis in South Africa illustrates a breakdown in the global program that is supposed to keep the disease, one of the world’s deadliest, under control.
The program was intended to detect tuberculosis cases, make sure patients were taking their antibiotics, test patients for resistance to those drugs and monitor the spread of the disease.
But international tuberculosis experts say the system is in deep trouble for an array of reasons: misuse of antibiotics; other bad medical practices, like failing to segregate high-risk patients in hospitals and clinics; and cuts in government spending for such basics as adequate supplies of drugs and laboratories to do the testing.
Such factors have led to the rise of drug-resistant tuberculosis bacteria, a menace the world has only begun to appreciate.
Mycobacterium tuberculosis, the microbe that causes the disease, was discovered 125 years ago this month. Today, the bacteria infect 8.8 million people a year and cause 1.6 million deaths. They are spread in tiny droplets when patients cough.
Tuberculosis is curable, as long as the bacteria are susceptible to antibiotics. It becomes deadlier when it attacks people who are also infected with H.I.V., the AIDS virus. And when the tuberculosis bacteria become extremely drug-resistant, the death rate soars.
That was the case in Tugela Ferry, a rural town in KwaZulu-Natal province in South Africa, when an outbreak of extremely drug-resistant tuberculosis — XDR-TB for short — killed 52 of its 53 victims, all of whom were also infected with H.I.V. The outbreak was detected in 2005, but it did not receive international attention until it was reported at the international AIDS meeting in Toronto last August.
The World Health Organization calls the extremely drug-resistant form “a grave public health threat” because of its potential explosiveness among the millions of H.I.V.-infected people in poor countries. It seems to be a lesser threat among people who do not have H.I.V., though it could be dangerous to the millions with weakened immune systems from treatment for cancer and other diseases.
XDR-TB is defined as tuberculosis that is resistant to the two most important antituberculosis drugs (isoniazid and rifampin), along with two other drugs: a member of the fluoroquinolone class and at least one of three others (capreomycin, kanamycin and amikacin).
A step lower on the resistance scale is a form of the disease called MDR-TB, for multidrug-resistant tuberculosis. An outbreak of that form struck in New York City in the early 1990s, and cost at least $1 billion in emergency measures to control and manage tuberculosis patients.
Experts say the tuberculosis outbreak in South Africa is the deadliest one that they can recall.
Although South African officials, who have known about the outbreak for a year, promised a prompt and full investigation, even experts there acknowledge that efforts are lagging.
“Unfortunately, we do not know much more than a year ago” mainly because “a systematic survey in each of the provinces has not yet started,” Dr. Karin Weyer of the South African Medical Research Council told the Conference on Retroviruses and Opportunistic Infections here recently.
Dr. Weyer said in an interview that she had hoped that rapid surveys and screening tests would have been completed by now to show better the geographic extent of the disease.
Using statistics from recent years, Dr. Weyer said her team estimated that 6,000 new cases of multidrug-resistant tuberculosis occurred in South Africa each year and that the rate of treatment failure was about 10 percent. Assuming that most failures were due to the extremely drug-resistant form, a conservative estimate is 600 cases of XDR-TB in her country each year, Dr. Weyer said.
In data that her team examined, about 85 percent of patients infected with XDR-TB and H.I.V. died, she said. The fatality rate in H.I.V.-negative patients seemed lower, but could not be determined until they complete long-term therapy.
What is known is that the deadly XDR-TB strain has been found in more than 40 hospitals in all nine provinces of South Africa, she said.
The rest of sub-Saharan Africa is at risk, she went on, because “control of airborne infection is either totally inadequate or even absent” in virtually all of those countries.
The outbreak is not limited to Africa. Dr. Paul Nunn, a tuberculosis expert at the World Health Organization, told the meeting here that one or more cases of XDR-TB had been found in at least 28 countries. Extrapolating from data about the multidrug-resistant form of tuberculosis, Dr. Nunn estimated that two-thirds of the XDR-TB cases were from China, India and Russia.
The recipe for spreading the disease is the same throughout the world: inappropriate use of antibiotics. When first-line drugs fail to kill the disease, Dr. Nunn said, doctors turn to a second group of drugs that are less widely used, and, they hope, more effective because the bacteria have not had a chance to become resistant to them.
“The little evidence we have suggests that this is not so much spread of resistant strains, but the creation of similar patterns of resistance in different strains around the world,” Dr. Nunn said, “because the drugs used are more or less the same everywhere, and unfortunately, so are the defects in the performance of TB control.”
South Africa has more laboratories to test tuberculosis strains for susceptibility to first- and second-line drugs than other sub-Saharan countries, Dr. Nunn said. He added, “Most African countries do not have a laboratory capable of carrying out first-line drug susceptibility tests, let alone for second-line drugs, which is technically more demanding.”
For those and other reasons, like a lack of doctors, health officials say they fear that tuberculosis may be spreading silently in other countries.
Experiments performed years ago have led some experts to speculate that drug-resistant tuberculosis bacteria are poorly transmissible. But that theory seems weakened by new studies from South African researchers working with colleagues from Harvard and the Centers for Disease Control and Prevention in Atlanta.
The researchers put caged guinea pigs in a ventilation stream leading from rooms housing patients with multidrug-resistant tuberculosis and possibly the extremely drug-resistant form. Skin tests showed that 80 percent of the animals were newly infected after four months, Dr. Weyer said.
XDR-TB may be just as infectious as regular tuberculosis and may be highly transmissible. And that is worrisome, Dr. Weyer said, because “most public health facilities in the developing world lack airborne infection control procedures.”
How the guinea pig findings translate to humans is uncertain because other studies have not been done or completed.
In one study, South African researchers tested 1,694 relatives and friends who had contact with 386 XDR-TB patients identified in Tugela Ferry. Among those contacts, only 12 cases of multidrug-resistant tuberculosis were found, and none of XDR-TB, Dr. Weyer reported.
The findings suggested that significant spread was not occurring in the community. But it was too soon to know, because even a drug-susceptible tuberculosis infection usually remains silent for years before it causes illness, Dr. Weyer said.
“This is the kind of exercise that we would like to see happening” in other areas and for longer periods to get a better understanding of the risk of transmission and getting sick, Dr. Weyer said.
The risk that the initial tuberculosis infection will progress to illness is compounded at 10 percent a year for those with H.I.V., compared with a lifetime risk of 10 percent among those who do not have the virus.
In medical journals and at scientific meetings, some doctors in South Africa and elsewhere have advocated enforced confinement of XDR-TB patients. But civil liberties aside, many experts say, these advocates have not thought through the practical aspects of such isolations. Enforced isolation “is much more difficult to implement than one would think,” Dr. Weyer said.
Because XDR-TB is believed to be incurable, such patients could be detained for life or until they die. All the while, infected patients may spread the disease to others.
Moreover, the disease is an occupational hazard for the health workers caring for patients; 4 were included among the 53 in the Tugela Ferry outbreak. Two additional cases in health workers were identified later.
So Dr. Weyer raised these questions, among others: What facilities would be used? Who would volunteer to take care of XDR-TB patients? How would these workers be protected? And without getting permission, how would health officials legally detect the many health workers who are infected with H.I.V.?
She offered no answers. And earlier this month, as if to illustrate the logistical hazards of caring for XDR-TB patients, 100 people walked out of a hospital in East London, South Africa, after paramedics wearing head-to-toe protection brought in eight patients with the disease.
Some South African hospitals are using engineering- and infection-control practices, like installing ultraviolet lights to kill tuberculosis microbes. Management studies show that health care facilities must be redesigned to prevent unnecessary contact between tuberculosis and H.I.V. patients in crowded clinics, X-ray departments, waiting lines and other areas, Dr. Weyer said.
On April 1, she said, South Africa plans to start field-testing 40,000 patients to determine the effectiveness of two new rapid tests to detect drug-resistant tuberculosis, and whether the results will lead to improved treatment outcomes. Elsewhere, researchers will test 60,000 patients under the direction of the Foundation for Innovative New Diagnostics in Geneva, Dr. Weyer said.
About 20 experimental drugs are being tested. But even if one is found effective in large-scale trials, it is unlikely to be marketed for a decade.
Essay: Tracing the Cigarette’s Path From Sexy to Deadly
By HOWARD MARKEL, M.D., The New York Times, March 20, 2007
For many Americans, the tobacco industry’s disingenuousness became a matter of public record during a Congressional hearing on April 14, 1994. There, under the withering glare of Representative Henry A. Waxman, Democrat of California, appeared the chief executives of the seven largest American tobacco companies.
Each executive raised his right hand and solemnly swore to tell the whole truth about his business. In sequential testimony, each one stated that he did not believe tobacco was a health risk and that his company had taken no steps to manipulate the levels of nicotine in its cigarettes.
Thirty years after the famous surgeon general’s report declaring cigarette smoking a health hazard, the tobacco executives, it seemed, were among the few who believed otherwise.
But it was not always that way. Allan M. Brandt, a medical historian at Harvard, insists that recognizing the dangers of cigarettes resulted from an intellectual process that took the better part of the 20th century. He describes this fascinating story in his new book, “The Cigarette Century: The Rise, Fall and Deadly Persistence of the Product that Defined America” (Basic Books).
In contrast to the symbol of death and disease it is today, from the early 1900s to the 1960s the cigarette was a cultural icon of sophistication, glamour and sexual allure — a highly prized commodity for one out of two Americans.
Many advertising campaigns from the 1930s through the 1950s extolled the healthy virtues of cigarettes. Full-color magazine ads depicted kindly doctors clad in white coats proudly lighting up or puffing away, with slogans like “More doctors smoke Camels than any other cigarette.”
Early in the 20th century, opposition to cigarettes took a moral rather than a health-conscious tone, especially for women who wanted to smoke, although even then many doctors were concerned that smoking was a health risk.
The 1930s were a period when many Americans began smoking and the most significant health effects had not yet developed. As a result, the scientific studies of the era often failed to find clear evidence of serious pathology and had the perverse effect of exonerating the cigarette.
The years after World War II, however, were a time of major breakthroughs in epidemiological thought. In 1947, Richard Doll and A. Bradford Hill of the British Medical Research Council created a sophisticated statistical technique to document the association between rising rates of lung cancer and increasing numbers of smokers.
The prominent surgeon Evarts A. Graham and a medical student, Ernst L. Wynder, published a landmark article in 1950 comparing the incidence of lung cancer in their nonsmoking and smoking patients at Barnes Hospital in St. Louis. They concluded that “cigarette smoking, over a long period, is at least one important factor in the striking increase in bronchogenic cancer.”
Predictably, the tobacco companies — and their expert surrogates — derided these and other studies as mere statistical arguments or anecdotes rather than definitions of causality.
Dr. Brandt, who has exhaustively combed through the tobacco companies’ internal memorandums and research documents, amply demonstrates that Big Tobacco understood many of the health risks of their products long before the 1964 surgeon general’s report.
He also describes the concerted disinformation campaigns these companies waged for more than half a century — simultaneously obfuscating scientific evidence and spreading the belief that since everyone knew cigarettes were dangerous at some level, smoking was essentially an issue of personal choice and responsibility rather than a corporate one.
In the 1980s, scientists established the revolutionary concept that nicotine is extremely addictive. The tobacco companies publicly rejected such claims, even as they took advantage of cigarettes’ addictive potential by routinely spiking them with extra nicotine to make it harder to quit smoking. And their marketing memorandums document advertising campaigns aimed at youngsters to hook whole new generations of smokers.
In 2004, Dr. Brandt was recruited by the Department of Justice to serve as its star expert witness in the federal racketeering case against Big Tobacco and to counter the gaggle of witnesses recruited by the industry. According to their own testimony, most of the 29 historians testifying on behalf of Big Tobacco did not even consult the industry’s internal research or communications. Instead, these experts focused primarily on a small group of skeptics of the dangers of cigarettes during the 1950s, many of whom had or would eventually have ties to the tobacco industry.
“I was appalled by what the tobacco expert witnesses had written,” Dr. Brandt said in a recent interview. “By asking narrow questions and responding to them with narrow research, they provided precisely the cover the industry sought.”
Apparently, the judge, Gladys Kessler of Federal District Court for the District of Columbia, agreed. Last August, she concluded that the tobacco industry had engaged in a 40-year conspiracy to defraud smokers about tobacco’s health dangers. Her opinion cited Dr. Brandt’s testimony more than 100 times.
Dr. Brandt acknowledges that there are pitfalls in combining scholarship with battle against the deadly pandemic of cigarette smoking, but he says he sees little alternative.
“If one of us occasionally crosses the boundary between analysis and advocacy, so be it,” he said. “The stakes are high, and there is much work to be done.”
Dr. Howard Markel is a professor of pediatrics, psychiatry and the history of medicine at the University of Michigan.
Skilled Ear for Music May Help Language
By ERIC NAGOURNEY, The New York Times, March 20, 2007
Anyone who has tried to learn Chinese can attest to how hard it is to master the tones required to speak and understand it. And anyone who has tried to learn to play the violin or other instruments can report similar challenges.
Now researchers have found that people with musical training have an easier time learning Chinese.
Writing in the online edition of Nature Neuroscience, researchers from Northwestern University say that both skills draw on parts of the brain that help people detect changes in pitch.
One of the study’s authors, Nina Kraus, said the findings suggested that studying music “actually tunes our sensory system.” This means that schools that want children to do well in languages should hesitate before cutting music programs, Dr. Kraus said. She said music training might also help children with language problems.
Mandarin speakers have been shown to have a more complex encoding of pitch patterns in their brains than English speakers do. This is presumably because in Mandarin and other Asian languages, pitch plays a central role. A single-syllable word can have several meanings depending on how it is intoned.
For this study, the researchers looked at 20 non-Chinese speaking volunteers, half with no musical background and half who had studied an instrument for at least six years.
As they were shown a movie, the volunteers also heard an audiotape of the Mandarin word “mi” in three of its meanings: squint, bewilder and rice. The researchers recorded activity in their brain stems to see how well they were processing the sounds.
Those with a music background showed much more brain activity in response to the Chinese sounds.
The lead author of the study, Patrick C. M. Wong, said it might work both ways. It appears that native speakers of tonal languages may do better at learning instruments, Dr. Wong said.
In New Hampshire, Towns Put Climate on the Agenda
By KATIE ZEZIMA, The New York Times, March 19, 2007
BARTLETT, N.H., March 18 — As they do every March at the town meeting here, residents debated and voted Thursday on items most local: whether to outfit the town fire truck with a new hose, buy a police cruiser and put a new drainpipe in the town garage.
But here and in schools and town halls throughout New Hampshire, between discussions about school boards and budgets, residents are also considering a state referendum on a global issue: climate change.
Of the 234 incorporated cities and towns in New Hampshire, 180 are voting on whether to support a resolution asking the federal government to address climate change and to develop research initiatives to create “innovative energy technologies.” The measure also calls for state residents to approve local solutions for combating climate change and for town selectmen to consider forming energy committees.
“This is an important issue to people in New Hampshire; it’s an environmentally friendly state,” said Kurt Ehrenberg, a spokesman from the Sierra Club’s New Hampshire office. “One of the driving factors here is the lack of federal leadership on this issue, and it’s forced people to find a solution on the local level.”
While the resolution is nonbinding, organizers hope to use it to force presidential candidates to address climate change during the New Hampshire presidential primary.
“We’re trying to bring to the attention of presidential candidates that we are concerned about this in little purple New Hampshire,” said Don Martin, 61, a real estate agent in Bristol who helped collect signatures to put the initiative on the agenda in his town, where it passed by a wide margin. “New Hampshire is fairly middle-of-the-road to conservative, and if we’re concerned about this, then maybe you guys should pay attention to it.”
As of Sunday, 134 towns had passed the initiative; some had yet to hold their meetings.
The New Hampshire Carbon Coalition, a bipartisan citizens group led by a former Republican state senator and the former chairman of the state Democratic Party, spearheaded the initiative to have climate change considered at town meetings. The last time voters in New Hampshire focused on a global issue at such meetings was in 1983, when more than 100 towns asked that the federal government do something about acid rain, which was polluting the state’s waterways.
A handful of towns often take up national issues at their meetings, said Steve Norton, executive director of the New Hampshire Center for Public Policy Studies, an independent state policy group, but “this is definitely a little more rare.”
“It might be somewhat normal for a town to take on a national initiative,” Mr. Norton said, “but not half the towns in the state.”
Here in Bartlett, a town of about 2,200 people in the White Mountains, the measure passed almost unanimously at the Thursday meeting. Bartlett’s interest is both economical and environmental: best known for its ski areas, the town suffered from a lack of snow last year and in the first half of this winter.
“We have a vested interest in climate change here. We like to get snow,” said Doug Garland, a town selectman who owns a snowshoeing and cross-country skiing area.
David P. Brown, a professor of climatology and geography at the University of New Hampshire, said that the state’s average winter temperatures had risen over the past 30 years and that snowfall had decreased. “Every reputable climate model projects a continued warming for New England,” Professor Brown said, “and I expect that trend to be mirrored in New Hampshire.”
While the resolution has been supported widely, not all voters have approved of it. Gene Chandler, a selectman in Bartlett, said he did not think national issues should be brought before town meetings.
Tom Naegeli, 74, of Mont Vernon, voted against the measure in his town meeting. It passed overwhelmingly. “I just don’t think it should be in the town meeting at all,” Mr. Naegeli said. “I don’t see any evidence of global warming.”
Barry Rabe, a professor of public policy at the University of Michigan who tracks local climate change initiatives, said that Colorado and Washington had passed renewable energy standards by ballot initiative and that Texas had held hearings on the issue.
“To me New Hampshire is breaking a little different ground, using the town meeting approach,” Professor Rabe said, “which isn’t a widely available operation.”
Mr. Ehrenberg, of the Sierra Club, said he and others hoped the votes would send a message that change could come from the bottom up.
“Those bumper stickers you see,” he said, “ ‘Think globally, act locally’ — this is really the embodiment of that.”
By LAWRENCE K. ALTMAN, M.D., The New York Times, March 20, 2007
LOS ANGELES — The spread of a particularly virulent form of tuberculosis in South Africa illustrates a breakdown in the global program that is supposed to keep the disease, one of the world’s deadliest, under control.
The program was intended to detect tuberculosis cases, make sure patients were taking their antibiotics, test patients for resistance to those drugs and monitor the spread of the disease.
But international tuberculosis experts say the system is in deep trouble for an array of reasons: misuse of antibiotics; other bad medical practices, like failing to segregate high-risk patients in hospitals and clinics; and cuts in government spending for such basics as adequate supplies of drugs and laboratories to do the testing.
Such factors have led to the rise of drug-resistant tuberculosis bacteria, a menace the world has only begun to appreciate.
Mycobacterium tuberculosis, the microbe that causes the disease, was discovered 125 years ago this month. Today, the bacteria infect 8.8 million people a year and cause 1.6 million deaths. They are spread in tiny droplets when patients cough.
Tuberculosis is curable, as long as the bacteria are susceptible to antibiotics. It becomes deadlier when it attacks people who are also infected with H.I.V., the AIDS virus. And when the tuberculosis bacteria become extremely drug-resistant, the death rate soars.
That was the case in Tugela Ferry, a rural town in KwaZulu-Natal province in South Africa, when an outbreak of extremely drug-resistant tuberculosis — XDR-TB for short — killed 52 of its 53 victims, all of whom were also infected with H.I.V. The outbreak was detected in 2005, but it did not receive international attention until it was reported at the international AIDS meeting in Toronto last August.
The World Health Organization calls the extremely drug-resistant form “a grave public health threat” because of its potential explosiveness among the millions of H.I.V.-infected people in poor countries. It seems to be a lesser threat among people who do not have H.I.V., though it could be dangerous to the millions with weakened immune systems from treatment for cancer and other diseases.
XDR-TB is defined as tuberculosis that is resistant to the two most important antituberculosis drugs (isoniazid and rifampin), along with two other drugs: a member of the fluoroquinolone class and at least one of three others (capreomycin, kanamycin and amikacin).
A step lower on the resistance scale is a form of the disease called MDR-TB, for multidrug-resistant tuberculosis. An outbreak of that form struck in New York City in the early 1990s, and cost at least $1 billion in emergency measures to control and manage tuberculosis patients.
Experts say the tuberculosis outbreak in South Africa is the deadliest one that they can recall.
Although South African officials, who have known about the outbreak for a year, promised a prompt and full investigation, even experts there acknowledge that efforts are lagging.
“Unfortunately, we do not know much more than a year ago” mainly because “a systematic survey in each of the provinces has not yet started,” Dr. Karin Weyer of the South African Medical Research Council told the Conference on Retroviruses and Opportunistic Infections here recently.
Dr. Weyer said in an interview that she had hoped that rapid surveys and screening tests would have been completed by now to show better the geographic extent of the disease.
Using statistics from recent years, Dr. Weyer said her team estimated that 6,000 new cases of multidrug-resistant tuberculosis occurred in South Africa each year and that the rate of treatment failure was about 10 percent. Assuming that most failures were due to the extremely drug-resistant form, a conservative estimate is 600 cases of XDR-TB in her country each year, Dr. Weyer said.
In data that her team examined, about 85 percent of patients infected with XDR-TB and H.I.V. died, she said. The fatality rate in H.I.V.-negative patients seemed lower, but could not be determined until they complete long-term therapy.
What is known is that the deadly XDR-TB strain has been found in more than 40 hospitals in all nine provinces of South Africa, she said.
The rest of sub-Saharan Africa is at risk, she went on, because “control of airborne infection is either totally inadequate or even absent” in virtually all of those countries.
The outbreak is not limited to Africa. Dr. Paul Nunn, a tuberculosis expert at the World Health Organization, told the meeting here that one or more cases of XDR-TB had been found in at least 28 countries. Extrapolating from data about the multidrug-resistant form of tuberculosis, Dr. Nunn estimated that two-thirds of the XDR-TB cases were from China, India and Russia.
The recipe for spreading the disease is the same throughout the world: inappropriate use of antibiotics. When first-line drugs fail to kill the disease, Dr. Nunn said, doctors turn to a second group of drugs that are less widely used, and, they hope, more effective because the bacteria have not had a chance to become resistant to them.
“The little evidence we have suggests that this is not so much spread of resistant strains, but the creation of similar patterns of resistance in different strains around the world,” Dr. Nunn said, “because the drugs used are more or less the same everywhere, and unfortunately, so are the defects in the performance of TB control.”
South Africa has more laboratories to test tuberculosis strains for susceptibility to first- and second-line drugs than other sub-Saharan countries, Dr. Nunn said. He added, “Most African countries do not have a laboratory capable of carrying out first-line drug susceptibility tests, let alone for second-line drugs, which is technically more demanding.”
For those and other reasons, like a lack of doctors, health officials say they fear that tuberculosis may be spreading silently in other countries.
Experiments performed years ago have led some experts to speculate that drug-resistant tuberculosis bacteria are poorly transmissible. But that theory seems weakened by new studies from South African researchers working with colleagues from Harvard and the Centers for Disease Control and Prevention in Atlanta.
The researchers put caged guinea pigs in a ventilation stream leading from rooms housing patients with multidrug-resistant tuberculosis and possibly the extremely drug-resistant form. Skin tests showed that 80 percent of the animals were newly infected after four months, Dr. Weyer said.
XDR-TB may be just as infectious as regular tuberculosis and may be highly transmissible. And that is worrisome, Dr. Weyer said, because “most public health facilities in the developing world lack airborne infection control procedures.”
How the guinea pig findings translate to humans is uncertain because other studies have not been done or completed.
In one study, South African researchers tested 1,694 relatives and friends who had contact with 386 XDR-TB patients identified in Tugela Ferry. Among those contacts, only 12 cases of multidrug-resistant tuberculosis were found, and none of XDR-TB, Dr. Weyer reported.
The findings suggested that significant spread was not occurring in the community. But it was too soon to know, because even a drug-susceptible tuberculosis infection usually remains silent for years before it causes illness, Dr. Weyer said.
“This is the kind of exercise that we would like to see happening” in other areas and for longer periods to get a better understanding of the risk of transmission and getting sick, Dr. Weyer said.
The risk that the initial tuberculosis infection will progress to illness is compounded at 10 percent a year for those with H.I.V., compared with a lifetime risk of 10 percent among those who do not have the virus.
In medical journals and at scientific meetings, some doctors in South Africa and elsewhere have advocated enforced confinement of XDR-TB patients. But civil liberties aside, many experts say, these advocates have not thought through the practical aspects of such isolations. Enforced isolation “is much more difficult to implement than one would think,” Dr. Weyer said.
Because XDR-TB is believed to be incurable, such patients could be detained for life or until they die. All the while, infected patients may spread the disease to others.
Moreover, the disease is an occupational hazard for the health workers caring for patients; 4 were included among the 53 in the Tugela Ferry outbreak. Two additional cases in health workers were identified later.
So Dr. Weyer raised these questions, among others: What facilities would be used? Who would volunteer to take care of XDR-TB patients? How would these workers be protected? And without getting permission, how would health officials legally detect the many health workers who are infected with H.I.V.?
She offered no answers. And earlier this month, as if to illustrate the logistical hazards of caring for XDR-TB patients, 100 people walked out of a hospital in East London, South Africa, after paramedics wearing head-to-toe protection brought in eight patients with the disease.
Some South African hospitals are using engineering- and infection-control practices, like installing ultraviolet lights to kill tuberculosis microbes. Management studies show that health care facilities must be redesigned to prevent unnecessary contact between tuberculosis and H.I.V. patients in crowded clinics, X-ray departments, waiting lines and other areas, Dr. Weyer said.
On April 1, she said, South Africa plans to start field-testing 40,000 patients to determine the effectiveness of two new rapid tests to detect drug-resistant tuberculosis, and whether the results will lead to improved treatment outcomes. Elsewhere, researchers will test 60,000 patients under the direction of the Foundation for Innovative New Diagnostics in Geneva, Dr. Weyer said.
About 20 experimental drugs are being tested. But even if one is found effective in large-scale trials, it is unlikely to be marketed for a decade.
Essay: Tracing the Cigarette’s Path From Sexy to Deadly
By HOWARD MARKEL, M.D., The New York Times, March 20, 2007
For many Americans, the tobacco industry’s disingenuousness became a matter of public record during a Congressional hearing on April 14, 1994. There, under the withering glare of Representative Henry A. Waxman, Democrat of California, appeared the chief executives of the seven largest American tobacco companies.
Each executive raised his right hand and solemnly swore to tell the whole truth about his business. In sequential testimony, each one stated that he did not believe tobacco was a health risk and that his company had taken no steps to manipulate the levels of nicotine in its cigarettes.
Thirty years after the famous surgeon general’s report declaring cigarette smoking a health hazard, the tobacco executives, it seemed, were among the few who believed otherwise.
But it was not always that way. Allan M. Brandt, a medical historian at Harvard, insists that recognizing the dangers of cigarettes resulted from an intellectual process that took the better part of the 20th century. He describes this fascinating story in his new book, “The Cigarette Century: The Rise, Fall and Deadly Persistence of the Product that Defined America” (Basic Books).
In contrast to the symbol of death and disease it is today, from the early 1900s to the 1960s the cigarette was a cultural icon of sophistication, glamour and sexual allure — a highly prized commodity for one out of two Americans.
Many advertising campaigns from the 1930s through the 1950s extolled the healthy virtues of cigarettes. Full-color magazine ads depicted kindly doctors clad in white coats proudly lighting up or puffing away, with slogans like “More doctors smoke Camels than any other cigarette.”
Early in the 20th century, opposition to cigarettes took a moral rather than a health-conscious tone, especially for women who wanted to smoke, although even then many doctors were concerned that smoking was a health risk.
The 1930s were a period when many Americans began smoking and the most significant health effects had not yet developed. As a result, the scientific studies of the era often failed to find clear evidence of serious pathology and had the perverse effect of exonerating the cigarette.
The years after World War II, however, were a time of major breakthroughs in epidemiological thought. In 1947, Richard Doll and A. Bradford Hill of the British Medical Research Council created a sophisticated statistical technique to document the association between rising rates of lung cancer and increasing numbers of smokers.
The prominent surgeon Evarts A. Graham and a medical student, Ernst L. Wynder, published a landmark article in 1950 comparing the incidence of lung cancer in their nonsmoking and smoking patients at Barnes Hospital in St. Louis. They concluded that “cigarette smoking, over a long period, is at least one important factor in the striking increase in bronchogenic cancer.”
Predictably, the tobacco companies — and their expert surrogates — derided these and other studies as mere statistical arguments or anecdotes rather than definitions of causality.
Dr. Brandt, who has exhaustively combed through the tobacco companies’ internal memorandums and research documents, amply demonstrates that Big Tobacco understood many of the health risks of their products long before the 1964 surgeon general’s report.
He also describes the concerted disinformation campaigns these companies waged for more than half a century — simultaneously obfuscating scientific evidence and spreading the belief that since everyone knew cigarettes were dangerous at some level, smoking was essentially an issue of personal choice and responsibility rather than a corporate one.
In the 1980s, scientists established the revolutionary concept that nicotine is extremely addictive. The tobacco companies publicly rejected such claims, even as they took advantage of cigarettes’ addictive potential by routinely spiking them with extra nicotine to make it harder to quit smoking. And their marketing memorandums document advertising campaigns aimed at youngsters to hook whole new generations of smokers.
In 2004, Dr. Brandt was recruited by the Department of Justice to serve as its star expert witness in the federal racketeering case against Big Tobacco and to counter the gaggle of witnesses recruited by the industry. According to their own testimony, most of the 29 historians testifying on behalf of Big Tobacco did not even consult the industry’s internal research or communications. Instead, these experts focused primarily on a small group of skeptics of the dangers of cigarettes during the 1950s, many of whom had or would eventually have ties to the tobacco industry.
“I was appalled by what the tobacco expert witnesses had written,” Dr. Brandt said in a recent interview. “By asking narrow questions and responding to them with narrow research, they provided precisely the cover the industry sought.”
Apparently, the judge, Gladys Kessler of Federal District Court for the District of Columbia, agreed. Last August, she concluded that the tobacco industry had engaged in a 40-year conspiracy to defraud smokers about tobacco’s health dangers. Her opinion cited Dr. Brandt’s testimony more than 100 times.
Dr. Brandt acknowledges that there are pitfalls in combining scholarship with battle against the deadly pandemic of cigarette smoking, but he says he sees little alternative.
“If one of us occasionally crosses the boundary between analysis and advocacy, so be it,” he said. “The stakes are high, and there is much work to be done.”
Dr. Howard Markel is a professor of pediatrics, psychiatry and the history of medicine at the University of Michigan.
Skilled Ear for Music May Help Language
By ERIC NAGOURNEY, The New York Times, March 20, 2007
Anyone who has tried to learn Chinese can attest to how hard it is to master the tones required to speak and understand it. And anyone who has tried to learn to play the violin or other instruments can report similar challenges.
Now researchers have found that people with musical training have an easier time learning Chinese.
Writing in the online edition of Nature Neuroscience, researchers from Northwestern University say that both skills draw on parts of the brain that help people detect changes in pitch.
One of the study’s authors, Nina Kraus, said the findings suggested that studying music “actually tunes our sensory system.” This means that schools that want children to do well in languages should hesitate before cutting music programs, Dr. Kraus said. She said music training might also help children with language problems.
Mandarin speakers have been shown to have a more complex encoding of pitch patterns in their brains than English speakers do. This is presumably because in Mandarin and other Asian languages, pitch plays a central role. A single-syllable word can have several meanings depending on how it is intoned.
For this study, the researchers looked at 20 non-Chinese speaking volunteers, half with no musical background and half who had studied an instrument for at least six years.
As they were shown a movie, the volunteers also heard an audiotape of the Mandarin word “mi” in three of its meanings: squint, bewilder and rice. The researchers recorded activity in their brain stems to see how well they were processing the sounds.
Those with a music background showed much more brain activity in response to the Chinese sounds.
The lead author of the study, Patrick C. M. Wong, said it might work both ways. It appears that native speakers of tonal languages may do better at learning instruments, Dr. Wong said.
In New Hampshire, Towns Put Climate on the Agenda
By KATIE ZEZIMA, The New York Times, March 19, 2007
BARTLETT, N.H., March 18 — As they do every March at the town meeting here, residents debated and voted Thursday on items most local: whether to outfit the town fire truck with a new hose, buy a police cruiser and put a new drainpipe in the town garage.
But here and in schools and town halls throughout New Hampshire, between discussions about school boards and budgets, residents are also considering a state referendum on a global issue: climate change.
Of the 234 incorporated cities and towns in New Hampshire, 180 are voting on whether to support a resolution asking the federal government to address climate change and to develop research initiatives to create “innovative energy technologies.” The measure also calls for state residents to approve local solutions for combating climate change and for town selectmen to consider forming energy committees.
“This is an important issue to people in New Hampshire; it’s an environmentally friendly state,” said Kurt Ehrenberg, a spokesman from the Sierra Club’s New Hampshire office. “One of the driving factors here is the lack of federal leadership on this issue, and it’s forced people to find a solution on the local level.”
While the resolution is nonbinding, organizers hope to use it to force presidential candidates to address climate change during the New Hampshire presidential primary.
“We’re trying to bring to the attention of presidential candidates that we are concerned about this in little purple New Hampshire,” said Don Martin, 61, a real estate agent in Bristol who helped collect signatures to put the initiative on the agenda in his town, where it passed by a wide margin. “New Hampshire is fairly middle-of-the-road to conservative, and if we’re concerned about this, then maybe you guys should pay attention to it.”
As of Sunday, 134 towns had passed the initiative; some had yet to hold their meetings.
The New Hampshire Carbon Coalition, a bipartisan citizens group led by a former Republican state senator and the former chairman of the state Democratic Party, spearheaded the initiative to have climate change considered at town meetings. The last time voters in New Hampshire focused on a global issue at such meetings was in 1983, when more than 100 towns asked that the federal government do something about acid rain, which was polluting the state’s waterways.
A handful of towns often take up national issues at their meetings, said Steve Norton, executive director of the New Hampshire Center for Public Policy Studies, an independent state policy group, but “this is definitely a little more rare.”
“It might be somewhat normal for a town to take on a national initiative,” Mr. Norton said, “but not half the towns in the state.”
Here in Bartlett, a town of about 2,200 people in the White Mountains, the measure passed almost unanimously at the Thursday meeting. Bartlett’s interest is both economical and environmental: best known for its ski areas, the town suffered from a lack of snow last year and in the first half of this winter.
“We have a vested interest in climate change here. We like to get snow,” said Doug Garland, a town selectman who owns a snowshoeing and cross-country skiing area.
David P. Brown, a professor of climatology and geography at the University of New Hampshire, said that the state’s average winter temperatures had risen over the past 30 years and that snowfall had decreased. “Every reputable climate model projects a continued warming for New England,” Professor Brown said, “and I expect that trend to be mirrored in New Hampshire.”
While the resolution has been supported widely, not all voters have approved of it. Gene Chandler, a selectman in Bartlett, said he did not think national issues should be brought before town meetings.
Tom Naegeli, 74, of Mont Vernon, voted against the measure in his town meeting. It passed overwhelmingly. “I just don’t think it should be in the town meeting at all,” Mr. Naegeli said. “I don’t see any evidence of global warming.”
Barry Rabe, a professor of public policy at the University of Michigan who tracks local climate change initiatives, said that Colorado and Washington had passed renewable energy standards by ballot initiative and that Texas had held hearings on the issue.
“To me New Hampshire is breaking a little different ground, using the town meeting approach,” Professor Rabe said, “which isn’t a widely available operation.”
Mr. Ehrenberg, of the Sierra Club, said he and others hoped the votes would send a message that change could come from the bottom up.
“Those bumper stickers you see,” he said, “ ‘Think globally, act locally’ — this is really the embodiment of that.”
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Luckily she had the sense to not listen to that!
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One of the things Markel leaves out in that review is how Brandt shows that anti-smoking campaigns started as soon as cigarettes did (there were actually smoking bans in a lot of states back in the 1920s!) so the recent campaign is not new.
The last third of the book is a very readable legal history :)