Thursday 10 November 2011

Ending African River Blindness


Thursday, 10 November 2011

Ending African River Blindness


Ending African River Blindness 
Entomologist Vincent Resh has leveraged science and diplomacy to help bring an epidemic under control along 30,000 miles of West African rivers.
By helping to control the larvae of black flies along rivers in West Africa, Vincent Resh also helped eliminate a crippling disease plaguing 11 African countries. His work there has contributed to the well-being of 30 million people - helping 
Statue of a child leading a blind manto end an epidemic.
From among the stacks of papers covering his desk, Vincent Resh pulls a small memento from his years of work in West Africa. It's a simple metal statue of two human figures, each clutching one end of a long stick. The one to the rear is tall and slender; the one in front smaller, with child-like proportions. It looks like an ordinary piece of folk art until Resh, a professor of organisms and the environment, explains what it represents: a blind man being led by a child - two of the hundreds of thousands of victims of a disease known as African river blindness.
Decades ago, says Resh, the statue's scene was common in Ivory Coast, Ghana, Guinea-Bissau, and more than a dozen other countries in the tropical belt just south of the Sahara Desert. "In Africa, when I first began my work, I would sometimes see 20 adults, each being led like this," Resh says. "By the time they were 40 - sometimes even by the time they were 20 - they were blind."
In some areas, as many as three in ten adults lost their sight and were unable to support their families, while children were pulled out of school to guide elders from place to place. "People who were blind had a much shorter life expectancy, because their families couldn't afford to feed them," says Dr. David Molyneux, an expert in onchocerciasis treatment at the Liverpool School of Tropical Medicine and Hygiene. To compound the problem, healthcare workers and teachers were reluctant to work in infected rural areas for fear of contracting the disease. Reoccurring in one village after another, in country after country, the disease drained the medical, economic, and educational resources of the entire region.
Resh, a UC Berkeley professor of entomology, spent 15 years working on a massive international program to control river blindness in 11 West African countries. During that time, he traveled throughout the shelf of countries facing the Gulf of Guinea, from the verdant forests of Guinea-Bissau and Senegal to the west, to the ancient trading crossroads of Benin to the east; meeting people, sharing their food, hearing their stories, and growing ever more determined to halt the transmission of the disease.
African river blindness, also known as onchocerciasis, is caused by the nematode roundworm Onchocerca volvulus. The worm's larvae lurk within another regional scourge - the biting black flies that swarm over rivers and streams and draw blood from those who venture near in broad daylight. With every bite, infected flies inject a few larval worms into the wound. Once inside a human body, the parasites proliferate by the hundreds of thousands, causing unsightly skin discolorations, continual itching and lesions, and eventually obliterating sight. Flies that bite an infected person pick up larval worms, completing the cycle of transmission.
White colonists, however, insisted on re-creating the riverside towns they remembered from home. By removing longstanding cultural prohibitions, they made onchocerciasis more prevalent than ever before.
River blindness has historically plagued the fertile valleys of West Africa, but it was the arrival of Europeans that unleashed the full force of the disease upon the region's inhabitants. Traditional taboos had kept people from settling along riverbanks or visiting streams in broad daylight, when black flies are most active. White colonists, however, insisted on re-creating the riverside towns they remembered from home. By removing longstanding cultural prohibitions, they made onchocerciasis more prevalent than ever before. By the 1970s, several hundred thousand people were blinded by the disease. Perhaps more tragically for the region, the most fertile farmland - an area roughly the size of Michigan - was abandoned due to the risk of contracting the disease.
The Onchocerciasis Control Programme (OCP) in West Africa was begun in 1974 by a coalition of the World Health Organization, the World Bank, the United Nations, and 20 donor countries and agencies. The $500 million campaign had three primary components.
  • One contingent treated infected residents with doses of the anti-parasitic drug ivermectin, which averted blindness and removed the human reservoir of the disease.
  • A second contingent aimed to break the cycle of transmission from human to fly by using widespread, long-term insecticide applications to control black fly populations.
  • The third contingent monitored river organisms to ensure that the biodiversity of the rivers - a major source of food - remained intact.
An expert in aquatic insects with a strong record of working on sprawling, multinational river projects, Resh served as an international science advisor for the program. He teamed up with local colleagues and science experts in participating countries to plan and implement the spraying and environmental sampling. He got the job done in classic Resh-style - a foundation of sound science administered with get-your- feet-wet-and-hands-dirty diplomacy. An easygoing man with a smile never far from his broad face, it's easy to see why he made such strong connections with scientists, drivers, translators, and guides from a dozen different cultures and countries.
While growing up in New York, Resh never dreamed he might become a regular traveler to Africa. For vacations, his parents took the family to locales such as New Jersey and Pennsylvania. Once on his own, he filled his passport pages quickly, researching and teaching in Belize, Guatemala, and then working on a large project in France, studying the ecology of the Rhone River.
In Africa, Resh's primary goal was to kill the black fly larvae maturing in river waters. He supervised the spraying of insecticides on 30,000 miles of rivers every week to interrupt transmission of the disease. It was a narrow path to walk. "Most of the populations living along the riverbanks also used the water for drinking," says Albert Akpoboua, a Togan who worked closely with Resh on both vector control and monitoring programs on behalf of the World Health Organization. "We had to make sure the insecticide dosages were safe for people." At the same time, they had to ensure that insects, fish, and other creatures would recolonize the waterways. "The biggest fear is that we would get rid of the disease and suddenly lose the protein source - the fish," Resh says. "Ecological integrity was the key." Meanwhile, the threat of insecticide resistance continued to loom large; efforts to eliminate malaria in Africa by spraying with the insecticide DDT had failed by 1969 because mosquitoes had developed immunity to the chemical.
To address all three needs - disease control, vector control, and wildlife preservation - the OCP rotated among seven different larvicides. During the wet season, when rivers ran high, the scientists applied harsher organophosphates, pyrethroids, and carbamate insecticides; during low flows, they applied the more benign, biodegradable agent Bti, which is widely used in environmentally sensitive habitats in California. "This avoided too much selective pressure from one larvicide on the target organisms, and reduced the chance of resistance," Akpoboua says.
To keep his finger on the pulse of aquatic life, Resh directed a vast aquatic biomonitoring operation in treated rivers. He helped train teams of local workers to sample the prevalence of fish and benthic macroinvertebrates, such as mayfly nymphs, shrimp, shellfish, and other species. Feedback from the monitoring helped modulate the spraying schedule, with drops in certain species or a resurgence of the biting flies prompting shifts in insecticide selection.
The project kept Resh on the road and in the rivers for weeks at a time to visit sampling sites, organize personnel, and train local contacts. Of course, being on the water exposed Resh to both biting flies and infection. "We would spread grease, like Vaseline, over ourselves. And if you missed any place, the flies would find you and go straight in through your sleeves. It was just awful." Even so, he says, his suffering was minor compared to those of residents, who might sustain 10,000 black fly bites a year, each bite threatening to infect or to aggravate existing disease.
"We would spread grease like Vaseline over ourselves. And if you missed anyplace the flies would find you, go straight in through your sleeves. It was just awful."
Resh witnessed many of the devastating and unexpected effects of the disease. On a visit to one village, he began chatting with a half-dozen children who had collected on the riverbank. "I said to my translator, these kids are very, very friendly. And he replied, 'they're not kids, they're adults.' The parasite load on their bodies was so high that their growth was stunted." A photo of the scene shows that the tallest man stands well below the shoulder of Resh's sturdy five-foot-eight frame.
Resh's journeys through the region gave him an unforgettable view of West Africa's rich quilt of cultures, customs, and landscapes. He was invited to a wedding in Burkina Faso where the main course was camel, the preferred beverage millet beer, and the drinking lasted for three days. He visited such marvels as an elaborate replica of St. Peter's Cathedral in Ivory Coast, accompanied by both his Muslim driver and guide, each fearful of divine retribution. Resh witnessed an uglier side of life in Africa, too, when he was caught in the midst of a revolution wherein he was "surrounded by 15-year-old Angolan soldiers twirling Kalashnikovs on their fingers." He often flew with pilots who were afraid to land because of gunfire.
"I came to know a fascinating group of people on a very intimate basis because we shared everything. It became clear to me early on that we were all deeply committed to the importance of this project and were willing to make personal sacrifices," Resh says. Resh made a similar impact on his African colleagues. "Dr. Resh was very meticulous with his work and all of his problem solving approaches," says Akpoboua, who worked and traveled with Resh on OCP business from 1995 onward. "He would always have time to listen to the technicians and advise them, and he was a very friendly and personable man with a sense of humor. You could get to like him very easily."
"I look on the work I did in Africa as the defining point in my life. You get caught in these movements where you see the potential to do good, so three million kids don't go blind."
Resh has paid a steep price for his African travels. In the 1990s he acquired a lung parasite that made him so ill for 3 years that he nearly retired. "I'd be sick from the last time I was there, and I'd be going back," he says. The malaria Resh caught there still haunts him with occasional bouts of fever and chills. Despite these drawbacks, Resh's experiences with the program have moved him deeply. "The work I did in Africa was the defining point in my life. You get caught in these movements where you see the potential to do good, so 3 million kids don't go blind," he says. "A day doesn't go by that I don't think about these things."
As planned, in 2002 Resh turned the program over to the Africans he had helped to train. When it was time to say farewell, he walked away content. His efforts reopened to farming 60 million acres of land once abandoned to the disease, and protected the sight of an estimated 30 million people at risk for blindness. "You control the disease, you grow food for 17 million more people, and you still have the fish," he says.
By all accounts, the OCP has made a tremendous difference in the everyday lives of rural residents. "In Burkina Faso, I see the change in the situation from what it was before the program and now," Akpoboua says. "All of the clinical manifestations of the disease used to be very common around the Volta River: young children leading the blind, the whole area without schools or health facilities. Today, schools have been built in these areas, they have health clinics, new houses are being constructed. The changes are very visible."
"You control the disease, you grow food for 17 million more people, and you still have the fish,"
The OCP was so successful that in 1996, the Programme for Onchocerciasis Control, a campaign to distribute ivermectin, was launched in the 19 remaining African countries infested with the disease.
Today, life-sized versions of Resh's small river-blindness statue stand at the headquarters of the World Health Organization, the World Bank, and Merck & Co. (the pharmaceutical company that donated the ivermectin used to treat the disease), as symbols of the program's phenomenal success. For those who toil to rid the globe of malaria, tuberculosis, HIV, and infant diarrhea, the statue is a reminder of the human suffering they aspire to relieve.
Reflecting on his work, Resh says he was lucky to have been part of such an important environmental program. "It was a very humanizing experience. When I was really sick with lung problems, I wondered whether what I had done was worth it. But you learn that there are things that are bigger than yourself - that 30 million is better than one."
-Kathleen M. Wong

Primates leapt to social living

Snub-nosed monkeys (Credit: Florian Mollers)Asian snub-nosed monkeys can live in groups more than 600 strong

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Scientists may be a step closer to understanding the origins of human social behaviour.
An analysis of over 200 primate species by a University of Oxford team suggests that our ancestors gave up their solitary existence when they shifted from being nocturnal creatures to those that are active during the day.
Communal living was likely adopted to protect against day time predators, the researchers say.
The results are published in Nature.
From work on social insects and birds, some biologists have suggested that social groups begin to form when young do not leave their natal ground, but instead hang around and help raise their siblings.
Now, the latest evidence from primates suggests that this might not have been the case for our ancestors.
Leaping to sociality
By looking at whether closely related species share similar social structures, the Oxford team of evolutionary biologists shows that a common history is important in shaping the way animals behave in a group.
Baboons (Credit: P. Flashing)
The team pinpointed the shift from non-social to social living to about 52 million years ago; a switch that appears to have happened in one step, and coincided with a move into daylight.
It did coincide with a change in family dynamics or female bonding, which emerged much later at about 16 million years ago.
"If you are a small animal active at night then your best strategy to avoid predation is to be difficult to detect," explained Oxford's Suzanne Shultz, who led the study.
"Once you switch to being active during the day, that strategy isn't very effective, so an alternative strategy to reduce the risk of being eaten is to live in social groups," she told BBC News.
Dr Shultz thinks that the move to day-time living in ancient primates allowed animals to find food more quickly, communicate better, and travel faster through the forest.
Gelada baboons (Credit: Old World gelada baboons form complex multi-level societies
The link between sociality and a switch to daytime living might have been missed until now, she suspects, because biologists interested in this question have tended to work with Old World monkeys, like baboons, which are characterised by female bonded groups, which are not characteristic of many primate species.
Flexibly social
Human societies likely descended from similar large, loosely aggregated creatures, Dr Shultz explained, but the key difference, she pointed out, is that our closest cousins' societies do not vary within a species, while humans' do.
"In human societies we have polgyeny... we have monogamy, and in some places we have females leaving the group they were born in, and in others males leave," she said.
Why this difference exist is still unclear.

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Circle signs historic Hinchingbrooke contract


Circle signs historic Hinchingbrooke contract


10 November 2011
Circle, the employee co-owned social enterprise, has today signed a ground-breaking contract to run Hinchingbrooke Healthcare NHS Trust in Huntingdonshire for ten years.
The East of England Strategic Health Authority (SHA) selected Circle as their preferred partner last November following a 14-month tendering process involving 19 initial potential bidders.  Circle will become the first ever non-state provider to deliver a full range of NHS district general hospital services when the contract commences in February.
Circle operate under a unique partnership model, where everyone from the consultants to the cleaners are co-owners in the business.  They have a track record of turning round NHS services through clinical leadership and devolved decision-making, delivering over 20% productivity gains as well as 99% patient satisfaction in their first year operating day-surgery hospitals in Nottingham and Burton.  Circle's founding ethos was to be above all else the agents of their patients.   Their social mission is to re-engineer the delivery of healthcare to make it better, simpler and smarter value for patients.
Circle Chief Executive, Ali Parsa, said:
"At a time when some healthcare commentators say the solution for small district general hospitals is simply to merge or be shut down, we believe the NHS Midlands and East's courage and zeal for innovation will enable us to show how clinician and staff control can provide a more sustainable alternative.  Our partners have now met hundreds of Hinchingbrooke staff, and we know that we share a core value of prioritising patients above all else, and a passion for reengineering healthcare delivery to make it simpler, better and smarter value for the patients. Circle arrives not with a top-down plan to impose change, but with a proven methodology of unleashing NHS professionals' talent through clinical leadership and devolved decision-making."
Dr Stephen Dunn, the strategic health authority's Director of Policy and Strategy, said:
"This is a momentous day.  Circle secured this operating franchise following an open competition. They outshone the best of the best from the NHS and independent sectors.  This will usher in a new era, unleashing innovation into the NHS, with staff and patients firmly at the centre."
Nigel Beverley, interim Chief Executive for Hinchingbrooke Health Care NHS Trust, said:
"We have been bowled over by Circle's enthusiasm and the efforts they have taken to engage with staff, patients and our other partners.  Circle recognises our excellent achievements at the hospital, and we look forward to working with them to build on our successes."

Circle 'in deal' to run Hinchingbrooke NHS hospital


Circle 'in deal' to run Hinchingbrooke NHS hospital

Hinchingbrooke HospitalHinchingbrooke serves a population of about 160,000 people

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A groundbreaking deal for a private firm to run a struggling NHS hospital is expected to be confirmed later.
Circle, which is part listed on the London Stock Exchange, is set to take over management of Hinchingbrooke hospital in Huntingdon, Cambridgeshire.
The deal would see Circle assume the financial risks of making the hospital more efficient and paying off its debts but the hospital would stay in the NHS.
The company must maintain services but unions fear staff numbers could be cut.
Hinchingbrooke hospital is one of about 20 hospitals in England which has faced an uncertain future, and the possibility of closure, because of long-term financial problems.
It is carrying about £40m of debt and its financial status has been given a high risk red rating by the NHS. The franchise deal with Circle was developed after concerns that the hospital had become unviable, and a local campaign to maintain services.
Circle describes itself as a social enterprise because 49.9% is owned by a partnership of employees. Others see it as a private business as the rest is owned by its parent company, Circle Holdings, which is listed on the stock market.
John Lewis model
Dr Stephen Dunn, from the NHS in the East of England, says the hospital will continue to be paid at NHS rates for its work while it is being run by Circle. The company was chosen after a competitive tendering process, and has to assume all the financial risk involved.

Is this the first of many?

For the moment this deal is a one off, but other hospitals are struggling financially. About 20 in England have been named by ministers as being unviable in their current form.
It follows a review which all NHS organisations in England have had to undertake of whether they can meet the financial standards required to be given the status of a foundation trust.
Some may try to merge with more successful nearby NHS hospital trusts. Others will watch what happens in Hinchingbrooke with interest.
If Circle manages to maintain the range and standards of care at Hinchingbrooke, but cut costs, that in itself could put pressure on NHS managers at other hospitals to do the same.
Circle believes it can do this with existing staff by looking at cutting extra costs like reducing the amount spend on agency staff and trying to use assets like the operating theatres more effectively.
As this deal has been subjected to very detailed scrutiny by the Treasury, it could also mean that other similar contracts could be agreed more quickly.
"It's a hugely original deal - we've managed to avoid the possibility of closing the hospital. We've got a solution to the debt - and have plans that allow us to meet the efficiency challenges the NHS faces."
Any significant changes in services at the hospital would have to be agreed with the local NHS and the public would have to be consulted.
Circle chief executive Ali Parsa accepted the company was taking on a challenge. He said the strength of its approach was in increasing the involvement of doctors and nurses.
"We want to create a John Lewis-style model with everyone who works there in charge of the hospital, letting them own the problems and solve them. We will try everything we can to make this small hospital viable - if we can how fantastic would that be?"
If the deal is confirmed it would have taken almost a year from the plans being sent to the government for approval to the contract being given the go ahead. The approval for the tendering process began under the last Labour government.
Circle, like other independent health providers, has experience of providing planned care but not of running a full range of services including emergency and maternity care.
'Patchy record'
Nuffield Trust chief economist Anita Charlesworth is not surprised by the level of scrutiny.
"I think the key question is does this deal provide a framework to resolve a financial problem, or put off the day when there has to be a decision about the hospital," she said.
She says Circle will have to make the hospital significantly more efficient, and is likely to look at areas like staffing levels and length of stay for patients.
Local GPs, now in a group getting ready to plan and buy services for the area, have been pressing for the deal to be signed off. They wrote to the prime minister to express concerns about the delay.
But the deal is potentially politically controversial and not all are convinced this is the only solution to keeping Hinchingbrooke open.
Public sector union Unison's head of health, Christina McAnea, said a new management team could have been found without putting a contract out to tender.
"We just don't accept there is no expertise within an organisation the size of the NHS, and to turn to the private sector which has a very patchy record in delivering these kind of services is an accident waiting to happen."

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Wednesday 9 November 2011

no official data is kept on the number of youngsters being given anti-psychotics.

The number of children - some as young as five - being prescribed powerful antipsychotic drugs has doubled in the past 10 years, according to an investigation by Channel 4 News.
Numbers of children on antipsychotic drugs doubles (Getty)
As many as 15,000 children and young people under the age of 18 were prescribed this medication last year. But these figures are only from GP surgeries and primary care trusts and do not include hospital prescribing, which suggests the true number could be far higher.

Astonishingly, no official data is kept on the number of youngsters being given anti-psychotics. This has only now been revealed after Channel 4 News commissioned a drug database company to collate them.

The investigation comes as the government announced that GPs could face jail if they are found to be "chemically coshing" elderly patients with dementia. But no mention was made of children and young people in the announcements.
Anti-psychotics are meant for patients with serious mental conditions such as schizophrenia, bipolar disorder and psychosis. But mental health experts now say that they would also appear, in some instances, to be being used to control children's behaviour.
If there is a doubling in the rate of children being given anti-psychotics that is a worry. My worry is that these drugs are being used for other purposes. Professor Tim Kendall
The investigation also found children are being left on the drugs for years at a time and are not being properly monitored, which is against best practice guidelines.
Professor Tim Kendall, who has been asked to write the first ever guidance on prescribing anti-psychotics to young people with serious mental illness, said that these findings are extremely concerning.
"As far as I am aware there is no evidence that there has been a doubling in the rate of psychosis. So if there is a doubling in the rate of children being given anti-psychotics, that is a worry," Prof Kendall said.
"My worry is that these drugs are being used for other purposes."
Family stories
And that would be appear to be what is happening. We have spoken to families whose children have been given the drug for attention deficit hyperactivity disorder (ADHD) and for autism.
The family of one young boy first prescribed an anti-psychotic when he was five for so-called "challenging behaviour" has subsequently been told that he was in fact in pain. The boy, now aged eight, is autistic and regularly banged his head against hard surfaces and lay on the floor kicking and screaming. But his parents said the anti-psychotics he had been on for three years had had no benefit at all.
Eventually he was seen by Professor Chris Oliver, of Birmingham University, who has been researching behavioural problems in children with autism. His conclusion was that the young boy was most probably in pain - suffering from gastro-oesophageal reflux, more commonly known as heartburn. But because of his autism he was not able to articulate that he was physically suffering.
Anti-psychotics were developed in the 1950s and have been widely prescribed to adults since the 1970s. But they can cause, among other things, dramatic weight gain, diabetes and heart disorders. They can also leave patients with a Parkinson's disease-like tremor which does not stop even if they are taken off the medication.
What nobody knows with any certainty, though, are the long-term effects on children. And all approaches made to authorities here to find out if there is any data on trials involving children have been blocked by the pharmaceutical companies.
Prof Kendall was even hampered by America's Food and Drug Administration, which does hold data on any trials conducted on anti-psychotics. When he requested access to the information he was told to put in a freedom of information request.
"If there are trials that are unpublished, what that means is there will either be trials which show the drugs work as well as we think or in fact they might be even more harmful than we think," he said.
"I am appalled, absolutely appalled. This data should be available for people such as us who are working on behalf of the NHS, patients and parents."
In a statement the Association of the British Pharmaceutical Industry told Channel 4 News: "The industry is committed to being as open and transparent as possible in its disclosure of information."
It added that any prescription of anti-psychotic drugs to children "will only occur after careful consideration and risk-benefit assessment by the health care professional on a case by case basis."
Of concern to a growing number of experts is the effect they have on developing brains. They said proper monitoring was essential. But Channel 4 News has obtained a confidential report into the way mental health trusts look after children and young people on anti-psychotic drugs. It found there was "no evidence" whatsoever that some young people are being properly monitored.
'No monitoring at all'
A young girl (her family did not want her identified) we met was put on the medication at the age of nine after she developed psychosis. It is agreed that she needed help, but her father said that he had been unprepared for the effect the anti-psychotic would have on his daughter.
"I was not told how dangerous this drug was," he said. "There was no monitoring at all."
The father said that his daughter lost her memory, could not dress herself, even needed help brushing her teeth.
I was not told how dangerous this drug was. Father of girl prescribed antipsychotics
"You have to get a hold of their hand and walk them everywhere, their thinking is so muddled and the increase in appetite is incredible," he said.
"She would eat raw sugar out of the packet. She would go through a whole bottle of ketchup."
After intervention she has now had her dosage and medication changed and is also receiving intensive therapy. Her behaviour is beginning to improve.
Professor Peter Tyrer, who is an expert in the use of anti-psychotics, said that the unmonitored use of this medication is a "slow fuse to disaster". Prof Tyrer, from Imperial College in London, said that drugs affect almost every part of the body.
"This is particularly alarming because of course children have got their whole lives ahead of them."
Chemical cosh?
What is also alarming experts is that these drugs are being used for the wrong reasons. While nobody disputed that they are sometimes needed and can, indeed, save lives, there is the fear that too often they are being used as a chemical cosh.
A Department of Health spokesperson told Channel 4 News: "NICE guidance states that children and adolescents should only be given antipsychotics following specialist assessment and they should be under specialist supervision.

"For children suffering from severe psychotic illnesses, appropriate drugs can help both the child and his or her parents live a more normal life, and in some cases this can mean the difference between a child going in to care or living at home.

"The government is committed to improving children's mental health and has recently announced £32million to provide access to effective psychological therapies specifically designed for children and young people."

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