An amoral editorial on decision aids for screening in BMJ

The BMJ just published my rapid response to an editorial on decision aids for screening - such as bowel cancer screening.  I was surprised that the BMJ (the journal I would probably choose to have on a desert island if only allowed one journal) published an editorial that was blind to the ethical issues associated with public health screening. My response is pasted below or you can read it in the BMJ. 

Gross National Happiness in Bhutan - how do you do it?

A Grossly Happy Baby we met in Bumthang

One of my main research priorities in Bhutan has been to understand how Gross National Happiness is integrated into policy development.  As you scratch the surface, many of the major proponents of GNH in Bhutan clearly state that it is still an "aspirational" goal - not quite achieved yet. 

"Delhi" Belly hits Com Game Swimmers - betting on Norovirus

Commonwealth Games reports are dominated by accounts of "Delhi" Belly among swimmers today.  My bet is that norovirus is the culprit - a highly infectious gastrointestinal bug that is easily spread from person to person.  Fingers are pointing at the swimming pool but it could be clustered among swimmers due to social contact or sharing the same facilities.  Norovirus is killed by chlorine but maybe not quickly enough if there is massive contamination of the pool and swimmers are swallowing the water immediately after the water is contaminated.   From the media reports it appears that some have been swimming in the pool within days of experiencing gastro when they could still be shedding virus - even though they have no symptoms. Additionally, there are reports of swimmers having to leave the pool due to illness - suggesting they may be actively contaminating the pool.

Restoring WISDOM to Universities - Macquarie VC's speech

When was the last time you heard the "W" word at a university - "Wisdom"?  Macquarie University Vice-chancellor Steven Schwartz's annual VCs lecture is very inspiring.  I particularly liked the quote from Confucious regarding the 3 ways of attaining wisdom - Reflection, Imitation (gosh - could this be a throwback to the unpopular concept of virtue ethics absorbed from the virtuous?), and Experience. If the link above is broken you can track down the transcripts and other talks by Professor Schwartz here.

He also highlights the danger of judging morality from the consequences of a decision - in a complex world we can rarely know the longterm consequences of our actions - so better to keep ourselves good in the present.

McDonalds Advert on Kids Channel - hmm...maybe they deserve some criticism

When I lived in Australia and America I used to eat a lot of McDonalds.  You have to see the adverts they are showing on Indian Cable TV kids channels (most of the TV in Bhutan is Indian cable).  But first, while driving through Tennessee some years back I bought the 4 Big Macs for $2 deal - with a thickshake for good measure.  About 20 miles down the freeway I had to pass the wheel to my less than impressed wife as I was entering some kind of hyper fat/protein induced coma. 

Last year I was at a Newcastle Chamber of Commerce talking about pandemic flu and shared a table with a McDonalds marketing manager - who had just finished talking about the McDonalds healthy choices menu.   Unfortunately, many of the healthy choices he promoted weren't actually available - take the vegie burger, you can't find a McDonalds that sells it anymore.  So, I sometimes think that McDonalds and other fast food outlets get a hard time - until I saw this commercial....

Bhutan's Smoking Ban Reinvigorated

Bhutan became famous in the public health world for its ban on the sale of tobacco in 2005 (not possession of tobacco just the sale), however, what is not so well known is that there has not been a strong regulatory response to punish the sale of tobacco.  Unfortunately this led to many calls to drop the ban on tobacco describing it as ineffective.  In response to these demands I wrote this opinion piece for the Bhutan Observer.
The good news is the new Tobacco Act will come into effect in January, 2011 - which includes jail sentences for selling tobacco.

PLoS Medicine: Social Relationships Are Key to Health, and to Health Policy

PLoS Medicine: Social Relationships Are Key to Health, and to Health Policy

So, there are difficulties with the methodology here of course, and you have to wonder why, as public health practitioners we jump through great hoops to "scientifically document" what is bleedingly obvious - that having friends and close relationships is good for you. There are no lobby groups explicitly arguing otherwise. However, the move to longer working hours suggests that collectively we forget the wider ramifications of societal impacts on relationships. Perhaps the Foucaultian biopower approach to lobbying for a better society is the justification for such studies.

Bhutanese Public Health Student's Novel Response to Climate Change Threat

So today we had a guest lecturer from the Climate Change and Health section of WHO talk to the class about the impacts of climate change on the Himalayas.  The point was made that while Bhutan was carbon negative, the emissions from surrounding countries and across the world will still have an impact.  Its not theoretical up here, glaciers are retreating and high lakes are threatening to burst and wash away entire valleys of people and mosquitoes are being found at higher altitude.  At the end of the experts talk on the health impacts, emerging infectious surveillance needs, emergency response preparations and sentinel site implementation, she asked the students if they had any question or comments on what should be done.  The students were typically quiet, and then one student raised his hand, and said: "Madam, I think its best that all the other countries stop their pollution so Bhutan does not have to do any of these things."

Flutracking hits 10,000 participants this week!

We have hit a milestone, just over 10,000 Flutrackers reported their rate of cough and fever this week!  I remember when we started we were really hoping to get just 1500 participants in the first few years. Thanks Flutrackers! 

Crocodile tears for health inequality - "its politics stupid"

Iona Heath sums up the difficulties of addressing health inequalities.  I remember the excitement of the reinvigorated social determinants of health war cry in the late '90s.  Public health practitioners were yelling raw uncontrollable truths about the impact of social inequalities on health - this was the real cause, this was our battle. I printed hundreds of copies of the WHO Solid Facts on the Social Determinants of Health by Marmot and sent it to mayors of councils, heads of social welfare organisations, anywhere I could.  This was a reinvigoration of the excitement that surrounded the release of The Black Report in 1980 and Margaret Whiteheads' The Health Divide in 1987.  Enthusiasm was rediscovered, collaborations were renewed. But then what.  Its 2010, enthusiasm is waning and maybe its harder than we imagined to change the power structures that produce the inequalities  - have we just been crying crocodile tears over health inequalities as Iona Heath suggests in this BMJ article? The rapid responses are also worth reading.  Here is her closing paragraph:

"So why is it that all those academics and others, like me, who participated in and benefited directly from the documentation of health inequalities, are not campaigning vociferously for more progressive taxation in the UK? Could it be because we have a fundamental conflict of interest in that almost all of us, situated on the gaining side of health inequality, would be expected to pay more tax if such a policy was implemented? If this is true, then it really is a case of crocodile tears."

It may not be that our conflict of interest is so direct as fear of income loss through progressive taxation, a reduction of inequalities requires  a shake up of all power structures within society and government agencies - an unpopular and often short-lived task.

The Dog "Problem" in Bhutan

Our apartment is on the 4^th floor which diminishes the constant barking of the thousands of nomadic dogs that inhabit the city.  Culling dogs is not OK in a Buddhist society, the last attempt to cull was thwarted when all the residents hid the stray dogs in their houses on the night of the announced dog cull.  The new “catch, sterilise, and release” program will take some years to control the dog population.  We have to learn the “bad dog” streets where they attack people in packs – but this seems manageable.  although a 4 year old was attacked inside an apartment building last week by a rabid dog and our 13 year old had to receive rabies post exposure prophylaxis after being bitten by a fiesty stray puppy that was terrorising his school - luckily he received pre-exposure vaccination in Australian and only needed two shots.

A Bhutanese lama was asked what can be done about the dog problem - the questioner suggesting it was all very good to respect buddhist principles regarding not killing, however, this was practical matter and a real problem. The lama answered - "how wonderful to live in a country that manifests problems such as this out of compassion, we should rejoice at this wonderful problem."

Teachers Day in Bhutan

The public health students exhibit an incredible motivation and sense of responsibility to give back to their country for the education they are provided by the government.  On “National Teacher’s Day” the students dedicated songs, dances and speeches to the teaching faculty of the Institute which gave me some cultural insight into the Himalayan concept of devotion to the teacher.   Even on the mundane level of teaching public health, students professed that “the teacher is everything to us – as important as our mother or father”.  Another warned her fellow students, “just an instant of disrespect for the teacher can lead to rebirth as a dog 500 times!” 

Hmm, no pressure, but I better deliver here, I thought. Followers of Buddhist lamas follow with great devotion as a personal discipline and to inspire their lama to teach them - so too the students inspire their public health teachers.

It's a little different teaching in Thimphu compared to Australia.  The students stand up when you enter the classroom with a "good morning sir!", make coffee for you during the break, and almost die of embarrassment if they forget to turn their mobile phone off - not that this is necessary or anything...

Study leave in Bhutan - why Bhutan?

We are starting an adventure in Bhutan, my wife and two boys 11 and 13 years of age and I are here for 8 months. I am teaching public health epidemiology to 26 students in the inauguaral Bachelor of Public Health Program in Thimphu at the Royal Institute of Health Sciences.  I am also doing some fact finding on operationalising Gross National Happiness from a public health perspective and looking into how Bhutan implemented and now manages their national ban on the sale of tobacco.  Bhutan's insistence on basing policy on a sound values base is unique and I am sure there is much to learn from this country. It contrasts greatly with the confusion of public policy making in the west.  I once asked a senior population health practitioner what was the foundational rationale for the activities of their unit - he responded by referring to the Precede-Proceed Model.  While the model is an excellent planning tool and emphasises community consultation, it is really only a methodology for doing, not knowing what is right to be doing.  Sensing my dissatisfaction with this response he suggested my search was "veering off into philosophy or spirituality or something like that".  So I have veered off to Bhutan. Perhaps the Mahayana Buddhist philosophy that inspired the concept of Gross National Happiness can provide insight for us in the west as well.

Visiting the Googleplex in NYC

So the Flutrends folks at Google.org noticed the work we were doing at Flutracking.net and invited me to Floogle March 25/26 2010 in NYC - to assist in their review of Google Flu Trends and to give us a "trusted tester" peek at some new tools.