TALK AS YOU LIKE!
Dr. Lester CN Simon
Sometimes in our lives, we get lucky. It is said that good luck is when preparation meets opportunity. So being lucky does not necessarily mean winning large sums of money. It can come from hearing a few bars of wonderful music, seeing a beautiful painting, or catching an overwhelming feeling in church. These moments seem to be in perfect harmony with nature. They represent a flash flood of ethos that causes the mind to become awash with respect for the limitless potential of the human spirit.
A few nights ago, preparation and opportunity collided when I heard the broadcast of an ALP political meeting in which a member of the audience urged the speaker to, “Talk as you like!” Most listeners have been concentrating on the words of the speaker and his superhuman feat of building a tamarind tree. My concentration was on the response of the audience. Taken together, the broadcast was a case of call-and-response that sits right up there with any fine piece of music that I would call simply classical.
In the opening pages of Calypso & Society, the author, Gordon Rohlehr referred to the work of the ethnomusicologist, Dena Epstein who wrote about the characteristic West African nature of the call-and–response musical form. Rohlehr noted that this musical element exists in Calypso and in folksong throughout the Caribbean. Indeed it has influenced Blues, Jazz, and other forms and styles of black music in the United States and the Caribbean. Some regard it as a defining feature of all black music.
Call-and –response is a musical style in which a leader sings a line (call) and a
chorus sings a line (response) alternately. At political and other meetings and in some churches, the response takes on the artful task of punctuating the speaker. The speaker has to be very mindful of the fact that he or she is the one in charge. If the speaker loses sight of this basic fact, the responding audience can become the caller, and the caller can be thrown out of rhythm, rhyme and reason.
The call-and-response interplay of the Tamarind Tree speech resonated because it was a classical involvement of the audience. This nexus between the audience and performer is the soul of our music. The music becomes participatory. You cannot watch this music from a distant, double-decker pavilion. Almost like little children clamouring for attention, fine music must be seen, not just heard.
When I listened to the political broadcast, I thought, here was a politician on the government side, organically involved with his audience in the very participatory way that the opposition party claims as its battle cry. Talk as you like! You have more words than he!
Some writers suggest that the interplay of call and response has been around for a long time. They claim that it might have been the first form of human dialogue and the derivation of language. Other writers see the concept of call-and-response as part of the drama of life. By this they mean: What life asks of us, and how we respond.
We are all currently engaged in the fervour of a very crucial call-and-response build-up to a general election in Antigua and Barbuda. Please be careful. Bob Barley said, “One good thing about music, when it hits you, you feel no pain”. In the heat of the political battle, you may feel you are on a Sauline road to conversion. What with all the dazzling, bright lights!
When you think you are doing the calling, you may in fact be responding to the real call from Jah, Rastafari. Do you really think that you have more words than He? Alternatively, your call may be a response to being led down the garden path of the forbidden fruit by the real serpent, Beelzebub. And please do not blame Eve simply because it is evening time.
If you talk as you like, you may not like what you talk. But if your heart is right, your mind is pure and you really and truly love this beautiful country, all you have to do without fear is open your mouth and : Talk as you like!
Tuesday, February 10, 2004
Saturday, January 24, 2004
A Bird In The Hand
TWO BIRDS IN THE BUSH
Dr. Lester CN Simon
This is not a political article. The title came to mind because of the outbreak of avian influenza (bird flu), which has spread from birds to humans. It also represents a comical look at some of our sayings and nursery rhymes. For example, I never expected to see the day (or night) when the cow jumped over the moon. But cows have made the lunar leap. They have become stark raving, non-grazing lunatics, as Mad Cow Disease shows us.
The basic science of influenza tells us that there are three types of influenza viruses. Type A, type B, and type C. Wild birds are the natural habitat of influenza A virus. From wild birds it can spread to chicken, pigs, whales, horses, and seals. On the surface of the influenza A virus, there are two proteins called protein H (hemagglutinin) and protein N (neuraminidase). There are 15 types of protein H (H1, H2 ….H15) and 9 types of protein N (N1, N2…..N9). Hence there are 135 (15 x 9 = 135) subtypes of influenza A viruses. Two subtypes of influenza A found in humans are A (H1N1) and A (H3N2). Influenza B and influenza C viruses are found only in humans.
Pigs can be infected with two different subtypes of influenza A virus. In the pig, the genes responsible for making protein H and protein N can become assorted and then they can re-assort. This can result in the formation of a new virus. For example, subtypes H3N4 and H5N6 viruses in a pig can swap genes to produce a third virus subtype, H3N6.
The pigs are crucial because pigs are susceptible to infection from both avian and mammalian viruses, including human influenza subtypes. Pigs act as “mixing vessels” for the creation of new subtypes. Recent research suggests that humans can serve as “mixing vessels” just like pigs. The danger with new subtypes is that most people may have little or no protection since they were never exposed to the new subtype, either by natural infection or by vaccination. This may allow for an epidemic or a pandemic.
Over the past 100 years, there have been 3 flu pandemics. In 1918-1919 the Spanish flu was caused by influenza A (H1N1). About 20 million people died worldwide.
In 1957-1958 the Asian flu by influenza A (H2N2) caused 98,000 deaths. In 1968-1969 about 46,000 people died from the Hong Kong Influenza A (H3N2) pandemic.
The flu (influenza) and the common cold affect the respiratory system. They are caused by different viruses. The flu is worse than the common cold. People with the cold have a runny or stuffy nose. It may be difficult to tell the difference, but the flu is usually more intense, with fever, body aches, extreme tiredness and dry cough. The flu may be complicated by pneumonia and can result in hospitalization, especially in high risk groups such as the elderly and the chronically ill.
Bird flu (avian influenza) is caused by influenza type A. Bird flu runs a spectrum from mild illness to rapidly fatal disease in birds. Fifteen subtypes of influenza A infect birds. Subtypes H5 and H7 are highly contagious among birds, and are rapidly fatal.
Bird flu in wild birds can spread to domestic poultry such as chickens and turkeys. Live birds markets in Asia play an important role in spreading epidemics of bird flu.
The control of an outbreak of influenza A (H5N2) among the poultry population in USA during a 1983-1984 epidemic cost US$65 million. More than 17 millions birds had to be destroyed. More than 13 million birds died or were destroyed in Italy during the 1999-2001 bird flu epidemic caused by influenza A ( H7N1) epidemic.
Can humans get bird flu? Yes. The bird flu viruses more often infect other birds and pigs. But in 1997, bird flu caused by avian influenza A (H5N1) infected humans. This was the first documented case of transmission of avian influenza from birds to humans. It took place in Hong Kong where 6 of 18 humans infected, died.
This first case of direct transmission of influenza from avian to humans was alarming to health authorities worldwide. In Hong Kong, destruction, in 3 days, of some 1.5 million birds, the entire poultry population, averted a pandemic.
The alarm bells went off again in 2003 with an outbreak of avian influenza A (H5N1) in Hong Kong. It caused 2 human cases with 1 death. Then there was avian influenza A (H7N7) in the Netherlands in 2003 with the death of a veterinarian. Mild cases of avian influenza A (H9N2) occurred in 2 children in Hong Kong in 1999 and in 1 child in 2003.
The most recent alarm bells rang out loudly this month. First, there was an outbreak of avian influenza A (H5N1)in the poultry population in Vietnam in December 2003. Then laboratory tests confirmed the presence of avian influenza A (H4N1) in humans in Viet Nam. Children died. It is thought that they became infected by playing in yards where chickens were kept. They probably made contact with infected avian faeces, a good source of influenza A. Two birds in the bush may be better than one bird in the hand.
There is no evidence yet of direct human to human spread of the recent avian influenza A (H5N1). Nonetheless, H5N1 is of particular concern because it can mutate into subtypes rapidly. Its genes can re-assort with others easily to form new subtypes. WHO notes that H5N1 has the unique capacity to cause severe disease, with high mortality, in humans.
The relationship between humans and animals is in the spotlight as new diseases emerge. The vegetarians should not laugh. Do we know what is going into plants and vegetables for human consumption?
If we worry about meat and other cattle-derived products, pigs, chicken, turkey and other avian products, what will be left to eat? The little dog laughed to see such fun, and the dish ran away with the spoon.
Dr. Lester CN Simon
This is not a political article. The title came to mind because of the outbreak of avian influenza (bird flu), which has spread from birds to humans. It also represents a comical look at some of our sayings and nursery rhymes. For example, I never expected to see the day (or night) when the cow jumped over the moon. But cows have made the lunar leap. They have become stark raving, non-grazing lunatics, as Mad Cow Disease shows us.
The basic science of influenza tells us that there are three types of influenza viruses. Type A, type B, and type C. Wild birds are the natural habitat of influenza A virus. From wild birds it can spread to chicken, pigs, whales, horses, and seals. On the surface of the influenza A virus, there are two proteins called protein H (hemagglutinin) and protein N (neuraminidase). There are 15 types of protein H (H1, H2 ….H15) and 9 types of protein N (N1, N2…..N9). Hence there are 135 (15 x 9 = 135) subtypes of influenza A viruses. Two subtypes of influenza A found in humans are A (H1N1) and A (H3N2). Influenza B and influenza C viruses are found only in humans.
Pigs can be infected with two different subtypes of influenza A virus. In the pig, the genes responsible for making protein H and protein N can become assorted and then they can re-assort. This can result in the formation of a new virus. For example, subtypes H3N4 and H5N6 viruses in a pig can swap genes to produce a third virus subtype, H3N6.
The pigs are crucial because pigs are susceptible to infection from both avian and mammalian viruses, including human influenza subtypes. Pigs act as “mixing vessels” for the creation of new subtypes. Recent research suggests that humans can serve as “mixing vessels” just like pigs. The danger with new subtypes is that most people may have little or no protection since they were never exposed to the new subtype, either by natural infection or by vaccination. This may allow for an epidemic or a pandemic.
Over the past 100 years, there have been 3 flu pandemics. In 1918-1919 the Spanish flu was caused by influenza A (H1N1). About 20 million people died worldwide.
In 1957-1958 the Asian flu by influenza A (H2N2) caused 98,000 deaths. In 1968-1969 about 46,000 people died from the Hong Kong Influenza A (H3N2) pandemic.
The flu (influenza) and the common cold affect the respiratory system. They are caused by different viruses. The flu is worse than the common cold. People with the cold have a runny or stuffy nose. It may be difficult to tell the difference, but the flu is usually more intense, with fever, body aches, extreme tiredness and dry cough. The flu may be complicated by pneumonia and can result in hospitalization, especially in high risk groups such as the elderly and the chronically ill.
Bird flu (avian influenza) is caused by influenza type A. Bird flu runs a spectrum from mild illness to rapidly fatal disease in birds. Fifteen subtypes of influenza A infect birds. Subtypes H5 and H7 are highly contagious among birds, and are rapidly fatal.
Bird flu in wild birds can spread to domestic poultry such as chickens and turkeys. Live birds markets in Asia play an important role in spreading epidemics of bird flu.
The control of an outbreak of influenza A (H5N2) among the poultry population in USA during a 1983-1984 epidemic cost US$65 million. More than 17 millions birds had to be destroyed. More than 13 million birds died or were destroyed in Italy during the 1999-2001 bird flu epidemic caused by influenza A ( H7N1) epidemic.
Can humans get bird flu? Yes. The bird flu viruses more often infect other birds and pigs. But in 1997, bird flu caused by avian influenza A (H5N1) infected humans. This was the first documented case of transmission of avian influenza from birds to humans. It took place in Hong Kong where 6 of 18 humans infected, died.
This first case of direct transmission of influenza from avian to humans was alarming to health authorities worldwide. In Hong Kong, destruction, in 3 days, of some 1.5 million birds, the entire poultry population, averted a pandemic.
The alarm bells went off again in 2003 with an outbreak of avian influenza A (H5N1) in Hong Kong. It caused 2 human cases with 1 death. Then there was avian influenza A (H7N7) in the Netherlands in 2003 with the death of a veterinarian. Mild cases of avian influenza A (H9N2) occurred in 2 children in Hong Kong in 1999 and in 1 child in 2003.
The most recent alarm bells rang out loudly this month. First, there was an outbreak of avian influenza A (H5N1)in the poultry population in Vietnam in December 2003. Then laboratory tests confirmed the presence of avian influenza A (H4N1) in humans in Viet Nam. Children died. It is thought that they became infected by playing in yards where chickens were kept. They probably made contact with infected avian faeces, a good source of influenza A. Two birds in the bush may be better than one bird in the hand.
There is no evidence yet of direct human to human spread of the recent avian influenza A (H5N1). Nonetheless, H5N1 is of particular concern because it can mutate into subtypes rapidly. Its genes can re-assort with others easily to form new subtypes. WHO notes that H5N1 has the unique capacity to cause severe disease, with high mortality, in humans.
The relationship between humans and animals is in the spotlight as new diseases emerge. The vegetarians should not laugh. Do we know what is going into plants and vegetables for human consumption?
If we worry about meat and other cattle-derived products, pigs, chicken, turkey and other avian products, what will be left to eat? The little dog laughed to see such fun, and the dish ran away with the spoon.
Tuesday, January 6, 2004
The Cow Jumps Over
HOW FAR FROM THE MADDING COW?
Dr. Lester CN Simon
In a previous article, we looked at the basic science of a group of degenerative, spongiform brain diseases in which the brain in reduced to a sponge. In this article, we look at the full spectrum of these diseases with emphasis on the more important ones.
There are at least 6 transmissible spongiform brain diseases that affect animals. For over 200 years, shepherds have recognized a spongiform brain disease called scrapie, in sheep and goats. It is called scrapie because the animals degenerate and itch to the extent that they rub against any object and scrape off their wool.
Chronic wasting disease of mule deer and Rocky Mountain elk is a spongiform disease seen in Colorado and Wyoming, USA. Scrapie and chronic wasting disease are the only 2 spongiform brain diseases that appear to be spread directly from animal to animal.
A third disease, transmissible mink encephalopathy, was discovered in Wisconsin, USA in 1947. Encephalopathy simply means brain disease. Ingestion of contaminated food stuffs is thought to be the mode of infection.
The remaining three spongiform brain diseases in animals include exotic ungulate encephalopathy, identified in British zoos in the mid-1980s. Ungulates are hoofed mammals including antelopes, cheetahs and others. Feline spongiform encephalopathy in domestic cats was discovered in 1990. These two spongiform diseases in ungulates and cats are thought to be due to the same infectious agent that causes Mad Cow Disease, the sixth and most notorious of animal spongiform brain diseases.
Mad Cow Disease or Bovine Spongiform Encephalopathy (BSE) was first discovered in Britain in November 1986. The cows’ mental state ranged from initial apprehension to frank madness. Since the 1940s, cattle feed was enriched with meat and bone meal from other animals including sheep and other cows. Ordinary grass was insufficient for cattle.
Offal refers to the entrails and internal organs of an animal that are used as food. The enriched meal for cattle includes offal from slaughterhouses. It goes through a process called rendering. Here, the melted fat is removed as tallow. Tallow is the hard fatty substance from animals. It can be used to make some candles and soap.
After the tallow is removed, the solids comprise meat and bone meal for cattle. How did the first cows with Mad Cow Disease get infected? They got infected from the enriched meal during the winter of 1981-1982. The rendering process had been altered. The use of chemicals called organic solvents and the high temperatures used in the rendering process were stopped. The lack of these chemicals and the absence of high temperatures meant that any infectious agents in the animals used in rendering, survived and were inadvertently passed on. The infectious agents came from scrapie-infected sheep.
The next time you hear someone say they do not eat meat, just smile. Some rendering processes use spoiled meats scraps and animal carcasses. In addition to preparing meat and bone meal to enrich cattle feed, many by-products are derived from the rendering process. Some of these rendered products include high-protein base used in soaps, medicine and candy. Render unto cattle and render unto Caesar.
According to the Wall Street Journal, processed cow fats are used to make cookies and salty snacks taste rich, and lipstick to glide on smoothly. Cow proteins end up in shampoo. Gelatin from cattle hide and bones is found in ice cream, candy, marshmallows and in capsules encasing drugs. Cow lips are used in taco filling and other offal parts are found in pet food.
The manufactures claim that none of the organs that are known to transmit Mad Cow Disease are used in their preparation. If we accept this as truth, we have to also accept that the science of Mad Cow Disease is evolving. The brain and the spinal cord are known to be the areas that harbour the infectious agents called prions.
Dr. Prusiner, the discoverer of prions, noted that there are discoveries that widen the spectrum of prion diseases in mice. These discoveries are prompting a search for human prion diseases that affect the peripheral nervous system and muscles.
The spongiform brain diseases in humans include Kuru, Creutzfeldt-Jakob Disease (CJD), Gerstmann-Straussler-Scheinker Disease and Fatal Insomnia.
CJD is the most common human spongiform disease. Yet it is very rare. The estimated incidence is about 1 case per million, per year, worldwide. Before 1995, it existed in 3 forms. Sporadic or random CJD (about 85%), familial CJD, and CJD from use of infected medical organs or products. Familial CJD means that bad genes are passed on to an offspring.
Sporadic CJD is rare in people under 30 years of age. There is progressive mental deterioration and death occurs in less than a year. In late 1995, a new form of CJD was observed in Britain. It was called new variant CJD. In retrospect, the first case was probably in 1994, some eight years after Mad Cow Disease was discovered. It was called new variant CJD because the patients were teenagers or younger than classic, random or spontaneous CJD patients. New variant CJD (nvCJD) patients survived longer.
Kuru is due to cannibalism among the Fore people of New Guinea. Industrial cannibalism in scrapie-enriched cattle feed is the cause of Mad Cow Disease and nvCJD is due to humans eating infected beef products.
Canine, ovine, bovine, asinine? Respectively: tooth, sheep, cow, stupid or foolish?
Dr. Lester CN Simon
In a previous article, we looked at the basic science of a group of degenerative, spongiform brain diseases in which the brain in reduced to a sponge. In this article, we look at the full spectrum of these diseases with emphasis on the more important ones.
There are at least 6 transmissible spongiform brain diseases that affect animals. For over 200 years, shepherds have recognized a spongiform brain disease called scrapie, in sheep and goats. It is called scrapie because the animals degenerate and itch to the extent that they rub against any object and scrape off their wool.
Chronic wasting disease of mule deer and Rocky Mountain elk is a spongiform disease seen in Colorado and Wyoming, USA. Scrapie and chronic wasting disease are the only 2 spongiform brain diseases that appear to be spread directly from animal to animal.
A third disease, transmissible mink encephalopathy, was discovered in Wisconsin, USA in 1947. Encephalopathy simply means brain disease. Ingestion of contaminated food stuffs is thought to be the mode of infection.
The remaining three spongiform brain diseases in animals include exotic ungulate encephalopathy, identified in British zoos in the mid-1980s. Ungulates are hoofed mammals including antelopes, cheetahs and others. Feline spongiform encephalopathy in domestic cats was discovered in 1990. These two spongiform diseases in ungulates and cats are thought to be due to the same infectious agent that causes Mad Cow Disease, the sixth and most notorious of animal spongiform brain diseases.
Mad Cow Disease or Bovine Spongiform Encephalopathy (BSE) was first discovered in Britain in November 1986. The cows’ mental state ranged from initial apprehension to frank madness. Since the 1940s, cattle feed was enriched with meat and bone meal from other animals including sheep and other cows. Ordinary grass was insufficient for cattle.
Offal refers to the entrails and internal organs of an animal that are used as food. The enriched meal for cattle includes offal from slaughterhouses. It goes through a process called rendering. Here, the melted fat is removed as tallow. Tallow is the hard fatty substance from animals. It can be used to make some candles and soap.
After the tallow is removed, the solids comprise meat and bone meal for cattle. How did the first cows with Mad Cow Disease get infected? They got infected from the enriched meal during the winter of 1981-1982. The rendering process had been altered. The use of chemicals called organic solvents and the high temperatures used in the rendering process were stopped. The lack of these chemicals and the absence of high temperatures meant that any infectious agents in the animals used in rendering, survived and were inadvertently passed on. The infectious agents came from scrapie-infected sheep.
The next time you hear someone say they do not eat meat, just smile. Some rendering processes use spoiled meats scraps and animal carcasses. In addition to preparing meat and bone meal to enrich cattle feed, many by-products are derived from the rendering process. Some of these rendered products include high-protein base used in soaps, medicine and candy. Render unto cattle and render unto Caesar.
According to the Wall Street Journal, processed cow fats are used to make cookies and salty snacks taste rich, and lipstick to glide on smoothly. Cow proteins end up in shampoo. Gelatin from cattle hide and bones is found in ice cream, candy, marshmallows and in capsules encasing drugs. Cow lips are used in taco filling and other offal parts are found in pet food.
The manufactures claim that none of the organs that are known to transmit Mad Cow Disease are used in their preparation. If we accept this as truth, we have to also accept that the science of Mad Cow Disease is evolving. The brain and the spinal cord are known to be the areas that harbour the infectious agents called prions.
Dr. Prusiner, the discoverer of prions, noted that there are discoveries that widen the spectrum of prion diseases in mice. These discoveries are prompting a search for human prion diseases that affect the peripheral nervous system and muscles.
The spongiform brain diseases in humans include Kuru, Creutzfeldt-Jakob Disease (CJD), Gerstmann-Straussler-Scheinker Disease and Fatal Insomnia.
CJD is the most common human spongiform disease. Yet it is very rare. The estimated incidence is about 1 case per million, per year, worldwide. Before 1995, it existed in 3 forms. Sporadic or random CJD (about 85%), familial CJD, and CJD from use of infected medical organs or products. Familial CJD means that bad genes are passed on to an offspring.
Sporadic CJD is rare in people under 30 years of age. There is progressive mental deterioration and death occurs in less than a year. In late 1995, a new form of CJD was observed in Britain. It was called new variant CJD. In retrospect, the first case was probably in 1994, some eight years after Mad Cow Disease was discovered. It was called new variant CJD because the patients were teenagers or younger than classic, random or spontaneous CJD patients. New variant CJD (nvCJD) patients survived longer.
Kuru is due to cannibalism among the Fore people of New Guinea. Industrial cannibalism in scrapie-enriched cattle feed is the cause of Mad Cow Disease and nvCJD is due to humans eating infected beef products.
Canine, ovine, bovine, asinine? Respectively: tooth, sheep, cow, stupid or foolish?
Monday, January 5, 2004
Mad Food
Eat This. But Not In Remembrance of Me!
Dr. Lester CN Simon
The title of this article is aimed at linking two crucial aspects of the basic science of Mad Cow Disease. Mad Cow Disease is the lay person’s term for Bovine Spongiform Encephalopathy (BSE). BSE is only one of a list of spongiform brain disorders in animals and humans in which the brain is literally reduced to a sponge.
To get a clear grasp of the basic science so that we can apply it to public health, we have to understand a peculiar set of diseases caused by agents called prions.
When we think of the causes of infections, parasites, fungi, bacteria and viruses readily come to mind. The first three agents contain many sophisticated, genetic chemicals including DNA and RNA. These three infectious agents grow, reproduce, make and use proteins once nutrients are available. Viruses, on the other hand, are not as sophisticated. A virus possesses either DNA or RNA, not both. Viruses cannot grow, reproduce and make or use proteins unless they inhabit living cells.
As important as proteins are, it was not considered possible that a protein could cause infection by itself. Infection means that the causative agent sets up shop in the host and multiples therein. Proteins should not be able to do this since they do not have the chemical genetic machinery in the form of DNA or RNA.
Enter the prion. In 1980, Dr. Stanley Prusiner evoked a good deal of scepticism when he proposed that the infectious agents causing spongiform brain diseases in animals and, more rarely, in humans might consist of protein and nothing else. At the time, Dr. Prusiner was considered a heretic. His work was revolutionary. He realised that dogma held that the conveyers of transmissible diseases required genetic material, DNA or RNA, in order to establish an infection in a host. Fifteen year later, Dr. Stanley Prusiner was awarded the Nobel Prize in Medicine for his work on prions.
The name prion (pronounced "pree-ons" by Dr. Prusiner), is an acronym. Actually you may say it is a prionic acronym, as you will see later. It comes from the words: proteinaceous infectious particle, using the first three letters of proteinaceous (pro) and the first two letters of infectious (in). Obviously, this would lead to the name, proin but it was decided to call it prion instead of proin, because prion has a better sound.
But even if prions cause diseases, they are proteins; and all proteins are made by genes (DNA and RNA). So how do the prions reproduce when they cause infections? Do they have a piece of genetic material attached to them? No. The genes that make prions are where all genes are: inside the cell. They make prion proteins (PrP) all the time without necessarily causing any sickness. This suggests that prion proteins exist in two states, a normal, innocent state and an abnormal, corrupted, sinister state.
Good prions are easily degraded by the usual protein-degrading enzymes in all cells. Unfortunately, bad prions resist this degradation. Hence, bad prions will always win and the good ones will lose. The concept of good prions is relatively new. When prions were first discovered, they were thought to be intrinsically bad. Just recently, in December 2003, it was considered that one sort of prion has a vital role to play in how memory can be stored in the brain. Hence the name of this article.
Shape or conformation is very important to proteins. Change the shape and the function can change. The bad prion acts as an infectious agent by somehow causing a change in the shape of the good prion, which then becomes a rebel prion and damages the body. The derivation of the name prion is itself prionic in that the name was changed from proin to prion.
The shape of a protein is only one aspect of its structure. There is a more basic building block comprising a sequence of amino acids. The closer 2 prions are in their basic structures, the easier it is for a bad, rebel prion to corrupt a normal prion by forcing it to alter its shape and become a rebel too. Birds of a feather do all sorts of things together.
This raises the concept of species barrier. Species barrier refers to the difficulty of prions made by one species causing disease in another species. The cause of this difficulty is unknown but it is important in light of Mad Cow Disease in which bad prions from other animals such as sheep and cows were part of the feed for cows.
The close genetic link between sheep and cows allows for the transformation of “Mad Sheep Disease’ to Mad Cow Disease. “Mad Sheep Disease”, known for over 200 years is called scrapie because the sheep have a terrible itch and scratch against a fence until they scrape off their wool.
Kuru is a prion disease that was found in 1957 among the Fore tribal population of Papua New Guinea. Transmission was due to the practice of ritualistic cannibalism. With the cessation of this social custom, Kuru has essentially disappeared. Kuru is the Fore word for shivering, trembling or “laughing death”.
Sheep and cow prions differ at 7 positions. Alternatively, cow and human prions differ at more than 30 positions. Because of this greater variance, Dr. Prusiner thinks that the likelihood of transmission of prions from cows to people is low. But low does not mean impossible because it does occur. Maybe only a small area of similarity is required for corruption of the human prions by the bovine prions. Additionally, other types of proteins called chaperone proteins may assist in the alteration and corruption of the good prions.
In genetic and other terms, are we humans far from the madding cow?
Dr. Lester CN Simon
The title of this article is aimed at linking two crucial aspects of the basic science of Mad Cow Disease. Mad Cow Disease is the lay person’s term for Bovine Spongiform Encephalopathy (BSE). BSE is only one of a list of spongiform brain disorders in animals and humans in which the brain is literally reduced to a sponge.
To get a clear grasp of the basic science so that we can apply it to public health, we have to understand a peculiar set of diseases caused by agents called prions.
When we think of the causes of infections, parasites, fungi, bacteria and viruses readily come to mind. The first three agents contain many sophisticated, genetic chemicals including DNA and RNA. These three infectious agents grow, reproduce, make and use proteins once nutrients are available. Viruses, on the other hand, are not as sophisticated. A virus possesses either DNA or RNA, not both. Viruses cannot grow, reproduce and make or use proteins unless they inhabit living cells.
As important as proteins are, it was not considered possible that a protein could cause infection by itself. Infection means that the causative agent sets up shop in the host and multiples therein. Proteins should not be able to do this since they do not have the chemical genetic machinery in the form of DNA or RNA.
Enter the prion. In 1980, Dr. Stanley Prusiner evoked a good deal of scepticism when he proposed that the infectious agents causing spongiform brain diseases in animals and, more rarely, in humans might consist of protein and nothing else. At the time, Dr. Prusiner was considered a heretic. His work was revolutionary. He realised that dogma held that the conveyers of transmissible diseases required genetic material, DNA or RNA, in order to establish an infection in a host. Fifteen year later, Dr. Stanley Prusiner was awarded the Nobel Prize in Medicine for his work on prions.
The name prion (pronounced "pree-ons" by Dr. Prusiner), is an acronym. Actually you may say it is a prionic acronym, as you will see later. It comes from the words: proteinaceous infectious particle, using the first three letters of proteinaceous (pro) and the first two letters of infectious (in). Obviously, this would lead to the name, proin but it was decided to call it prion instead of proin, because prion has a better sound.
But even if prions cause diseases, they are proteins; and all proteins are made by genes (DNA and RNA). So how do the prions reproduce when they cause infections? Do they have a piece of genetic material attached to them? No. The genes that make prions are where all genes are: inside the cell. They make prion proteins (PrP) all the time without necessarily causing any sickness. This suggests that prion proteins exist in two states, a normal, innocent state and an abnormal, corrupted, sinister state.
Good prions are easily degraded by the usual protein-degrading enzymes in all cells. Unfortunately, bad prions resist this degradation. Hence, bad prions will always win and the good ones will lose. The concept of good prions is relatively new. When prions were first discovered, they were thought to be intrinsically bad. Just recently, in December 2003, it was considered that one sort of prion has a vital role to play in how memory can be stored in the brain. Hence the name of this article.
Shape or conformation is very important to proteins. Change the shape and the function can change. The bad prion acts as an infectious agent by somehow causing a change in the shape of the good prion, which then becomes a rebel prion and damages the body. The derivation of the name prion is itself prionic in that the name was changed from proin to prion.
The shape of a protein is only one aspect of its structure. There is a more basic building block comprising a sequence of amino acids. The closer 2 prions are in their basic structures, the easier it is for a bad, rebel prion to corrupt a normal prion by forcing it to alter its shape and become a rebel too. Birds of a feather do all sorts of things together.
This raises the concept of species barrier. Species barrier refers to the difficulty of prions made by one species causing disease in another species. The cause of this difficulty is unknown but it is important in light of Mad Cow Disease in which bad prions from other animals such as sheep and cows were part of the feed for cows.
The close genetic link between sheep and cows allows for the transformation of “Mad Sheep Disease’ to Mad Cow Disease. “Mad Sheep Disease”, known for over 200 years is called scrapie because the sheep have a terrible itch and scratch against a fence until they scrape off their wool.
Kuru is a prion disease that was found in 1957 among the Fore tribal population of Papua New Guinea. Transmission was due to the practice of ritualistic cannibalism. With the cessation of this social custom, Kuru has essentially disappeared. Kuru is the Fore word for shivering, trembling or “laughing death”.
Sheep and cow prions differ at 7 positions. Alternatively, cow and human prions differ at more than 30 positions. Because of this greater variance, Dr. Prusiner thinks that the likelihood of transmission of prions from cows to people is low. But low does not mean impossible because it does occur. Maybe only a small area of similarity is required for corruption of the human prions by the bovine prions. Additionally, other types of proteins called chaperone proteins may assist in the alteration and corruption of the good prions.
In genetic and other terms, are we humans far from the madding cow?
Monday, December 22, 2003
Observation Must be Seen
The Commonwealth Observer Fluke
Dr. Lester CN Simon
Have you read the official report on the 1999 general elections in Antigua and Barbuda by the Commonwealth Observer Group? You should. When you read it, please put aside your political allegiance. Try to read it dispassionately to determine if the Group fulfilled its terms of reference. You may find that it gets a score of only 66.7%, not enough for a distinction.
The Group’s terms of reference include three essential tasks: “To determine in its own judgment whether the conditions exist for a free expression of will by the electors and if the results of the elections reflect the wishes of the people… [and]...to propose to the authorities…..such actions….as would assist the holding of elections”.
Regardless of your political persuasion, you must be dissatisfied when you read the conclusions and recommendations of the Group. The conclusions note that the “electoral process we observed on polling day had allowed the people of Antigua and Barbuda to freely express their will at the polls…” So far, one out of three (33.3%). Remember, the judgement is that of the Group, not anyone else’s. Put your political persuasion aside.
In addition, the Group pens a long list of recommendations, a number of which are “in line with those contained in the Supervisor of Elections’ report on the 1994 general election”. So far the Group gets two out of three, with no extra points for “cogging”.
Strangely, the report does not issue a single word about whether “the results of the elections reflected the wishes of the people”. It failed miserably this part of the examination. Nought! This raises the question: How did the Group plan to determine, as objectively as possible, the wishes of the people? Put your political persuasion aside.
Indeed, how can anyone determine this? Try to be unbiased in your answer. Assessing the wishes of the people may not be as simple as it seems at first. At its most rudimentary level, it involves a combination of factors and observations which cannot be undertaken, together with the other aspects of the terms of reference, in 8 days. The Group arrived in Antigua on March 4, 1999 and departed on March 11, 1999.
The Group should have paid more attention to its terms of reference. It should have worked harder and longer to answer all three compulsory questions. We are taught to read the instructions at the start and during the middle of the examination. Some even read them at the end and beg an extra half mark by noting that they misread the instructions.
And as if to add salt to salt fish, the Group showed its poor powers of observation of local politics when it allowed the colour of the cover of its report to be blue! Was this a veiled reference to the wishes of the people? No! No more than the Group expected the report to be “read”! The Group simply blew the most crucial aspect of its terms of reference.
Dr. Lester CN Simon
Have you read the official report on the 1999 general elections in Antigua and Barbuda by the Commonwealth Observer Group? You should. When you read it, please put aside your political allegiance. Try to read it dispassionately to determine if the Group fulfilled its terms of reference. You may find that it gets a score of only 66.7%, not enough for a distinction.
The Group’s terms of reference include three essential tasks: “To determine in its own judgment whether the conditions exist for a free expression of will by the electors and if the results of the elections reflect the wishes of the people… [and]...to propose to the authorities…..such actions….as would assist the holding of elections”.
Regardless of your political persuasion, you must be dissatisfied when you read the conclusions and recommendations of the Group. The conclusions note that the “electoral process we observed on polling day had allowed the people of Antigua and Barbuda to freely express their will at the polls…” So far, one out of three (33.3%). Remember, the judgement is that of the Group, not anyone else’s. Put your political persuasion aside.
In addition, the Group pens a long list of recommendations, a number of which are “in line with those contained in the Supervisor of Elections’ report on the 1994 general election”. So far the Group gets two out of three, with no extra points for “cogging”.
Strangely, the report does not issue a single word about whether “the results of the elections reflected the wishes of the people”. It failed miserably this part of the examination. Nought! This raises the question: How did the Group plan to determine, as objectively as possible, the wishes of the people? Put your political persuasion aside.
Indeed, how can anyone determine this? Try to be unbiased in your answer. Assessing the wishes of the people may not be as simple as it seems at first. At its most rudimentary level, it involves a combination of factors and observations which cannot be undertaken, together with the other aspects of the terms of reference, in 8 days. The Group arrived in Antigua on March 4, 1999 and departed on March 11, 1999.
The Group should have paid more attention to its terms of reference. It should have worked harder and longer to answer all three compulsory questions. We are taught to read the instructions at the start and during the middle of the examination. Some even read them at the end and beg an extra half mark by noting that they misread the instructions.
And as if to add salt to salt fish, the Group showed its poor powers of observation of local politics when it allowed the colour of the cover of its report to be blue! Was this a veiled reference to the wishes of the people? No! No more than the Group expected the report to be “read”! The Group simply blew the most crucial aspect of its terms of reference.
Monday, October 20, 2003
Feeling Sick
HOSPITAL: A PLACE FOR HORSES?
Dr. Lester CN Simon
Is it impossible to make some sense of the transition from Holberton Hospital to the Mount St. John Medical Centre (MSJMC)? Is it possible to say something enlightening and useful? Something to assist in formulating a roadmap for the resolution of the complex management problems confronting us? Of course it is. But there are at least three basic requirements: a sense of history, a sense of humour, and a good dose of common sense.
The central thesis of this article is that no one in this country is ideally qualified to work at the MSJMC. No one. If this is true, it makes sense to create a road map that is more inclusive and to draw back from the silly notion that suggests that there are a few, chosen people who know everything.
Let us start near the top. Imagine yourself as the Chief Executive Officer (CEO) coming to Antigua and Barbuda from North America. The main reason you would undertake this job is for the challenge it throws up. It is not just a new geographic territory for you; the entire management system that is required is new to you and to the locals. You cannot simply recreate the USA system.
The old local system has many faults and an altogether new system catering for local idiosyncrasies must be forged. However, we must not pay any attention to the sentimental notion that we have to accept less here simply because we are a developing nation. There is a minimum standard of health that guards against unnecessary sickness and death. This requires a new, improved, complete and all-inclusive approach to management. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the CEO.
Our next stop is to look at the medical management of Holberton and take a peek at the proposal for the MSJMC. The modern history of medicine in Antigua and Barbuda seems to have begun in the late 1970’s and early 1980’s when an increasing number of local doctors returned home from studies overseas. Imagine yourself as a bright, young, committed and enthusiastic doctor coming home with new ideas and dreams of a new hospital. You do your research as any good doctor would.
You find a number of the Annual Medical and Sanitary Reports from the 1950’s to the 1970’s. The 1957 edition noted, “The combined post of Medical Superintendent and Surgeon Specialist was abolished at the end of 1956 and instead a Medical Superintendent was appointed, while the post of Surgeon Specialist continued as a separate entity from the 1st January, 1957”.
In 1973, Dr. C.E.S Bailey was the Chief Medical Officer and Mr. George Jamieson was appointed Hospital Administrator. This was a newly created post and the former post of Medical Superintendent was abolished. Mr. Jamieson, a non-Antiguan, was appointed for two years. Two local candidates were in training as Hospital Administrator, viz,
Mr. Ryves Merchant, who went to Britain and Mr. Dorbrene O’Marde, who studied in Canada.
In 1974, Mr. Merchant was appointed as Deputy Hospital Administrator. Some time after 1974, it is alleged that Mr. Merchant became the Hospital Administrator and
Mr. O’Marde became his deputy. It is also alleged that one of them was subsequently transferred to the Ministry of Agriculture and the other one was sent to the Ministry of Culture. Can one assume that this dislocation was part of a grand insightful medical benefit scheme to offset the sickness that would later attend these two ministries? Or was this the first serious episode of the disarticulation of medical benefits so that up to now we still cannot put our medical benefit monies in our medical benefit mouths?
In 1974, a feasibility study was carried out for the provision of a new general hospital to replace Holberton Hospital. The British team of experts, which included the Medical Advisor, Dr. J.A. Oddie, delivered their report to the government for consideration and approval. The need for a new hospital such as MSJNC is not the bright, novel idea of this century, despite the numerous stories to this claim.
In 1983 (when I returned to Antigua and Barbuda), and probably before then, the post of Medical Superintendent had been re-established. The Medical Superintendent seemingly had a direct line of communication to the then Prime Minister. Disentangling the combined post of Medical Superintendent and Surgeon Specialist in 1956, appointing a Hospital Administrator and abolishing the post of Medical Superintendent in 1973, re-creating the post of Medical Superintendent, appointing and then “disappointing” and re-locating two trained hospital administrators, suggest that the management of Holberton Hospital was a perennial problem.
Enter the dragon, you might say. Or, if you prefer: The Return of the Jedi. Time to clear up all this confusion, build a new hospital and take us into the New Millennium. The first roadblock is the empire of civil service bureaucracy. It’s impossible to get the simplest thing done using these channels. But this is health. You have a direct line to the Prime Minister, just like the previous Medical Superintendent. Were it not for this, you would go crazy trying to effect the kind of health service we desperately need. Channels have to be circumvented because the empire of bureaucracy is too circuitous and it seems designed to frustrate everyone, including the very patient who is at the heart of any health service.
How could you involve all the other doctors when the usual reply when they were approached on any matter was: The obstetricians thought you were labouring under a misconception; the dermatologists preferred no rash moves; the cardiologist didn’t have the heart to say no or yes; the urologist felt the scheme wouldn’t hold water; the opthalmologist considered the idea short-sighted; the orthopaedists always wanted a joint solution; the pediatricians wouldn’t grow up; the Ear Nose and Throat surgeon, despite his bounteous musical skills, would not listen, he always smelled a rat and he could not swallow the idea since it got stuck in his throat; the other surgeons washed their hands of the whole thing and the pathologist, of all persons, the one who had a hard time building the lab and who should know better, yelled, “over my dead body”!
So you finally succeed in building a new state-of-the-art hospital. In the process you are blamed for some things you have done and even for some things you have not even dreamed of. Such is the price, or is it the cost, according to one of the POWA ladies? So how are you configured in the management of this new MSJMC?
There are many routes to becoming a Medical Director----no more of that Medical Superintendent, British nomenclature nonsense. You do your research. You find two key articles called “Executives in White Coats”, by Drs. Bodenheimer and Casalino published in 1999 in the New England Journal of Medicine (NEJM). The article noted that during the past two decades a new breed of physician called the medical director has emerged, with substantial influence over medical practice.
In answer to the key question of the routes by which they come to their jobs, the two doctors interviewed 50 medical directors. Examination of the career paths of medical directors revealed that membership in the American College of Physician Executives grew from 64 in 1975 to 14,000 in 1998. Medical directors arrived at their positions through a clinical path. Most of the medical directors in the study had spent many years as clinicians, had then taken on some part-time administrative duties, and had gradually increased their administrative responsibilities and reduced their clinical activities. Another study had found that the average medical director spent 16 years in clinical practice before assuming a management role.
During the early years of managed care, few medical directors had business degrees. Most learned their administrative skills on the job. Gradually, more physicians interested in administrative careers began obtaining graduate degrees in business. These include master’s degree in business administration, in medical management, or in health administration. Most of the medical directors with a strong clinical background interviewed in the NEJM study, found formal training in business very useful.
The NEJM article also noted that the business path to medical directorship involves a few years in clinical practice and emphasis on administrative more than clinical acumen. Indeed, medical students can now earn a five-year M.D.-M.B.A. degree and become physician executives without ever seeing a patient outside the training program. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the Medical Director.
Let us now look at the worst possible worker at Holberton: the uncooperative, the lazy, the inefficient, and the absolute worst. You do this not to excuse these workers but to understand them. This is essential because as the number of such workers increases you have to wonder why they behave that way, especially since you know that they were once cooperative, reliable and efficient workers. You consult the experts on management.
You ask them about money and motivation. They tell you that getting more money simply motivates you to get more money. Effective motivation factors include elements like achievement, recognition of achievement, advancement and growth.
One of the core assets of the hospital or any workplace is the intellectual capital of the workers. So what do you think will happen when we the workers are not made an integral part of the plant, when they do not take our suggestions on board, when we feel apart from, instead of a part of, the workplace? A vicious cycle is created in which, without knowing our history, we seemingly become constitutively unproductive. But the majority of us who make the most noise and give the most trouble are actually crying out for help! The disinterested, quiet ones may actually be fooling you. If we need probation, I hope they hire an industrial psychologist because management and ministry and all of us need a probationary period to learn how to work together. This synergy is the physiology of productivity. We are not horses running wild in disarray around a racetrack.
In 1957, there were 139 beds at Holberton, which amounted to 2.7 beds per 1,000 population. Two years later, there were 180 beds or 3.5 beds per 1,000 population.
The 1972 Annual Medical and Sanitation Report recorded the population census as
64,794 people and it noted that Holberton Hospital had 216 beds. These data amount to 3.3 beds per 1,000 population in 1972.
It was reported in a local newspaper that an official of the MSJMC said that the bed capacity at MSJMC would be 186. The total de facto population listed in the 2001 Preliminary Census Report was 77,426. These two data amount to 2.4 beds per 1000 population when MSJMC is opened in 2004 compared to 3.5 beds per 1,000 population in 1959 and 2.7 beds per 1,000 population in 1957.
Let not your heart be troubled. The key to get around this decrease in beds per 1,000 population is that the average length of stay in MSJMC will be much shorter. With a markedly improved bed turn over rate, the present lower bed per 1,000 population will not affect the efficiency of the MSJMC negatively.
But this raises the important question of the relationship between MSJMC and the rest of the health service since bed turnover rate and patient recovery are dependent on factors within and without the hospital. It underscores the fact that for MSJMC to function efficiently and effectively, there must be a complete reformation of the entire health service in Antigua and Barbuda including public and private clinics and indeed public and private healthcare in general.
Indeed, I tried to compare the proportion of hospital beds per 1,000 population using data from PAHO Epidemiological Bulletin, Vol. 21, No.4, December 2000. The comparison is difficult because the article does not declare whether the number of beds refers to only acute care general hospital beds or if psychiatric and geriatric hospital beds are included. Nonetheless, an article by Valerie Nelson (December 31, 1997 in NurseWeek) started thus: Quick, a little Health Care 101: How do you measure the size of a hospital? If you answered, "by the number of beds," step to the back of the class. That answer’s years behind the times.
The article continued: “Hospitals now deliver so many different kinds of services that it’s almost hard to tell what a hospital is," said Paul Torrens, MD, professor of health services at the UCLA School of Public Health. It’s no longer a question of beds, but of what services a hospital is trying to deliver, he said. Thinking about how many beds a hospital needs ties into "the whole nature of the way health care is changing," Torrens said. Healthcare services, once separate entities, now are connected like so many lights on a string. Hospitals are becoming part of integrated delivery systems that are a far cry from the past, when the different facets of health care—prevention, outpatient services, nursing homes, home care—operated independently.”
Looking towards the future the article noted thus: “In the next five to 10 years, the traditional role and structure of the American hospital will be expanded and re-examined, Torrens predicts. New models will spring up that "are much broader and offer a much wider range of services than the old hospital," he said. The healthcare model developing around the nation is a continuum of services in which the hospital is a large cog in the [wheel] and "there is much more integration of services across lines," Torrens said.”
What is the view of the American Hospital Association (AHA)? The article concluded: Hospitals in urban areas that are duplicating services "gets to the whole issue of ‘what does the community need?’ " said Carol Schadelbauer, spokesperson for the AHA. Working together is what it will be about. A record number of hospital collaborations and mergers are helping to fuel the downsizing trend, she said. Did I hear you ask: Where are the public clinics, Adelin Medical Centre, and other private medical facilities in this national picture?
The same empire of bureaucracy with the mass of workers that was bypassed, to try to manage Holberton and other public health facilities, on the way up to Mount must now be confronted on the way down. The empire strikes back. The empire can only be defeated by a meaningful, combined attack involving a fairly constituted board, top management officials, the head of departments and representatives of the workers, rather than the occasional sortie and sally against the empire using handpicked, compliant generals.
The alternative is a continuation of the status quo, with overemphasis on outside assistance, which will only incur the charge of foreignization of MSJMC. If the better of the aforementioned actions is not undertaken, you will have to raise your head to the sky and bawl out: Jah! Rastafari! What have I done? What have I done?
Dr. Lester CN Simon
Is it impossible to make some sense of the transition from Holberton Hospital to the Mount St. John Medical Centre (MSJMC)? Is it possible to say something enlightening and useful? Something to assist in formulating a roadmap for the resolution of the complex management problems confronting us? Of course it is. But there are at least three basic requirements: a sense of history, a sense of humour, and a good dose of common sense.
The central thesis of this article is that no one in this country is ideally qualified to work at the MSJMC. No one. If this is true, it makes sense to create a road map that is more inclusive and to draw back from the silly notion that suggests that there are a few, chosen people who know everything.
Let us start near the top. Imagine yourself as the Chief Executive Officer (CEO) coming to Antigua and Barbuda from North America. The main reason you would undertake this job is for the challenge it throws up. It is not just a new geographic territory for you; the entire management system that is required is new to you and to the locals. You cannot simply recreate the USA system.
The old local system has many faults and an altogether new system catering for local idiosyncrasies must be forged. However, we must not pay any attention to the sentimental notion that we have to accept less here simply because we are a developing nation. There is a minimum standard of health that guards against unnecessary sickness and death. This requires a new, improved, complete and all-inclusive approach to management. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the CEO.
Our next stop is to look at the medical management of Holberton and take a peek at the proposal for the MSJMC. The modern history of medicine in Antigua and Barbuda seems to have begun in the late 1970’s and early 1980’s when an increasing number of local doctors returned home from studies overseas. Imagine yourself as a bright, young, committed and enthusiastic doctor coming home with new ideas and dreams of a new hospital. You do your research as any good doctor would.
You find a number of the Annual Medical and Sanitary Reports from the 1950’s to the 1970’s. The 1957 edition noted, “The combined post of Medical Superintendent and Surgeon Specialist was abolished at the end of 1956 and instead a Medical Superintendent was appointed, while the post of Surgeon Specialist continued as a separate entity from the 1st January, 1957”.
In 1973, Dr. C.E.S Bailey was the Chief Medical Officer and Mr. George Jamieson was appointed Hospital Administrator. This was a newly created post and the former post of Medical Superintendent was abolished. Mr. Jamieson, a non-Antiguan, was appointed for two years. Two local candidates were in training as Hospital Administrator, viz,
Mr. Ryves Merchant, who went to Britain and Mr. Dorbrene O’Marde, who studied in Canada.
In 1974, Mr. Merchant was appointed as Deputy Hospital Administrator. Some time after 1974, it is alleged that Mr. Merchant became the Hospital Administrator and
Mr. O’Marde became his deputy. It is also alleged that one of them was subsequently transferred to the Ministry of Agriculture and the other one was sent to the Ministry of Culture. Can one assume that this dislocation was part of a grand insightful medical benefit scheme to offset the sickness that would later attend these two ministries? Or was this the first serious episode of the disarticulation of medical benefits so that up to now we still cannot put our medical benefit monies in our medical benefit mouths?
In 1974, a feasibility study was carried out for the provision of a new general hospital to replace Holberton Hospital. The British team of experts, which included the Medical Advisor, Dr. J.A. Oddie, delivered their report to the government for consideration and approval. The need for a new hospital such as MSJNC is not the bright, novel idea of this century, despite the numerous stories to this claim.
In 1983 (when I returned to Antigua and Barbuda), and probably before then, the post of Medical Superintendent had been re-established. The Medical Superintendent seemingly had a direct line of communication to the then Prime Minister. Disentangling the combined post of Medical Superintendent and Surgeon Specialist in 1956, appointing a Hospital Administrator and abolishing the post of Medical Superintendent in 1973, re-creating the post of Medical Superintendent, appointing and then “disappointing” and re-locating two trained hospital administrators, suggest that the management of Holberton Hospital was a perennial problem.
Enter the dragon, you might say. Or, if you prefer: The Return of the Jedi. Time to clear up all this confusion, build a new hospital and take us into the New Millennium. The first roadblock is the empire of civil service bureaucracy. It’s impossible to get the simplest thing done using these channels. But this is health. You have a direct line to the Prime Minister, just like the previous Medical Superintendent. Were it not for this, you would go crazy trying to effect the kind of health service we desperately need. Channels have to be circumvented because the empire of bureaucracy is too circuitous and it seems designed to frustrate everyone, including the very patient who is at the heart of any health service.
How could you involve all the other doctors when the usual reply when they were approached on any matter was: The obstetricians thought you were labouring under a misconception; the dermatologists preferred no rash moves; the cardiologist didn’t have the heart to say no or yes; the urologist felt the scheme wouldn’t hold water; the opthalmologist considered the idea short-sighted; the orthopaedists always wanted a joint solution; the pediatricians wouldn’t grow up; the Ear Nose and Throat surgeon, despite his bounteous musical skills, would not listen, he always smelled a rat and he could not swallow the idea since it got stuck in his throat; the other surgeons washed their hands of the whole thing and the pathologist, of all persons, the one who had a hard time building the lab and who should know better, yelled, “over my dead body”!
So you finally succeed in building a new state-of-the-art hospital. In the process you are blamed for some things you have done and even for some things you have not even dreamed of. Such is the price, or is it the cost, according to one of the POWA ladies? So how are you configured in the management of this new MSJMC?
There are many routes to becoming a Medical Director----no more of that Medical Superintendent, British nomenclature nonsense. You do your research. You find two key articles called “Executives in White Coats”, by Drs. Bodenheimer and Casalino published in 1999 in the New England Journal of Medicine (NEJM). The article noted that during the past two decades a new breed of physician called the medical director has emerged, with substantial influence over medical practice.
In answer to the key question of the routes by which they come to their jobs, the two doctors interviewed 50 medical directors. Examination of the career paths of medical directors revealed that membership in the American College of Physician Executives grew from 64 in 1975 to 14,000 in 1998. Medical directors arrived at their positions through a clinical path. Most of the medical directors in the study had spent many years as clinicians, had then taken on some part-time administrative duties, and had gradually increased their administrative responsibilities and reduced their clinical activities. Another study had found that the average medical director spent 16 years in clinical practice before assuming a management role.
During the early years of managed care, few medical directors had business degrees. Most learned their administrative skills on the job. Gradually, more physicians interested in administrative careers began obtaining graduate degrees in business. These include master’s degree in business administration, in medical management, or in health administration. Most of the medical directors with a strong clinical background interviewed in the NEJM study, found formal training in business very useful.
The NEJM article also noted that the business path to medical directorship involves a few years in clinical practice and emphasis on administrative more than clinical acumen. Indeed, medical students can now earn a five-year M.D.-M.B.A. degree and become physician executives without ever seeing a patient outside the training program. So who on earth was mad enough to talk about nurses undergoing a probation period as if they were the only ones venturing into this new environment? It’s probation time for all of us including the Medical Director.
Let us now look at the worst possible worker at Holberton: the uncooperative, the lazy, the inefficient, and the absolute worst. You do this not to excuse these workers but to understand them. This is essential because as the number of such workers increases you have to wonder why they behave that way, especially since you know that they were once cooperative, reliable and efficient workers. You consult the experts on management.
You ask them about money and motivation. They tell you that getting more money simply motivates you to get more money. Effective motivation factors include elements like achievement, recognition of achievement, advancement and growth.
One of the core assets of the hospital or any workplace is the intellectual capital of the workers. So what do you think will happen when we the workers are not made an integral part of the plant, when they do not take our suggestions on board, when we feel apart from, instead of a part of, the workplace? A vicious cycle is created in which, without knowing our history, we seemingly become constitutively unproductive. But the majority of us who make the most noise and give the most trouble are actually crying out for help! The disinterested, quiet ones may actually be fooling you. If we need probation, I hope they hire an industrial psychologist because management and ministry and all of us need a probationary period to learn how to work together. This synergy is the physiology of productivity. We are not horses running wild in disarray around a racetrack.
In 1957, there were 139 beds at Holberton, which amounted to 2.7 beds per 1,000 population. Two years later, there were 180 beds or 3.5 beds per 1,000 population.
The 1972 Annual Medical and Sanitation Report recorded the population census as
64,794 people and it noted that Holberton Hospital had 216 beds. These data amount to 3.3 beds per 1,000 population in 1972.
It was reported in a local newspaper that an official of the MSJMC said that the bed capacity at MSJMC would be 186. The total de facto population listed in the 2001 Preliminary Census Report was 77,426. These two data amount to 2.4 beds per 1000 population when MSJMC is opened in 2004 compared to 3.5 beds per 1,000 population in 1959 and 2.7 beds per 1,000 population in 1957.
Let not your heart be troubled. The key to get around this decrease in beds per 1,000 population is that the average length of stay in MSJMC will be much shorter. With a markedly improved bed turn over rate, the present lower bed per 1,000 population will not affect the efficiency of the MSJMC negatively.
But this raises the important question of the relationship between MSJMC and the rest of the health service since bed turnover rate and patient recovery are dependent on factors within and without the hospital. It underscores the fact that for MSJMC to function efficiently and effectively, there must be a complete reformation of the entire health service in Antigua and Barbuda including public and private clinics and indeed public and private healthcare in general.
Indeed, I tried to compare the proportion of hospital beds per 1,000 population using data from PAHO Epidemiological Bulletin, Vol. 21, No.4, December 2000. The comparison is difficult because the article does not declare whether the number of beds refers to only acute care general hospital beds or if psychiatric and geriatric hospital beds are included. Nonetheless, an article by Valerie Nelson (December 31, 1997 in NurseWeek) started thus: Quick, a little Health Care 101: How do you measure the size of a hospital? If you answered, "by the number of beds," step to the back of the class. That answer’s years behind the times.
The article continued: “Hospitals now deliver so many different kinds of services that it’s almost hard to tell what a hospital is," said Paul Torrens, MD, professor of health services at the UCLA School of Public Health. It’s no longer a question of beds, but of what services a hospital is trying to deliver, he said. Thinking about how many beds a hospital needs ties into "the whole nature of the way health care is changing," Torrens said. Healthcare services, once separate entities, now are connected like so many lights on a string. Hospitals are becoming part of integrated delivery systems that are a far cry from the past, when the different facets of health care—prevention, outpatient services, nursing homes, home care—operated independently.”
Looking towards the future the article noted thus: “In the next five to 10 years, the traditional role and structure of the American hospital will be expanded and re-examined, Torrens predicts. New models will spring up that "are much broader and offer a much wider range of services than the old hospital," he said. The healthcare model developing around the nation is a continuum of services in which the hospital is a large cog in the [wheel] and "there is much more integration of services across lines," Torrens said.”
What is the view of the American Hospital Association (AHA)? The article concluded: Hospitals in urban areas that are duplicating services "gets to the whole issue of ‘what does the community need?’ " said Carol Schadelbauer, spokesperson for the AHA. Working together is what it will be about. A record number of hospital collaborations and mergers are helping to fuel the downsizing trend, she said. Did I hear you ask: Where are the public clinics, Adelin Medical Centre, and other private medical facilities in this national picture?
The same empire of bureaucracy with the mass of workers that was bypassed, to try to manage Holberton and other public health facilities, on the way up to Mount must now be confronted on the way down. The empire strikes back. The empire can only be defeated by a meaningful, combined attack involving a fairly constituted board, top management officials, the head of departments and representatives of the workers, rather than the occasional sortie and sally against the empire using handpicked, compliant generals.
The alternative is a continuation of the status quo, with overemphasis on outside assistance, which will only incur the charge of foreignization of MSJMC. If the better of the aforementioned actions is not undertaken, you will have to raise your head to the sky and bawl out: Jah! Rastafari! What have I done? What have I done?
Sunday, November 17, 2002
Tim Hector
ONE DEATH
And the Dying is Hard
Dr. Lester CN Simon
There are some things in life you do not forget: Where you were when you heard that President Kennedy was shot; watching the television and seeing Nelson Mandela waking to freedom; and hearing that Tim Hector was dead.
My thoughts flashed back to 1963 and my first encounter with the great man. I remember sitting in the second to last row, on the right side, in first form, at the Antigua Grammar School. Sounding like a bassoon, Mr. Hector had invaded, captured and laid waste the class with a poem, The Creation, by James Weldon Johnson. The remarkable thing about the poem was the first line, “ And God stepped out on space.” I had never heard that construction before, “stepped out on space.” Not just “stepped out”, or “stepped out in space”; but “stepped out on space.”
Only God can do that, and for that entire class, Mr. Hector was like a messenger from God, as he stepped all over on the space of classroom. When he told us that the poem was written by a black man, I thought that if a black man could write that, then I could do absolutely anything. It was as if I too had stepped out on life. This was the real Hector to me, the son of King Priam of Troy, commander of the Trojan army, the arch nemesis of Achilles and the emissary of Zeus to us.
Now, Tim had finally stepped out. Stepping out: The sort of remark you make when you leave home to jot round the corner and expect to return in a little while. But the warning, amber lights do not always work. Sometimes you step straight from green to red to dead.
In the days leading up to Tim’s death, I was in Jamaica for our son’s graduation and for a workshop and conference of Forensic Pathology. It was a stalk contrast between the joy of graduation and the sadness of crime in Jamaica. So I was heartened to discover a book in our daughter’s flat written by Jamaican criminologist, Dr. Bernard Headley called, “The Jamaican Crime Scene”. At last someone was making sense out of the seemingly senseless killings in Jamaica. Unbeknownst to me, I returned to Antigua the very night Tim was not going “gently into that good night”, but was raging, raging “against the dying of the light”.
Antiguans don’t commit that sort of crime! When the last comptroller of Customs was brutally killed in a botched robbery, it was said that that sort of crime was alien to Antigua and Barbuda and that the perpetrators were surely the dregs of Jamaica and such natural born criminals (an oxymoron). Surprise, surprise! We too have a bitch’s brew from which such dregs are easily drawn. No wonder the scene of the multiple murders of some English tourists aboard the Computer Challenger yacht in Barbuda was so familiar to the eye. Blood has an inquisitive and nasty, vulgar way of soiling everything, every time, everywhere.
In Forensic Pathology, you learn about the cause of death and the manner of death. The cause of death is determined by the pathologist and it may be gunshot wound to the head. The manner of death is the legal determination of the circumstances of death and explains how the cause of death came about. Manners of death include natural, accident, suicide, homicide and undetermined. Yet, at some point you come to realize that there is but one death; that someone stepped out. And that dying is always hard for someone, somewhere.
Dr. Bernard talks about the societal phenomena of crime and violence in Jamaica; a relationship between crime and violence and social, political, economic and cultural objective features. Some Antiguans will continue to believe that “Jamaican crimes” cannot happen in Antigua and Barbuda. We must not just look at numbers; we must regard the root causes and the density of crime, or the numbers of crime per population. The absurdity of not regarding the density of crime is dazzlingly brought home when you find yourself basking in the safety of a low suicide rate in a country with a population of one!
Dr. Bernard contrasts individualised crimes to street or conventional crimes. Individualised crimes are of two types. One type is impersonal and it is perpetuated by someone who “derives some warped satisfaction from the act of violence.” There persons are psychopath and they are likely to kill any vulnerable person. The other type of individualized crime is directly personal and intimate. “Satisfaction comes from meting out aggression towards a specific person”; e.g. domestic violence. Dr. Bernard noted that for all acts of individualized crimes, their occurrence, however frequent, upsetting, and distasteful, signals no real danger or coming apart at the seams in the social contract”.
In contract, writes Dr, Bernard, “ Most street crimes such as robbery, are not really motivated by any complicated psychological abstraction. Instead, they become a tool in the service of achieving some “higher” objective”…such as to “ obtain money, food, or other usable items; control political or drug turf, …..” Dr. Bernard makes the point that street-level crimes usually indicate some deep-rooted pathology within the social system……” He goes on to conclude that “the underlying source is arithmetic growth in the size of an at-risk population that is faced with precious few alternatives to crime….. The cause of all street-level crime and violence ---must be found in the nature of society, not in the mental or emotional states of its citizens” (as in individualized crimes).
The Dr. Bernard makes a case for the root causes of street-level crimes. And these root caused should be familiar to all Caribbeans. “ Three major interrelated forces are responsible for the growth of the country’s “at-risk” or “crime-disposed” population: The decline of agricultural production which led to internal and external migration. The evolution of a disarticulated modern economy. The steady, continuous increases in the rate of growth in the youthful age cohorts without sufficient base for their productive absorption into the economy.” Tim is on record for registering the disastrous failure of the Caribbean in economics and politics
Crime in Jamaica and crime in Antigua (and in Trinidad and Guyana, etc) bespeaks the exclusion of youth. This is why I am almost frightened to death ( a serious crime!) when some disarticulated women seem to buzz with glee to hear that girls are exceeding boys in school and at University.
When Tim Hector and I discussed my wrongful and arbitrary dismissal from Holberton Hospital in 1996, the overwhelming and recurrent theme of our discussion was that the wanton practice of exclusion (or else nepotistic inclusion) in Antigua was excessive, unfair and dangerous. We discussed this exclusion practice in the Health Care services in Antigua in general and at the hospital in particular. And this is why I wonder how Tim felt in his dying hours in Holberton. We doctors have to understand that no matter how much we know, patients have a natural and insatiable desire to see doctors working together and consulting each other. Our bodies work that way.
The proper practice of medicine demands much more than the administration of drugs, the application of a knife, the drawing of blood, cleaning an incapacitated patient, or getting paid. For the sake of the Tims to come. Even the night crawlers: drug pushers, addicts, slashing muggers, night soil technicians, and whoring prostitutes know that!
…………………“And where He trod
His footsteps hollowed the valleys out
And bulged the mountains up.”
Farewell dear master and friend.
And the Dying is Hard
Dr. Lester CN Simon
There are some things in life you do not forget: Where you were when you heard that President Kennedy was shot; watching the television and seeing Nelson Mandela waking to freedom; and hearing that Tim Hector was dead.
My thoughts flashed back to 1963 and my first encounter with the great man. I remember sitting in the second to last row, on the right side, in first form, at the Antigua Grammar School. Sounding like a bassoon, Mr. Hector had invaded, captured and laid waste the class with a poem, The Creation, by James Weldon Johnson. The remarkable thing about the poem was the first line, “ And God stepped out on space.” I had never heard that construction before, “stepped out on space.” Not just “stepped out”, or “stepped out in space”; but “stepped out on space.”
Only God can do that, and for that entire class, Mr. Hector was like a messenger from God, as he stepped all over on the space of classroom. When he told us that the poem was written by a black man, I thought that if a black man could write that, then I could do absolutely anything. It was as if I too had stepped out on life. This was the real Hector to me, the son of King Priam of Troy, commander of the Trojan army, the arch nemesis of Achilles and the emissary of Zeus to us.
Now, Tim had finally stepped out. Stepping out: The sort of remark you make when you leave home to jot round the corner and expect to return in a little while. But the warning, amber lights do not always work. Sometimes you step straight from green to red to dead.
In the days leading up to Tim’s death, I was in Jamaica for our son’s graduation and for a workshop and conference of Forensic Pathology. It was a stalk contrast between the joy of graduation and the sadness of crime in Jamaica. So I was heartened to discover a book in our daughter’s flat written by Jamaican criminologist, Dr. Bernard Headley called, “The Jamaican Crime Scene”. At last someone was making sense out of the seemingly senseless killings in Jamaica. Unbeknownst to me, I returned to Antigua the very night Tim was not going “gently into that good night”, but was raging, raging “against the dying of the light”.
Antiguans don’t commit that sort of crime! When the last comptroller of Customs was brutally killed in a botched robbery, it was said that that sort of crime was alien to Antigua and Barbuda and that the perpetrators were surely the dregs of Jamaica and such natural born criminals (an oxymoron). Surprise, surprise! We too have a bitch’s brew from which such dregs are easily drawn. No wonder the scene of the multiple murders of some English tourists aboard the Computer Challenger yacht in Barbuda was so familiar to the eye. Blood has an inquisitive and nasty, vulgar way of soiling everything, every time, everywhere.
In Forensic Pathology, you learn about the cause of death and the manner of death. The cause of death is determined by the pathologist and it may be gunshot wound to the head. The manner of death is the legal determination of the circumstances of death and explains how the cause of death came about. Manners of death include natural, accident, suicide, homicide and undetermined. Yet, at some point you come to realize that there is but one death; that someone stepped out. And that dying is always hard for someone, somewhere.
Dr. Bernard talks about the societal phenomena of crime and violence in Jamaica; a relationship between crime and violence and social, political, economic and cultural objective features. Some Antiguans will continue to believe that “Jamaican crimes” cannot happen in Antigua and Barbuda. We must not just look at numbers; we must regard the root causes and the density of crime, or the numbers of crime per population. The absurdity of not regarding the density of crime is dazzlingly brought home when you find yourself basking in the safety of a low suicide rate in a country with a population of one!
Dr. Bernard contrasts individualised crimes to street or conventional crimes. Individualised crimes are of two types. One type is impersonal and it is perpetuated by someone who “derives some warped satisfaction from the act of violence.” There persons are psychopath and they are likely to kill any vulnerable person. The other type of individualized crime is directly personal and intimate. “Satisfaction comes from meting out aggression towards a specific person”; e.g. domestic violence. Dr. Bernard noted that for all acts of individualized crimes, their occurrence, however frequent, upsetting, and distasteful, signals no real danger or coming apart at the seams in the social contract”.
In contract, writes Dr, Bernard, “ Most street crimes such as robbery, are not really motivated by any complicated psychological abstraction. Instead, they become a tool in the service of achieving some “higher” objective”…such as to “ obtain money, food, or other usable items; control political or drug turf, …..” Dr. Bernard makes the point that street-level crimes usually indicate some deep-rooted pathology within the social system……” He goes on to conclude that “the underlying source is arithmetic growth in the size of an at-risk population that is faced with precious few alternatives to crime….. The cause of all street-level crime and violence ---must be found in the nature of society, not in the mental or emotional states of its citizens” (as in individualized crimes).
The Dr. Bernard makes a case for the root causes of street-level crimes. And these root caused should be familiar to all Caribbeans. “ Three major interrelated forces are responsible for the growth of the country’s “at-risk” or “crime-disposed” population: The decline of agricultural production which led to internal and external migration. The evolution of a disarticulated modern economy. The steady, continuous increases in the rate of growth in the youthful age cohorts without sufficient base for their productive absorption into the economy.” Tim is on record for registering the disastrous failure of the Caribbean in economics and politics
Crime in Jamaica and crime in Antigua (and in Trinidad and Guyana, etc) bespeaks the exclusion of youth. This is why I am almost frightened to death ( a serious crime!) when some disarticulated women seem to buzz with glee to hear that girls are exceeding boys in school and at University.
When Tim Hector and I discussed my wrongful and arbitrary dismissal from Holberton Hospital in 1996, the overwhelming and recurrent theme of our discussion was that the wanton practice of exclusion (or else nepotistic inclusion) in Antigua was excessive, unfair and dangerous. We discussed this exclusion practice in the Health Care services in Antigua in general and at the hospital in particular. And this is why I wonder how Tim felt in his dying hours in Holberton. We doctors have to understand that no matter how much we know, patients have a natural and insatiable desire to see doctors working together and consulting each other. Our bodies work that way.
The proper practice of medicine demands much more than the administration of drugs, the application of a knife, the drawing of blood, cleaning an incapacitated patient, or getting paid. For the sake of the Tims to come. Even the night crawlers: drug pushers, addicts, slashing muggers, night soil technicians, and whoring prostitutes know that!
…………………“And where He trod
His footsteps hollowed the valleys out
And bulged the mountains up.”
Farewell dear master and friend.
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