Alison Sinclair

The British Medical Journal’s September 27th issue is dedicated to the theme of communicating risk, exploring the challenges of combining patient-empowerment with evidence-based medicine when the doctors themselves struggle to make sense of the numbers. As one of the writers asks, “Can you explain why a test with 95% sensitivity [ie ability to detect disease in someone who has the disease] might identify only 1% of affected people in the general population?” before offering a pictoral explanation of the measures used to interpret the meaning of a positive or negative test. In another interesting article, the relationship between risk and public perception of risk is explored, with a slant on it – the risk perception is not to oneself, but to children, and the examples used are those of vaccination, BSE (this is a UK publication, after all), and road accidents. Not surprisingly, controversy influences perception of risk. A doctor turned medical journalist describes his own struggles against the journalistic cultural urge not to let detail stand in the way of a good story. And the Internet receives the usual wistful mixed review.

Here is another bio I stumbled over while looking for something else – I can no longer remember what. Rena Marwick was a GP from Orkney, who was landed in Normandy in 1944 to work in military hospitals and then went on with the Allies when they liberated Belsen.

I take the last sentence back. This last week I decided to give up on the weblog, having decided that it wasn’t my preferred form, and that all I was doing was contributing to what David Sheck called “data smog”. Then I had a noxious item of spam forwarded to me that disproved the assertion in my last statement of my last entry. It was from an individual claiming to be a Dr of alternative medicine, advancing a conspiracy theory about the origin of SARS (that it is intended as a population reduction measure) and that there is a big coverup going on, that the media and public health were involved in scaremongering. No sources referenced, needless to say, and in tone and strategy fitting the very case-definition of quackery. NB: personal opinion is that alternative medicine is not quackery; in a broad sense the wise application of the principles underlying alternative medicine will carry us further beyond absence-of-disease than conventional medicine, but certain of its practitioners are, not to put too fine a point on it, a menace.

So, here I go, with my own preferred SARS links:

• World Health Organization site, offers daily updates and the occasional summary (see April 11 update) where the tone is sober and the perspective global. The SARS outbreak shares space with reports of Ebola, drought and the looting of hospitals in Iraq.
• The Canadian Medical Association Journal based in Ottawa (3-4 hours on the ground from Toronto), has a SARS update page with the latest consensus advice for physicians and patients, public contact numbers, and news items, and in addition is starting to produce preprint copies of articles and commentaries around the outbreak – describing the experience of patients, health care workers and families in one of the affected hospitals and describing the use of the web and the internet in enabling collaboration.
• The Globe and Mail has an annoying tendency to qualify the word ‘virus’ with the word ‘deadly’ – one might call it a ‘reflex’ or perhaps a ‘knee jerk reflex’ – and they have the automatic newspaper skew that the new and disturbing developments and concerns get reported but the boring old follow-up and implementation of counter-measures don’t. But I’m still with them.

• Sarswatch is a weblog dedicated to detailed, considered reporting of SARS.

I was narked to read in my local paper at the beginning of this week a quote from a local public health spokesman to the effect that ‘we are in the midst of a major epidemic and Ontario has lost control’ … followed by the usual mealymouthed exhortations against excessive concern. At medical school our instructors drummed into us that we have to watch our language. To the specialist ‘epidemic’ means essentially that we’re seeing a rise above background levels of a disease. To the layperson, ‘epidemic’ means ‘we’re all going to die!’ And as for Ontario losing control, not at that point. There was no evidence that it had got out into the community, that there are any chains of transmission that did involve contact with SARS patients in hospital – whose disease in turn could be traced to Asia. Whether that will change, with an eighth person dying of SARS in Toronto yesterday, and ongoing emergence of new cases and suspect contacts, remains to be seen.

An article by Jan Wong in the Globe and Mail Saturday summarized the information that has belatedly emerged from China about the initial spread of the disease. She attributes the release of the information to the WHO having issued a travel-advisory, thus bringing the problem to the attention of the travel and tourism industry. Up until then the official position of the Chinese government was ‘no problem, everything’s fine’ …

The Canadian Medical Journal and the New England Journal of Medicine both have pages dedicated to SARS, monitoring the outbreak and its response. The NEJM has an ongoing plot of cases and deaths, and an early release of an editorial by Julie Louise Gerberding from the CDC that describes the impressive international collaboration and Internet-wide information sharing involved in identifying and containing the outbreak – and also wonders whether the fast response will be fast enough. At this stage, we don’t know. But at least with SARS all the ingenuity and all the heroes are on the same side.

This, in the BMJ was a shocker. One in sixteen women in Africa die from complications of pregnancy and childbirth. Compared to one in 4 600 in the United Kingdom (which still puts it above a whole bunch of other causes of death that are talked about more). Which means that, taking the UN projection of 819 million for 2000 (which I gather is now considered high, because of AIDS), assuming about half of them are women, still works out to 25 million women by my reckoning. 25 million women.

This, from The Lancet only evoked a sigh of requited pessimism. The Bush administration’s anti-abortion policies may well result in strings being attached to AIDS prevention funding in developing countries that may decrease its accessibility by the very people who need it most. As Marge Piercy puts in in her poem on the Iraq situation “we dote on embryos … but people, who needs them?” It’s not her best poem, too declarative, but contains one striking internal rhyme. I am rereading a fourth or fifth hand (found in a charity store for 50c) copy of her novel Vida, a portrait of an American radical activist after years living underground, wanted for bombings and acts of sabotage against institutions and corporations, a frank and sympathetic portrait of her life, politics, relationships and times; I wonder if it would be published today? For a country that takes freedom speech as a near-religious tenet, America seems oddly unable to find undamaging forms of settling its internal strife. Freedom of speech seems to be freedom to be abusive. Never more evident in the arguments over Iraq.