Saturday, October 25, 2014

Another Example of How Our Friends in America Rewrite Our History to Firm Up Their Own Prejudices

Saturday, October 25, 2014

This article was written by Chimamanda Ngozi Adichie under the title "Problem and Solution 6" and posted on this blog.


Nigeria has been declared Ebola-free.

On October 20, 2014, The Washington Post wrote this:

According to WHO, the success of Nigeria — Africa’s most populous nation — was attributable to ample funding, quick action and assistance from the WHO, the U.S. Centers for Disease Control and the non-profit Doctors Without Borders.”
This is a lie.

Below is a direct quote from the WHO report (in case you are wondering who WHO is: World Health Organization)

“What accounts for this great news?
To a large extent, the answer is straightforward: the country’s strong leadership and effective coordination of the response. The Nigerian response to the outbreak was greatly aided by the rapid utilization of a national public institution (NCDC) and the prompt establishment of an Emergency Operations Centre, supported by the Disease Prevention and Control Cluster within the WHO country office.
Another key asset was the country’s first-rate virology laboratory affiliated with the Lagos University Teaching Hospital. That laboratory was staffed and equipped to quickly and reliably diagnose a case of Ebola virus disease, which ensured that containment measures could begin with the shortest possible delay.
In addition, high-quality contact tracing by experienced epidemiologists expedited the early detection of cases and their rapid movement to an isolation ward, thereby greatly diminishing opportunities for further transmission.”

Also, WHO writes about the investigation into the possible spread of Ebola in Port Harcourt here:

“An investigation undertaken by a team of epidemiologists from the Nigerian Centre for Disease Control (NCDC), the Nigeria Field Epidemiology and Laboratory Training Programme and the State Ministry of Health, assisted by WHO, revealed an alarming number of high-risk and very high-risk exposures for hundreds of people.”

WHO certainly does not dismiss the impact and importance of foreign help (and this being a WHO report, WHO always seems to be in the middle of the action but hey.)

WHO however is clear about this: the success in Nigeria was mostly as a result of NIGERIAN action.

Why then does the Washington Post not credit a single Nigerian body?

This is very poor journalism.

This is the kind of journalism that is not about informing the reader but about making sure that the readers’ real and imagined petty prejudices remain undisturbed.

In the mind of the Washington Post, the American reader thinks that all the problems in the world are solved because of American action. And the American reader expects that Africa is a continent of people who cannot act, who are limp dolls, who have no agency.

And so the American reader has not been informed about this simple truth: it is mostly local Nigerian action that helped contain Ebola in Nigeria.

And while we are at it, here’s the New York Times of October 30 2014, writing about the containment of Ebola in Nigeria:

“The success was in part the result of an emergency command center financed in 2012 by the Bill & Melinda Gates Foundation to fight polio…Also, the C.D.C. had 10 experts in Nigeria working on polio and H.I.V., who had already trained 100 local doctors in epidemiology; 40 of them were immediately reassigned to Ebola and oversaw the contact tracing.”

All well and good. America The Beautiful.

But if you are going to have that level of detail in a newspaper piece, why not start with the most significant details? First Consultants Hospital in Lagos and Dr. Ameyo Adadevoh.

Nigeria is a country that has no history with Ebola. We Nigerians think Ebola happens to other Africans. So in comes a man with symptoms. If he had not gone to a good hospital and if he had not been diagnosed by an excellent and conscientious doctor (who I am assuming had never had to diagnose Ebola in the past) and if the staff of First Consultants Hospital had not resisted the intense political pressure to release the Ebola patient and if hundreds of Nigerians had not volunteered in the Ebola effort and if federal and state governments had not acted quickly and if religious and community leaders had not educated their members, then Nigeria would have ended up with a big Ebola outbreak like Sierra Leone. Even with a thousand American CDC experts.

And if Doctors Without Borders and the American CDC are solely responsible for the success in Nigeria, why have they not succeeded in other countries? Are we to assume that they are not helping our brothers and sisters in Liberia and Guinea and Sierra Leone?

This is not to discredit the wonderful work of so many dedicated foreigners (more on Doctors Without Borders, tomorrow) but the story of Ebola in Nigeria must be told with honesty, and without the small-minded arrogance that comes with power.

If a doctor like Ameyo Adadevoh had been in that Dallas Hospital the first time the Liberian Ebola patient arrived with symptoms, perhaps the United States would not be in the Ebola panic that it is in now.

Sometimes it takes a small, local effort to prevent a catastrophe.

Those small, local efforts must be acknowledged – and encouraged.

Wednesday, October 22, 2014

Reading an ECG

October 22, 2014

This post may be meaningless to you if you are not a doctor.

Reading an ECG was not the most pleasant of tasks during the days of my internship (housemanship). At the time, I considered myself lucky that I somehow managed to avoid the Cardiology Unit during my rotation through Internal Medicine.

With the benefit of the gray hairs I have acquired over the several months that have intervened between September 2010 and now, I have come to appreciate the need for the clinician to be able to read an ECG effectively, systematically, accurately, and in a way that ensures that he doesn't miss anything. That is the inspiration behind what follows hereunder.

Step 1 - Calculate the Heart Rate

You can easily calculate the patient's heart rate by:
  • working out the number of large squares in one R-R interval
  • then dividing 300 by this number (i.e. the number of large squares in one R-R interval)
The answer you get is the patient's heart rate.

In the example illustrated in the graph above, there are four large squares in the R-R interval. The patient's heart rate is therefore calculated as 300/4 = 75bpm.

Step 2 - Determine the Regularity of the Heart Rhythm

Heart rhythm can be either regular or irregular. Again, this can be demonstrated by looking at the R-R interval.

The heart rhythm is classed as irregular if the R-R interval is inconsistent.

Note that an irregular rhythm with no distinct P-waves suggests atrial fibrillation.

Step 3 - Characterize the Cardiac Axis

The cardiac axis describes the overall direction of electrical spread within the heart. In a healthy individual, the axis should spread from 11 o'clock to 5 o'clock.

To figure out the cardiac axis, you need to look at leads I, II, and III.

Normal Cardiac Axis

In a normal cardiac axis, lead II has the most positive deflection compared to leads I and III.

Right Axis Deviation

In right axis deviation, lead III has the most positive deflection and lead I should be in negative territory. This is commonly seen in individuals with right ventricular hypertrophy.

Left Axis Deviation

In left axis deviation, Lead I has the most positive deflection, and leads II and III are negative. This is commonly seen in patients with heart conduction defects.

Step 4 - Look at the P-Waves

When looking at the P-waves, try to answer the following questions:
  • Are P-waves present?
  • Do they occur regularly?
  • Does a P-wave precede each QRS complex? (in other words, is there sinus rhythm?)
  • Do the P-waves look normal? (Meaning: are they smooth, rounded, upright?)
Note that if P-waves are absent and there is irregular rhythm, this may suggest atrial fibrillation.

Step 5 - Assess the PR Interval

The P-R interval should be between 0.12 - 0.20second (Each small square corresponds to 0.04second. The P-R interval should therefore be between 3-5 small squares), although it may be longer in elderly people.

The interval shortens with increased heart rate such as may occur following moderate to severe physical exertion.
Prolonged P-R interval

A prolonged P-R interval may suggest the presence of heart block, whereas a shortened P-R interval suggests that the patient may have Wolff-Parkinson-White syndrome WPW.

Step 6 - Assess the QRS Complex

The QRS complex should be 0.08-0.12second (2-3 small squares).

Step 7 - Assess the S-T Segment

The S-T segment is that part of the ECG between the end of the S-wave and the start of the T-wave; in healthy individuals, it is usually an isoelectric line (with no elevation or depression). Abnormalities of the ST segment should raise the red flag for investigation so as to rule out any pathology.

S-T elevation is significant when it is > 1mm (> 1 small square) in relation to the baseline. S-T elevation is commonly seen in acute myocardial infarction. The morphology of the elevation differs however depending on how long ago the myocardial infarction occurred.

S-T depression is significant when it is > 1mm (> 1 small square) in relation to the baseline. Because S-T depression lacks specificity, its detection does not give one leave to jump to any diagnostic conclusions. A few of the many different conditions that can produce S-T depression are:
  • anxiety
  • tachycardia
  • digoxin toxicity
  • hemorrhage, hypokalemia, myocarditis
  • coronary artery insufficiency
  • myocardial ischemia

A look at the rather small list above and a consideration of the many different ways in which their modes of management vary, one from another, is enough to convince the reader that an ECG finding of S-T depression has to be interpreted within the context of the health circumstances of the particular patient undergoing review.

Step 8 - Consider the T-Waves

Are the T-Waves Inverted?

Among the most common abnormalities found on the ECG is the inverted T-wave. This happens because T-waves can be altered by many different processes. As a result, the finding of an inverted T-wave is a non-specific finding and is not normally used as a standalone factor in the clinching of a diagnosis. Besides, if the inverted T-waves are seen in V1 and V2, then they are not significant because V1 and V2 inverted T-waves are seen in normal individuals.

Some of the causes of inverted T-waves are:
  • smoking
  • anxiety
  • tachycardia, hemorrhage, and shock
  • hypokalemia
  • pericarditis
  • myocardial ischemia (acute and previous)
  • bundle branch block
  • Wolff-Parkinson-White sydrome

Are the T-waves Tall (and Tented)?

A T-wave is considered as tall when it is:
  • 5mm in the standard leads
  • 10mm in the precordial leads
Tall T-waves are caused by:
  • hyperkalemia
    • in hyperkalemia, the T-waves are described as tall, tented T-waves; this is because, in addition to being tall, they are also very narrow, with a sharp apex.
  • myocardial ischemia
    • the tall T-waves of (hyperacute) myocardial ischemia are not as narrow as those that are seen in hyperkalemia.

If the clinician can accurately interpret the information presented on the patient's ECG according to the guidelines above, he can be sure that he has captured a large part of the important information displayed on that tracing.

The above information has been compiled using material sourced from here and here.

Sunday, October 19, 2014

Ebola: The Nigerian Success Story

October 19, 2014
Schoolchildren in Nigeria wash their hands as they learn about Ebola prevention

A nightmare scenario of Ebola raging unchecked among millions of slum-dwellers in Africa's largest city has given way to a rare example of a victory over the virus.

Amid the gloom surrounding the escalating crisis in West Africa, developments in Lagos show how the right techniques at the right speed can bring about a welcome result.

With a population of more than 170 million, Nigeria is Africa's most populous nation and there were fears that Ebola would take hold when a Liberian-American arrived with the disease in July.

Instead, along with much smaller Senegal, Nigeria is now on the brink of being clear of the virus for a 42-day period at which point the World Health Organization (WHO) can declare it Ebola-free.

The outcome could so easily have been far uglier, and the fact that the news is happier is due to an astonishing story of medical detective work.

Textbook Case

Patrick Sawyer, seen here with his daughter, became the first person to die of Ebola in Nigeria

The starting-point was the arrival of Patrick Sawyer at Lagos airport where he collapsed and was suspected of suffering from malaria.

Taken to a private clinic, tests were carried out and during the wait for the results several staff became infected.

By the time confirmation of Ebola came through, the infections had spread to 11 of the staff - four of whom later died. This was the point where things could have gone catastrophically wrong.

An official response did not get off to a fast start but by good fortune a team of experts working to tackle polio was in place and ready to be redirected.

What followed was a text-book case of one of the guiding principles of disease control: identifying and tracking down everyone who might possibly have been in contact with the patient.

It began with the medical staff and their families and then extended to take in increasingly large numbers.

An initial contact list of 281 people soon increased to a staggering 894 - each of them visited and checked repeatedly for signs of infection.

26,000 homes

Nigeria was quick to check the temperature of new arrivals: fever is one of the first symptoms

But the sleuthing did not end there. Specialists then calculated how many people were living within a particular radius of the 894 people who were being monitored. This depended on the density of the housing in each particular area.

The result was that officials and volunteers embarked on rounds of visits that would take them to an extraordinary 26,000 households.

A key policy throughout this arduous process was to involve the communities and to encourage people to be as honest as possible about their movements and contacts. It obviously worked.

In all, there have been 19 confirmed cases of infection in Nigeria and eight deaths, including Patrick Sawyer - figures that are tragic for the families involved but infinitely smaller than they might have been.

In an ideal world, the same approach of careful record-keeping and diligent footwork would now be applied to the battered countries of Guinea, Liberia and Sierra Leone - but that is not very likely.

Nigeria, though notorious for its corruption and inefficiency, evidently has a bureaucracy that functions effectively enough for the strategy to counter Ebola to succeed - unlike the three hardest-hit countries which were suffering from extreme poverty and the aftermath of conflict even before the virus struck.

Burning Embers

Despite the best efforts of health workers, stopping Ebola across West Africa will be immensely difficult

There is one more note of caution in this tale: making sure the storm has really passed.

The director of the US Centers for Disease Control and Prevention, Dr Tom Frieden has warned that Ebola is like fighting a forest fire - "leave one burning ember, one case undetected, and the epidemic could re-ignite."

As an example, he described how at one stage it had been thought that every case in Nigeria had been identified, when it turned out that one had been missed, resulting in a new cluster of cases in Port Harcourt.

That incident has now passed and the country remains on course to complete the required 42 days to be clear.

But with the WHO judging that as many as 15 African countries are at risk, these remain anxious times.

And a new concern is emerging among specialists: that the scale of the outbreak is now so large and so spread over so many areas, that following Nigeria's example of tracking down literally every case may never be possible, which means the disease may linger, sometimes unseen, sometimes not, for decades to come.

Tuesday, October 7, 2014

Dearth of doctors drags on China private healthcare drive

October 07, 2014

As China tries to privatize an overburdened public healthcare system, private hospitals face a shortage ... of doctors.
The bottleneck – the result of resistance from both public hospitals and doctors themselves – could dent a drive to reform China's hospital sector, just as investors flock to a healthcare delivery market that's set to more than double to $600 billion by the end of the decade, according to consultancy Bain & Co.
Part of the problem is that doctors across most of China need permission from the state-owned hospitals where they practice before they can also work in the private sector. And many public hospitals don't want to let their best doctors go.
"Some government-owned hospitals are hampering doctors somewhat from going outside," said Charles Elcan, president of Chinaco Healthcare Corp (CHC), whose 500-bed hospital in the eastern city of Cixi admitted its first patient in July. "Some are very much open and support it, and some of them don't," added Elcan. "It's an ongoing challenge."
The Cixi hospital, a joint venture with local government, is operating at just a fifth of its capacity for in-patients, and is looking to recruit more doctors. CHC has invested close to 1 billion yuan ($163 million) in the project and is eyeing other hospitals for acquisition and development.
Privatization is a key plank in China's push to revamp an unpopular national healthcare system, blighted by crowded hospitals, corruption and simmering tension between patients and staff. China wants to raise the number of private hospital beds to a fifth of the total by next year.
The reforms have attracted local and overseas investors looking to take a slice of China's healthcare bill. McKinsey & Co expects total healthcare spending, including drugs and medical devices, to hit $1 trillion by 2020.
Late last month, private equity group Trustbridge Partners broke ground on a $500 million general hospital in Shanghai. German hospital operator Artemed Group, Chinese drugmaker Fosun Pharmaceutical (600196.SS), investment firm TPG Capital [TPG.UL] and property developers China Vanke (000002.SZ) and Evergrande (3333.HK) are also investing in Chinese hospitals.

Despite widespread dissatisfaction with public hospitals, a challenge for private institutions - even those boasting world-class equipment and sparkling decor - is that some Chinese patients are still dubious about the quality and affordability of private care.
"Private hospitals are expensive and you often can't claim for reimbursement from national insurance. Plus, I trust the level of medical care at public hospitals more," says Cai Jiejing, a 27-year-old researcher in Shanghai.
As a result, while almost half of China's 24,700 hospitals are private, most healthcare is still delivered by public institutions, with some 84 percent of in-patients coming through public facilities, according to a Deutsche Bank report in June.
State hospitals depend on drug sales and tests for their revenues, making hospitals fertile ground for bribes from pharmaceutical companies, unnecessary drug prescriptions and excessive testing. Patients start queuing outside top hospitals before dawn, only to get as little as 2-3 minutes with a doctor.

Beijing wants to open the sector as China's burgeoning middle class, aging society and environmental pollution fuel demand for more and better healthcare.
Currently, patients flock to the top hospitals for care because of the perceived poor quality of local primary care institutions, putting enormous pressure on big city hospitals.
Over the last five years, Beijing has expanded national health insurance coverage, encouraged greater private investment in the sector, and sought to control drug costs. It has also raised the threshold for foreign ownership of hospitals. In August, it loosened rules to allow foreign investors to wholly own hospitals in seven cities and provinces.
Beijing views relaxing rules on private investment in the sector both as a way to offer more options for patients and as a fillip for the reform of public hospitals, said Ellon Xu, Shanghai-based principal at consultancy Bain.
However, at a local level, public hospital leaders are often reluctant to even share their best doctors, let alone see them leave. Private rivals have to pay a premium to bring in star names, lure doctors from abroad or opt for younger doctors seeking a career boost. Only in August did Beijing become the first municipality to let doctors work in more than one place without permission from their boss.
Part of the problem, doctors say, is that public hospitals are shortstaffed.
China has 1.4 physicians per 1,000 people, compared to 2.4 in the United States and 2.8 in the UK, according to the World Health Organization. The number of doctors per 1,000 patients fell 26 percent in public hospitals and 16 percent in private hospitals between 2008 and 2012, according to Deutsche Bank.
While health authorities acknowledge a shortage, their focus is on getting more doctors for rural areas. The National Health and Family Planning Commission set targets in 2011 for increasing the numbers and quality of primary care physicians in these areas by 2020, in part through improvements in education.
However, the difficulties in attracting Chinese doctors to the private sector go beyond government policy.
Zhu Yan, who left a good job at the prestigious Peking Union Medical College Hospital to start his own clinic in the southern city of Shenzhen, ticked off a list of issues that prevent more doctors from working in private hospitals: Chinese doctors prefer the security and prestige of state hospitals; private hospitals want to hire older, more experienced doctors, but it's mostly younger doctors who are motivated to leave; public hospitals haven't figured how they would pay physicians who divide their time between private and public sectors; and public hospitals are already at full capacity, and don't want to risk losing any doctors.

The Trustbridge-invested hospital, known as Shanghai Jiahui International Hospital and due to be completed in 2017, aims to bring Chinese doctors from North America and use U.S. management techniques to help reward and retain staff, said Gilbert Mudge, president of Boston-based hospital group Partners HealthCare International, which is a consultant to Jiahui.
While there are examples of successful private hospitals in China, reputation and prestige, a key draw for patients, take years to build and depend on the quality of doctors. That puts new private hospitals at a disadvantage - at least initially.
Investors often see the business opportunity in hospitals without understanding how challenging they are to run well, Mudge said.
"Anyone who came in a private sector mode and thought, well, I'm a land developer, I can run a hospital, I can build a hospital and run it - I think they're underestimating the complexity of healthcare."

Wednesday, October 1, 2014

Internet Data Plans - Prices, Data Volumes/Validity (HowToSubscribeComingSoon)

September 30, 2014.

A few times, I have had friends ask me what network I think they should turn to for their data services. 

I intend over the next few weeks to provide tables that will help these and other people make informed choices about their internet service providers.

The table(s) below has/have been constructed using information gleaned from the websites of the four major Nigerian mobile network providers, Airtel Nigeria, Etisalat Nigeria, Globacom Nigeria, and MTN Nigeria. This is meant to help you streamline your thought processes as you decide on a data network. However, you are encouraged to consult the Customer Care section of these networks for clarification before subscribing to any data plan.

4MB/24 HRS
10MB/24 HRS
10MB/24 HRS
20MB/24 HRS
10MB/24 HRS
80MB/14 DAYS
150MB/24 HRS
150MB/7 DAYS
195MB/24 HRS
150MB/24 HRS
125MB/30 DAYS
260MB/30 DAYS
100MB/30 DAYS
200MB/30 DAYS
350MB/30 DAYS
100MB/30 DAYS
325MB/30 DAYS
250MB/30 DAYS
20 HRS
650MB/30 DAYS
500MB/30 DAYS
800MB/30 DAYS
500MB/30 DAYS
3GB/30 DAYS [9PM – 6AM]
1.3GB/30 DAYS
1.5GB/30 DAYS
4.5GB/30 DAYS
1.5GB/30 DAYS
3.9GB/30 DAYS
4GB/30 DAYS [8PM-9AM + all day during the weekend]
100 HRS
4GB/30 DAYS OR 100 HRS
4GB/30 DAYS [8AM-9PM]
3GB/30 DAYS [9AM – 9PM]
6.6GB/30 DAYS
10GB/30 DAYS
11GB/30 DAYS
15GB/30 DAYS
17GB/30 DAYS
12GB/3 MTHS OR 300 HRS
300 HRS
20GB/30 DAYS
21GB/30 DAYS
19.9GB/30 DAYS