OBAMA: US CAN’T CUT ITSELF OFF FROM WEST AFRICA | October 18, 2014

AFP

WASHINGTON (AP) — President Barack Obama urged Americans on Saturday not to succumb to hysteria about Ebola, even as he warned that addressing the deadly virus would require citizens, government leaders and the media to all pitch in.

In his weekly radio and Internet address, Obama also pushed back against calls for the U.S. to institute a travel ban. Lawmakers have called it a common-sense step to prevent more people with Ebola from entering the U.S., but Obama said such a ban would only hamper aid efforts and screening measures.

“Trying to seal off an entire region of the world – if that were even possible – could actually make the situation worse,” Obama said.

Growing U.S. concern about Ebola and the three cases diagnosed so far in Dallas prompted Obama on Friday to tap a former top White House adviser to be his point person on Ebola. Striking a careful balance, Obama said there’s no “outbreak” or “epidemic” of Ebola in the U.S., but said even one case is too many.

“This is a serious disease, but we can’t give in to hysteria or fear-because that only makes it harder to get people the accurate information they need,” Obama said. “We have to be guided by the science.”

As Obama sought to reassure anxious Americans, U.S. officials were still working to contain the fallout from the Ebola cases identified in the U.S. so far, rushing to cut off potential routes of infection for those who may have come into contact with individuals who contracted Ebola. Obama said he was “absolutely confident” the U.S. could prevent a serious outbreak at home – if it continues to elevate facts over fear.

“Fighting this disease will take time,” Obama said. “Before this is over, we may see more isolated cases here in America. But we know how to wage this fight.”

AP

In a Changing Climate, We Can’t Do Conservation as Usual | October 17, 2014

By Valerie Hickey and Habiba Gitay

At the 12th Conference of the Parties to the Convention on Biological Diversity happening right now in Korea, there has been a lot of talk about adaptation. Most importantly, how can nature help countries and communities adapt to climate change?

Ecosystem-based adaptation (EBA), or using nature’s own defense characteristics to reduce the vulnerability of people and capital, is an essential component of climate-resilient development. EBA isn’t about how we can protect nature. It’s about how nature – through the ecosystem services that constitute EBA, be it flood protection, water provision during droughts, or wave energy attenuation, among other things – can protect people and their capital.

We already know that we can’t eradicate extreme poverty without investing in nature because of the safety net she provides to families in the stubborn pockets of poverty at the rural frontier. Nor can we truly share prosperity with the bottom 40 percent unless we help them reap the benefits of what is often the only capital they have access to – natural capital. And now, climate change has given us another truism: We can’t eradicate extreme poverty or protect the development gains of the bottom 40 percent in the face of climate change, without investing in nature in a different way. And this is the first lesson that we are learning about EBA – it is not conservation as usual.

The success of EBA must be measured in how effectively it has enhanced the resilience of communities and their capital assets. It is about nature helping communities sustain their hard-fought economic gains and climate-proofing future development wins. This is what our investments in EBA through the Pilot Program on Climate Resilience are doing in Samoa and Zambia – we are using EBA to build a protective shell around communities that are vulnerable to coastal erosion, floods, and the loss of scarce freshwater resources. Yes, EBA delivers biodiversity benefits; but first and foremost, it must deliver real and timely benefits for vulnerable people and communities who rely on natural capital.

EBA is not a new idea. In many ways it is the archetype of the triple bottom line in action. A

First and foremost, it provides vulnerable families and communities protection from the vicissitudes and cruelties of a world that is experiencing a rapidly changing climate and a multitude of climate extremes. In a world where most of the poor live in rural areas, and live in dispersed, often remote communities, we know that other types of adaptation measures and infrastructure may never reach them. Islands simply don’t have the resources to ring-fence their entire sovereignty with high concrete sea-walls. Water-stressed countries don’t have the resources to channelize their scarce freshwater resources to support all small-holder agriculture. EBA is a cost-effective way to protect people against climate change, which reduces fiscal pressures on governments while accruing economic and environmental co-benefits.

This is the second lesson of EBA: While hard infrastructure depreciates over time, the benefits of nature-based approaches accrue value. Mangrove forests dampen wave energy, delivering adaptation benefits to coastal and island communities during storms. But over time they also provide nursery grounds for many fish species and critical habitat for marine biodiversity, allowing communities and countries to reap the food security, economic benefits and jobs from improving artisanal and industrial fishing.

But EBA is not a cure-all. While we know a lot about how ecosystems function, we don’t know enough about how they provide ecosystem services, including those that are critical to climate resilient development. Under what conditions will EBA work best? What are the ecological tipping points beyond which ecosystems stop functioning and helping people adapt to climate change? As we learn more about how to optimize EBA, we must embed EBA approaches within broader development strategies. We must employ multi-stakeholder and multi-sectoral approaches at multiple scales across time and space. And most importantly, we must interweave traditional and indigenous knowledge about local ecosystems and how they work into development decisions. This is the third lesson about EBA: Since we don’t know enough about how they work, we must apply them only with the informed and active participation of those communities and countries we are asking to trust in them.

We are investing in EBA, and the delegates at the COP are discussing EBA, because it must be part of our adaptive response to climate change. This is the fourth lesson of EBA: It can and must co-exist with other approaches to adaptation to give countries and communities every opportunity to confront a world that is experiencing climate change. Each approach to adaptation strengthens the other. Greening hard infrastructure will make it last longer and go further. Engineering green infrastructure will make it more effective and help us optimize the delivery of adaptation benefits. In a rapidly changing world where the rural poor are heavily dispersed and countries and communities have limited resources, a full adaptation toolbox that includes EBA is the surest salve to reduce vulnerability and enhance resiliency.

BY VALERIE HICKEY, CO-AUTHORS: HABIBA GITAY

Calculating the Grim Economic Costs of Ebola Outbreak | By ANDREW ROSS SORKIN | OCTOBER 13, 2014

Lagarde, the I.M.F. head, cautioned against scaring the world away from all of Africa. Reuters photo

The topic everyone on Wall Street is discussing urgently but quietly isn’t the volatile stock market.

It is Ebola.

While thousands of health care workers seek to control the deadly virus in West Africa, and the Centers for Disease Control and Prevention and other medical professionals seek to prevent its outbreak in the United States, financial analysts and others have been trying to estimate — or “model,” in Wall Street parlance — the potential effect on the global economy.

The math is not pretty.

The most authoritative model, at the moment, suggests a potential economic drain of as much as $32.6 billion by the end of 2015 if “the epidemic spreads into neighboring countries” beyond Liberia, Guinea and Sierra Leone, according to a recent study by the World Bank.

That estimate is considered a worst-case scenario, but it does not account for any costs beyond the next 18 months, nor does it assume a global pandemic.

Over the weekend, the topic of Ebola was front and center at the annual meeting of the International Monetary Fund and World Bank in Washington, where central bankers, world leaders and some of Wall Street’s senior executives held a series of meetings and dinners.

Christine Lagarde, the managing director of the I.M.F., was seen wearing a button that read: “Isolate Ebola, Not Countries.” She implored the audience: “We should be very careful not to terrify the planet in respect of the whole of Africa.”

That’s because the economic cost of fear, far more than medical costs, may be the most expensive outcome.

“Economic consequences also result when fear and concern change behavior,” David R. Kotok, the chairman and chief investment officer of Cumberland Advisors, wrote in a report late last week, addressing the potential fallout on gross domestic products. “If consumers and businesses retrench by reducing flights on airplanes, changing vacation plans or altering business connections in a globally interdependent world, G.D.P. growth rates will fall farther. We do not know how much, at what speed, or for how long.”

Shares of airline stocks like United and American fell on Monday as some investors began to worry about the prospect of travel bans for airlines from West Africa to Europe and the United States.

Andrew Zarnett, an analyst at Deutsche Bank, wrote a recent report that examined the potential effects of Ebola and compared it to the economic toll of the SARS epidemic, which cost Asian airlines about $6 billion in 2003.

“History has shown us that should the Ebola epidemic spread domestically, it will have a significant impact on the airline and the entire hospitality sector,” he wrote, according to FXStreet, a financial news service.

And nobody has yet fully calculated the numbers on the cost to the health care system: training, testing, treatment, waste disposal — and all the hospital beds that are sitting unused in isolation areas. (Perversely enough, many of the health care costs could conceivably help that industry in the short term because additional money is being spent.)

Of course, the greatest economic danger is in the economic isolation of countries. “By default or design, it really is an economic embargo,” Kaifala Marah, finance minister of Sierra Leone, said over the weekend about his country, which has been all but cut off from the outside world.

The newest estimates about the economic cost of Ebola, conducted by John Panzer and Francisco Ferreira of the World Bank, may be the deepest look at the problem by any analyst or economist. The report notes that in the very short term, assuming that the spread of Ebola is contained, the economic costs should be low, about $359 million.

The study gets more worrying as the authors examine the economic prospects 18 months out.

The authors developed the “Ebola Impact Index.” As one of their advisers, Marcelo Giugale, senior director of the World Bank’s global practice for macroeconomics and fiscal management, wrote of the index: “It roughly tells you how likely countries in Africa, Europe and the U.S. are to be affected by Ebola. They then used some pretty sophisticated statistical tools to model the economic links between West Africa and the rest of the world. And finally, they built two ‘scenarios’ for how governments and people might behave.”

One scenario contemplates containment of the virus with no more than 20,000 cases. That’s the good version. The bad version is this: Governments make a series of mistakes that lead to 200,000 cases of Ebola.

It is that scenario that they estimate would cost $32.6 billion. (This may sound cynical, but that is still lower than one-quarter of Apple’s annual revenue.)

“What makes all this very interesting is that the final economic toll of Ebola will not be driven by the direct costs of the disease itself — expensive drugs, sick employees and busy caregivers. It will be driven by how much those who are not infected trust their governments,” Mr. Giugale wrote.

Wall Street has long built spreadsheets trying to estimate employment, economic growth figures and the values of businesses. But the economic variables of a true pandemic are almost incalculable. It becomes a series of guesstimates about the psychology of global citizens.

Right now, the economic challenges of the outbreak of Ebola are minimal. Let’s hope they remain that way.

The New York Times

It’s not just Ebola. Health care is pretty dangerous work. By Jason Millman | October 14, 2014

Health workers in protective gear. (AP Photo/ Abbas Dulleh)

The Ebola outbreak shows that being on the front lines of disease can be particularly dangerous business for health-care workers. More than 230 workers have died overseas trying to battle the deadly virus, and the infection of a Dallas nurse treating the first U.S. patient diagnosed with Ebola is a reminder that health-care workers put themselves at risk to treat the sick.

When it comes to treating Ebola patients, it’s hard to understate how careful health-care workers must be. As this graphic explains, there’s about 30 distinct steps workers have to take to avoid a risk of infection. After the infection of the Dallas nurse, the CDC is rethinking protocols for care — and that’s after the country’s largest nurse’s union has warned that its members haven’t been adequately trained on Ebola.

Of course, Ebola is a special case, but health-care workers face significant risks on the job. In fact, working in health care is about the unhealthiest profession you could choose.

Health-care and social assistance workers reported 653,900 injury and illness cases in 2010, far more than any other private industry sector, according to the Occupational Safety and Health Administration. That’s significantly more than manufacturing and construction, which used to be much more dangerous industries by comparison. The following chart showing injury and illness rates over a 20-year period indicates that health-care’s modest safety improvements have been far outpaced by other sectors.

So, what makes health care work so dangerous? Here’s OSHA’s explanation:

Healthcare workers face a number of serious safety and health hazards. They include bloodborne pathogens and biological hazards, potential chemical and drug exposures, waste anesthetic gas exposures, respiratory hazards, ergonomic hazards from lifting and repetitive tasks, laser hazards, workplace violence, hazards associated with laboratories, and radioactive material and x-ray hazards. Some of the potential chemical exposures include formaldehyde, used for preservation of specimens for pathology; ethylene oxide, glutaraldehyde, and paracetic acid used for sterilization; and numerous other chemicals used in healthcare laboratories.

Not for the faint of heart, basically. Fortunately, the U.S. health-care industry in the past 20 years has significantly reduced the risk of contracting pretty terrible diseases. Between 2003 and 2011, hospitals reported 37 cases of work-related fatalities from exposure to harmful substances — about 14 percent of all workplace deaths reported for hospitals during that time, according to OSHA. And in 2011, exposure to substances accounted for just about 4 percent of all hospital worker injuries resulting in days off.

There’s also been a huge drop in the reported cases of occupational transmissions of hepatitis B since federal regulators issued guidelines nearly 25 years ago to stem the epidemic of infections among health-care workers. Cases of contracting hepatitis B on the job decreased from 17,000 cases in 1983 to 400 in 1995, and there were only 10 reported cases in 2010, according to a Public Citizen report.

The health-care industry has been even better at preventing HIV transmissions. There’s been just 57 cases of documented transmissions and 143 possible transmissions of HIV to U.S. health-care workers on the job, according to the Centers for Disease Control and Prevention. And it’s been about 15 years since a reported case, though the CDC said it’s possible this could be because of underreporting. Again, the improvements are the result of better federal guidelines for limiting transmission risks on the job, as well as treatments when possible exposures occur.

But a comprehensive 2005 report from the World Health Organization painted a bit of a bleaker picture. The group at the time estimated 35 million people make up the global health workforce, with 2 million incidents each year of workers injured on the job by sharp instruments. Those incidents result in about 66,000 annual transmissions of hepatitis B, 16,000 of hepatitis C and about 1,000 HIV infections among health workers around the world each year, according to WHO estimates.

The Washington Post

Dallas nurse with Ebola gets blood from survivor | BY EMILY SCHMALL AND NOMAAN MERCHANT | OCT. 14, 2014

DALLAS (AP) — A Dallas nurse infected with Ebola while treating the first patient diagnosed in the U.S. has received a plasma transfusion from a doctor who beat the virus.

Nurse Nina Pham was among about 70 staff members at Texas Health Presbyterian Hospital who cared for Thomas Eric Duncan, according to medical records. The 26-year-old nurse was in the Liberian man’s room often, from the day he was placed in intensive care until the day before he died last week.

Pham and other health care workers wore protective gear, including gowns, gloves, masks and face shields — and sometimes full-body suits — when caring for Duncan, but she became the first person to contract the disease within the United States. Duncan died Wednesday.

Health care workers including Pham were told to monitor themselves by taking their temperatures. She went to the hospital Friday night after finding she had a fever.

As Pham was being treated in isolation Tuesday, the World Health Organization projected that West Africa could see up to 10,000 new Ebola cases a week within two months and confirmed the death rate in the current outbreak has risen to 70 percent.

The agency’s assistant director-general, Dr. Bruce Aylward, gave the figures during a news conference in Geneva. Previously, the WHO had estimated the Ebola mortality rate at around 50 percent.

If the world’s response to the crisis isn’t stepped up within 60 days, “a lot more people will die,” Aylward said.

Meanwhile in Berlin, a U.N. medical worker infected with Ebola in Liberia died. The 56-year-old man, whose name has not been released, died overnight of the infection, the St. Georg hospital in Leipzig announced Tuesday.

Members of the Pham family’s church held a special Mass for her in Fort Worth on Monday night. Rev. Jim Khoi, of the Our Lady of Fatima Church, said Pham’s mother told him the nurse had received a transfusion that could save her life.

“Her mom says that she got the blood from the gentleman, a very good guy. I don’t know his name but he’s very devoted and a very good guy from somewhere,” Khoi said.

Jeremy Blume, a spokesman for the nonprofit medical mission group Samaritan’s Purse, confirmed that the plasma donation came from Kent Brantly, the first American to return to the U.S. from Liberia to be treated for Ebola. Brantly received an experimental treatment and fought off the virus, and has donated blood to three others, including Pham.

“He’s a doctor. That’s what he’s there to do. That’s his heart,” Blume said.

Brantly said in a recent speech that he also offered his blood for Duncan, but that their blood types didn’t match.

Khoi said Pham’s mother assured him the nurse was comfortable and “doing well,” and that the two women had been able to talk via Skype. She was in isolation and in stable condition, health officials said. Another unidentified person who had close contact with her has also been isolated as a precaution.

Since Pham tested positive for Ebola, public-health authorities have intensified their monitoring of other hospital workers who cared for Duncan.

Centers for Disease Control and Prevention Director Tom Frieden said he would not be surprised if more fall ill because Ebola patients become more contagious as the disease progresses.

Pham’s name appears frequently throughout the hundreds of pages of medical records provided to The Associated Press by Duncan’s family. They show she was in his room Oct. 7, the day before he died.

Her notes describe nurses going in and out of his room wearing protective gear to treat him and to mop the floor with bleach.

She also notes how she and other nurses ensured Duncan’s “privacy and comfort,” and provided “emotional support.”

Frieden has said a breach of protocol led to the nurse’s infection, but officials are not sure what went wrong. Pham has not been able to point to any specific breach.

Among the things the CDC will investigate is how the workers took off protective gear, because removing it incorrectly can lead to contamination. Investigators will also look at dialysis and intubation — the insertion of a breathing tube in a patient’s airway. Both procedures have the potential to spread the virus.

Members of a Texas task force on Ebola have scheduled their first public hearing for next week. They’ll develop recommendations and a comprehensive state plan to deal with emerging infectious diseases.

Officials said there was a dog in the nurse’s apartment that has been removed to an undisclosed location for monitoring and care. They do not believe the pet shows any signs of Ebola. A dog belonging to an infected Spanish nurse was euthanized, drawing thousands of complaints.

Ebola has killed more than 4,000 people, mostly in the West African countries of Liberia, Sierra Leone and Guinea.

PHOTO: This 2010 photo provided by tcu360.com, the yearbook of Texas Christian University, shows Nina Pham, 26, who became the first person to contract the disease within the United States. Records show that Pham and other health care workers wore protective gear, including gowns, gloves, masks and face shields and sometimes full-body suits when caring for Thomas Eric Duncan. (AP Photo/Courtesy of tcu360.com)

___

Schmall reported from Fort Worth, Texas. Associated Press writers Mike Stobbe in New York, Martha Mendoza and Maud Beelman in Dallas and Tammy Webber in Chicago also contributed to this report.

Nigeria’s global lesson for quashing Ebola | By William Wallis in Lagos | October 14, 2014

Bucking the regional trend & despite hurdles, Nigeria seems to have stopped Ebola spread.

When Liberian development consultant Patrick Sawyer collapsed in the arrivals hall of Lagos airport with the symptoms of Ebola in July, the initial reaction, both inside and outside Nigeria, was close to panic.

The fear was that Nigeria’s rickety, overstretched health service would be unable to contain the deadly virus. In a sign of the strains the system was under, Nigerian doctors were on strike for higher pay when Mr Sawyer entered the country.

Against the odds, however, public health officials say one of the world’s more chaotic nations has provided an object lesson in how to deal with Ebola. It is a lesson that could prove salutary for western governments scrambling to come up with their own response.

For public-health experts, the idea of Ebola gaining a grip in Nigeria – Africa’s most populous nation and largest economy – is a nightmare scenario. There are 170m Nigerians, eight times the combined population of Guinea, Sierra Leone and Liberia, where the disease is raging. The country’s peripatetic elites and prolific traders have connections across the globe.

Yet Nigeria has quashed its outbreak – and is now just a week short of being clear of a live case for 42 days, the period required by the World Health Organisation before it can be officially declared Ebola free.

Dr Simon Mardel, a global specialist in emerging pathogens, describes the effects of the disease as a series of vicious circles. These attack the individual first and then the surrounding society, he says. On both counts Nigeria appears to have broken the cycle.

That outcome, far from assured at the outset, is the result of a rare national effort that saw the Lagos state government, federal institutions, the private sector and global non-governmental organisations all pulling in the same direction to defeat the disease.

Together they have provided hope at a time when public confidence in the state has been knocked by large-scale corruption scandals and the poor performance of the army in combating Islamist insurgents in the country’s north.

“President [Bill] Clinton, when he came here 14 years ago, said that from what he could see there is no problem Nigerians can’t fix if they get together,” says Dr Benjamin Ohiaeri, director at the First Consultants clinic where Sawyer was taken on July 20 and later died.

Like the current case in Texas, Nigeria’s outbreak was the result of a lone traveller entering from Liberia. Dr Ohiaeri’s clinic bore the brunt of the tragedy that subsequently unfolded and it was partly thanks to the courage of his staff in preventing Sawyer from leaving the premises that the disease did not spread further.

Eleven of his staff and their family members contracted Ebola, many in the 48 hours between Sawyer’s admission and the positive result of the laboratory tests. Four of them later died. But Nigeria got its act together quickly after that.

An emergency presidential decree enabled officials to access mobile phone records and empowered them to lean on law-enforcement agencies where necessary to track down people at risk. Thereafter, a strict system to monitor potential cases was put in place by the Lagos state government.

“They were very organised. They put resources into tracking down every contact. In the US the wife [of the first Ebola victim in Texas] was left for five days with contaminated material. Here they disinfected houses immediately,” says Dr Eilish Cleary, a public health expert on contract to WHO who has been debriefing the Nigerian survivors.

Senegal, which borders Guinea, where the current outbreak of Ebola took root, has been even more successful in containing an initial scare to just one case.

In total 20 Nigerians became infected, of whom eight died. Teams of state officials and volunteers tracked down more than 800 people who had primary or secondary contact with the Sawyer case. These included the congregations of two churches in the city of Port Harcourt where an infected man had worshipped, according to Dr Tochi Okwor, who runs the public awareness campaign in Lagos state.

In addition, hundreds of private clinics have been trained in identifying Ebola patients and keeping them away from the community until they are evacuated to isolation wards. A social media campaign set up in the wake of the first case by volunteer technology experts, manning twitter handles, web sites and helplines, complemented these efforts.

In the process, according to Dr Cleary and other top World Health Organisation officials, Nigeria has shown the importance of logistics and public information awareness on top of medical care in containing the disease.

Nigeria was fortunate that Mr Sawyer entered the country through the airport, into the commercial capital and straight to a top private clinic. The country could be far more vulnerable, according to Dr Mardel, if another case arrives by land, and ends up in a remote public hospital.

But if Ebola strikes again, the country will be better prepared. “People are determined that they don’t want Ebola in Nigeria. We could have had much higher casualty figures. But within weeks we would still have got it right,” says Dr Okwor.

Treatment: Rehydration seen as key for patients No one would guess that Dr Ada Igonoh recently emerged from two weeks battling Ebola in an isolation ward in Lagos.

Radiating good health, the doctor, who was infected at her Lagos clinic by Patrick Sawyer, the Liberian who brought Ebola to Nigeria, insists there is no magic formula or miracle cure to thank for her recovery. She credits plenty of water and her own determination to survive for her ability to defeat the deadly virus.

Her experience is consistent with other survivors of the disease in Nigeria – all of whom engaged in an endurance test of rehydration as soon as they were diagnosed, drinking up to five litres of a solution of water combined with rehydration salts each day.

“The disease knocks every system slightly. But when it comes to dehydration it is shocking. It takes you by surprise every time,” says Dr Simon Mardel. “Behind every survivor there is a heroic tale of rehydration.”

Dr Mardel, who has examined more Ebola patients than anyone, believes there are important public health lessons to be learnt from Nigeria’s survivors. He argues the case, in a forthcoming article for the Lancet magazine, that far more attention needs to be given to providing rehydration than is currently practised in the worst affected countries.

This means ensuring that patients are drinking a rehydration solution consistently during the early stages of the disease. Later it becomes much more difficult.

“With Ebola things multiply – they don’t add up,” he says, adding that if you miss a day of water, you have to make up for it the next with twice as much. “Changing this from an epidemic of fear to a disease that is treatable is central to defeating this outbreak,” he says.

The psychology of patients is key. In Nigeria, according to World Health Organisation officials, those victims who believed that only medicine from the west could save them, mostly died. Those who lived, would not have done so without simple H2O combined with salts.

“All of them decided to survive. Because they wanted to survive they forced themselves to take more oral rehydration solution. The mind has huge power over the body. That’s not talked about enough,” says Dr Eilish Cleary, the Ebola expert.

FT

These Maps Show The Drunkest Countries In The World | JENNIFER POLLAND | SEP. 22, 2014

Perhaps surprisingly, Russia is not the drunkest country in the world. That title goes to Belarus, whose residents enjoy just over 2 liters of alcohol more a year than Russians.

Wasted Worldwide, a website that compares drinking habits around the world, created a series of maps that reveal which countries drink the most, what types of alcohol are most popular, and which countries have the most alcohol-related deaths. To create these maps, they used data from the 2014 Global Status Report On Alcohol and Health. 

They’ve allowed us to publish some of their maps below. 

Belarus drinks the most alcohol in the world, with an average consumption of 17.5 liters. Russia comes in second with an average consumption of 15.1 liters. The United States consumes a a relatively reasonable average of 9.2 liters, which is also less than the UK (11..6 liters) and Ireland (11.9 liters).

Unsurprisingly, countries in the Middle East and northern Africa drink the least: People in Libya and Mauritania drink an average 0.1 liters, Saudi Arabia drinks 0.2 liters, and Egypt drinks 0.4 liters.

Men drink the most alcohol in Belarus, consuming an incredibly high average 27.5 liters. Russian men also like their alcohol, drinking an average of 23.9 liters, as do Romanian men, who drink 22.6 liters. American men drink 13.6 liters on average.

Women generally drink less than men, but in some countries they drink a lot. Women in Belarus still drink the most of any country, consuming an average 9.1 liters of alcohol. Moldova comes in right behind at 8.9 liters. Russian and Czech women drink an average 7.8 liters, Portuguese women drink 7.6 liters, and Australian and Ukrainian women drink 7.2 liters.

Surprisingly, beer is the most popular alcoholic drink in Yemen and Bhutan, where it’s the only type of alcohol consumed. It’s also the most popular drink in Vietnam (97.3%), Namibia (96.7%), Indonesia (84.5%), Myanmar (82.6%), and Mexico (75.7%).

Wine is the most popular beverage of choice in Europe by far. In Italy, 65.6% of the alcohol consumed is wine, in France it’s 56.4%, and in Portugal it’s 55.5%. It’s also a popular drink in Uruguay (59.9%) and Argentina (48%)

Haitians love their hard liquor: 99.6% of the alcohol consumed there is spirits. It’s also the most popular form of alcohol in Saudi Arabia (97.9%), North Korea (94.9%), India (93.9%), and Liberia (88.1%).

No Risky Chances: The conversation that matters most | By Atul Gawande

Being Mortal: Medicine and What Matters in the End

I learned about a lot of things in medical school, but mortality wasn’t one of them.

Although I was given a dry, leathery corpse to dissect in anatomy class in my first term, our textbooks contained almost nothing about aging or frailty or dying. The purpose of medical schooling was to teach how to save lives, not how to tend to their demise.

I had never seen anyone die before I became a doctor, and when I did, it came as a shock. I’d seen multiple family members—my wife, my parents, and my children—go through serious, life-threatening illnesses, but medicine had always pulled them through. I knew theoretically that my patients could die, of course, but every actual instance seemed like a violation, as if the rules I thought we were playing by were broken.

Dying and death confront every new doctor and nurse. The first times, some cry. Some shut down. Some hardly notice. When I saw my first deaths, I was too guarded to weep. But I had recurring nightmares in which I’d find my patients’ corpses in my house—even in my bed.

I felt as if I’d failed. But death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things. I knew these truths abstractly, but I didn’t know them concretely—that they could be truths not just for everyone but also for this person right in front of me, for this person I was responsible for.

You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. These days are spent in institutions—nursing homes and intensive-care units—where regimented, anonymous routines cut us off from all the things that matter to us in life.

As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did. Lacking a coherent view of how people might live successfully all the way to the very end, we have allowed our fates to be controlled by medicine, technology, and strangers.

But not all of us have. That takes, however, at least two kinds of courage. The first is the courage to confront the reality of mortality—the courage to seek out the truth of what is to be feared and what is to be hoped when one is seriously ill. Such courage is difficult enough, but even more daunting is the second kind of courage—the courage to act on the truth we find.

A few years ago, I got a late night page: Jewel Douglass, a 72-year-old patient of mine receiving chemotherapy for metastatic ovarian cancer, was back in the hospital, unable to hold food down. For a week, her symptoms had mounted: They started with bloating, became waves of crampy abdominal pain, then nausea and vomiting.

Her oncologist sent her to the hospital. A scan showed that, despite treatment, her ovarian cancer had multiplied, grown, and partly obstructed her intestine. Her abdomen had also filled with fluid. The deposits of tumor had stuffed up her lymphatic system, which serves as a kind of storm drain for the lubricating fluids that the body’s internal linings secrete. When the system is blocked, the fluid has nowhere to go. The belly fills up like a rubber ball until you feel as if you will burst.

But walking into Douglass’ hospital room, I’d never have known she was so sick if I hadn’t seen the scan. “Well, look who’s here!” she said, as if I’d just arrived at a cocktail party. “How are you, doctor?”

“I think I’m supposed to ask you that,” I said.

She smiled brightly and pointed around the room. “This is my husband, Arthur, whom you know, and my son, Brett.” She got me grinning. Here it was, 11 at night, she couldn’t hold down an ounce of water, and she still had her lipstick on, her silver hair was brushed straight, and she was insisting on making introductions.

Her oncologist and I had a menu of options. A range of alternative chemotherapy regimens could be tried to shrink the tumor burden, and I had a few surgical options too. I wouldn’t be able to remove the intestinal blockage, but I might be able to bypass it, I told her. Or I could give her an ileostomy, disconnecting the bowel above the blockage and bringing it through the skin to empty into a bag. I would also put in a couple of drainage catheters—permanent spigots that could be opened to release the fluids from her blocked-up drainage ducts or intestines when necessary. Surgery risked serious complications—wound breakdown, leakage of bowel into her abdomen, infections—but it was the only way she might regain her ability to eat.

I also told her that we did not have to do either chemo or surgery. We could provide medications to control her pain and nausea and arrange for hospice care at home.

This is the moment when I would normally have reviewed the pros and cons. But we are only gradually learning in the medical profession that this is not what we need to do. The options overwhelmed her. They all sounded terrifying. So I stepped back and asked her a few questions I learned from hospice and palliative care physicians, hoping to better help both of us know what to do: What were her biggest fears and concerns? What goals were most important to her? What trade-offs was she willing to make?

Not all can answer such questions, but she did. She said she wanted to be without pain, nausea, or vomiting. She wanted to eat. Most of all, she wanted to get back on her feet. Her biggest fear was that she wouldn’t be able to return home and be with the people she loved.

I asked what sacrifices she was willing to endure now for the possibility of more time later. “Not a lot,” she said. Uppermost in her mind was a wedding that weekend that she was desperate not to miss. “Arthur’s brother is marrying my best friend,” she said. She’d set them up on their first date. The wedding was just two days away. She was supposed to be a bridesmaid. She was willing to do anything to make it, she said.

Suddenly, with just a few simple questions, I had some guidance about her priorities. So we made a plan to see if we could meet them. With a long needle, we tapped a liter of tea-colored fluid from her abdomen, which made her feel at least temporarily better. We gave her medication to control her nausea. We discharged her with instructions to drink nothing thicker than apple juice and to return to see me after the wedding.

She didn’t make it. She came back to the hospital that same night. Just the car ride, with its swaying and bumps, made her vomit, and things only got worse at home.

We agreed that surgery was the best course now and scheduled it for the next day. I would focus on restoring her ability to eat and putting drainage tubes in. Afterward, she could decide if she wanted more chemotherapy or to go on hospice.

She was as clear as I’ve seen anyone be about her goals, but she was still in doubt. The following morning, she canceled the operation. “I’m afraid,” she said. She’d tossed all night, imagining the pain, the tubes, the horrors of possible complications. “I don’t want to take risky chances,” she said.

Her difficulty wasn’t lack of courage to act in the face of risks; it was sorting out how to think about them. Her greatest fear was of suffering, she said. Couldn’t the operation make it worse rather than better?

It could, I said. Surgery offered her the possibility of being able to eat again and a very good likelihood of controlling her nausea, but it carried substantial risk of giving her only pain without improvement or adding new miseries. She had, I estimated, a 75 percent chance that surgery would make her future better, at least for a little while, and a 25 percent chance it’d make it worse.

The brain gives us two ways to evaluate experiences like suffering—how we apprehend such experiences in the moment and how we look at them afterward. People seem to have two different selves—an experiencing self who endures every moment equally and a remembering self who, as the Nobel Prize–winning researcher Daniel Kahneman has shown, gives almost all the weight of judgment afterward to just two points in time: the worst moment of an ordeal and the last moment of it. The remembering self and the experiencing self can come to radically different opinions about the same experience—so which one should we listen to?

This, at bottom, was Jewel Douglass’ torment. Should she heed her remembering self—or, in this case, anticipating self—which was focused on the worst things she might endure? Or should she listen to her experiencing self, which would likely endure a lower average amount of suffering in the days to come if she underwent surgery rather than just going home—and might even get to eat again for a while?

In the end, a person doesn’t view his life as merely the average of its moments—which, after all, is mostly nothing much, plus some sleep. Life is meaningful because it is a story, and a story’s arc is determined by the moments when something happens. Unlike your experiencing self, which is absorbed in the moment, your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. Football fans will let a few flubbed minutes at the end of a game ruin three hours of bliss—because a football game is a story, and in stories, endings matter.

Jewel Douglass didn’t know if she was willing to face the suffering that surgery might inflict and feared being left worse off. “I don’t want to take risky chances,” she said. She didn’t want to take a high-stakes gamble on how her story would end. Suddenly I realized, she was telling me everything I needed to know.

We should go to surgery, I told her, but with the directions she’d just spelled out—to do what I could to enable her to return home to her family while not taking “risky chances.” I’d put in a small laparoscope. I’d look around. And I’d attempt to unblock her intestine only if I saw that I could do it fairly easily. If it looked risky, I’d just put in tubes to drain her backed-up pipes. I’d aim for what might sound like a contradiction in terms: a palliative operation—an operation whose overriding priority was to do only what was likely to make her feel immediately better.

She remained quiet, thinking.

Her daughter took her hand. “We should do this, Mom,” she said.

“OK,” Douglass said. “But no risky chances.”

When she was under anesthesia, I made a half-inch incision above her belly button. I slipped my gloved finger inside to feel for space to insert the fiberoptic scope. But a hard loop of tumor-caked bowel blocked entry. I wasn’t even going to be able to put in a camera.

I had the resident take the knife and extend the incision upward until it was large enough to see in directly and get a hand inside. There were too many tumors to do anything to help her eat again, and now we were risking creating holes we’d never be able to repair. Leakage inside the abdomen would be a calamity. So we stopped.

No risky chances. We shifted focus and put in two long, plastic drainage tubes. One we inserted directly into her stomach to empty the contents backed up there; the other we laid in the open abdominal cavity to empty the fluid outside her gut. Then we closed up, and we were done.

I told her family we hadn’t been able to help her eat again, and when Douglass woke up, I told her too. Her daughter wept. Her husband thanked us for trying. Douglass tried to put a brave face on it. “I was never obsessed with food anyway,” she said.

The tubes relieved her nausea and abdominal pain greatly—“90 percent,” she said. The nurses taught her how to open the gastric tube into a bag when she felt sick and the abdominal tube when her belly felt too tight. We told her she could drink whatever she wanted and even eat soft food for the taste. Three days after surgery, she went home with hospice care to look after her.

Before she left, her oncologist and oncology nurse practitioner saw her. Douglass asked them how long they thought she had. “They both filled up with tears,” she told me. “It was kind of my answer.”

A few days later, she and her family allowed me to stop by her home after work. She answered the door, wearing a robe because of the tubes, for which she apologized. We sat in her living room, and I asked how she was doing.

OK, she said. “I think I have a measure that I’m slip, slip, slipping,” but she had been seeing old friends and relatives all day, and she loved it. She was taking just Tylenol for pain. Narcotics made her drowsy and weak, and that interfered with seeing people.

She said she didn’t like all the contraptions sticking out of her. But the first time she found that just opening a tube could take away her nausea, she said, “I looked at the tube and said, ‘Thank you for being there.’ ”

Mostly, we talked about good memories. She was at peace with God, she said. I left feeling that, at least this once, we had done it right. Douglass’ story was not ending the way she ever envisioned, but it was nonetheless ending with her being able to make the choices that meant the most to her.

Two weeks later, her daughter Susan sent me a note. “Mom died on Friday morning. She drifted quietly to sleep and took her last breath. It was very peaceful. My dad was alone by her side with the rest of us in the living room. This was such a perfect ending and in keeping with the relationship they shared.”

Excerpted from Being Mortal: Medicine and What Matters in the End, by Atul Gawande, published on Tuesday by Macmillan.

Lacking a coherent view of how people might live successfully all the way to the very end, we have allowed our fates to be controlled by medicine, technology, and strangers.
Photo by Julio de la Higuera Rodrigo/Thinkstock

A new challenge | The Gates Foundation’s Grand Challenges in Global Health programme is a decade old. How has it done, and what should it do in the future? | Oct 11th 2014

Reaching out to the world: Mr & Mrs Gates tend to a child on a visit to the Mushar community, India.

TEN years ago the Bill & Melinda Gates Foundation began divvying up the money for what it hoped would be a novel approach to the task of solving the world’s health problems. The new programme’s organisers, led by Mr and Mrs Gates themselves, had identified 14 “grand challenges” in the field—from “preparing vaccines that do not require refrigeration” to “developing a genetic strategy to deplete or incapacitate a disease-transmitting insect population”—and had invited suggestions from the world’s scientists for specific projects of a sort that might not otherwise get funded, which might meet these goals. Not surprisingly, since the foundation had announced a year earlier that it was making $200m available to pay for all this, hundreds of research groups lined up to dip their bread in the gravy.

A bold idea then, perhaps bordering on the naive. And that word was used more than once by Mr Gates, in a tenth-anniversary review meeting of the Grand Challenges in Global Health programme, as it is known, which was held this week in Seattle. He and his fellow board members had hoped their philanthropic version of venture capitalism would lead to breakthroughs in the search for vaccines and other treatments for widespread and destructive diseases such as malaria. A decade—and $1 billion—later, neither the original project nor its offspring, Grand Challenges Explorations (which gives seed money to young researchers rather than relying, as the original did, on established names) has thrown up any of the blockbusters that real venture capitalism requires to counterbalance the numerous, inevitable failures. Undaunted, though, Mr and Mrs Gates used this week’s meeting to announce a new set of challenges, this time spreading the net wider than the strictly science-based suggestions the programme has encouraged until now.

The story so far

Though not as spectacular as its organisers had hoped at the outset, Grand Challenges in Global Health has enjoyed at least modest success. Of the 44 original projects, a fifth are moving towards fruition and another fifth have worked in part. Scott O’Neill of Monash University, in Melbourne, for example, was one of the original challengers. He plans to attack dengue fever not by killing the mosquitoes which transmit it, but by making those insects immune to the virus that causes it. Conveniently, such immunity is conferred by a bacterium called Wolbachia. More conveniently still, this bacterium is sexually transmitted in a way that encourages it to become ubiquitous (it passes from mother to egg, and if an uninfected female mates with an infected male, her eggs will not develop—so the number of infected mosquitoes increases with each generation).

That might wipe dengue out, at least locally. Grand Challenges has therefore invested $44m in Dr O’Neill’s project, and the Wellcome Trust, the Tahija Foundation and the Gillespie Family Foundation, three other charities, have added more. Dr O’Neill and his team have begun field trials in Australia, Brazil, Indonesia and Vietnam, releasing Wolbachia-infected mosquitoes to see if these can establish themselves as theory predicts they should.

Another promising project, led by James Collins of Boston University, is attempting to create a drink laced with bacteria that kill other, cholera-causing bacteria after they have become established in someone’s intestines. Dr Collins’s genetically engineered bugs will produce anti-cholera drugs, and then disintegrate when their work is done. He has started a company, called Synlogic, to develop this idea and to investigate whether it can be extended to other diseases.

Tinkering with gut microbes to treat disease is all the rage now, so Dr Collins could be on to a good thing. But other grand-challenge ideas are more speculative. The “explorations” part of the project is, for instance, backing an astrophysicist who proposes to use lasers to herd malarial mosquitoes away from people, and a car mechanic who is trying to help the health of newborns by adapting a common car-repair tool to assist with difficult births.

One grand-challenges investment in neonatal health that is already paying off is a machine designed to stop the lungs of premature babies collapsing. Such machines have been around in rich countries for a long time but, at $6,000 a pop, the poor cannot afford them. Rebecca Richards-Kortum, a bioengineer at Rice University, in Houston, Texas, has developed a version that costs $400. These have been installed in 17 hospitals in Malawi, the country that has the world’s highest rate of pre-term births. The survival rate for premature infants born in these hospitals has, as a consequence, risen from 24% to 65%.

All of this is good, of course, and may end up justifying the original investment. But it is not quite the stuff of grands projets. The Gateses had been hoping for something more spectacular when the programme started. Hence, perhaps, this week’s change of course.

The new grand challenges are rather different from the existing ones. “All children thriving”, “putting women and girls at the centre of development” and “creating new interventions for global health” sound more like aspirations than proposals for action. Indeed, the third of them embraces 11 of the original grand challenges under a single heading. And this time the foundation is not going it alone. All sorts of partners, from America’s foreign-aid agency to the governments of Brazil, Canada, India and South Africa, are being recruited.

The new challenges are, in part, a response to criticism that the original ones were too technocratic. The Victorians, for example, got rid of cholera not by treating people who developed it, but by developing the political will to build sewers. More generally, public health depends on educating people and persuading them to change their behaviour, as well as on having the right medicines, as the example of HIV and AIDS eloquently shows. That sort of approach requires social change as well as appropriate technology.

Hot fuzz?

Ideas like “all children thriving” and “putting women and girls at the centre of development” do indeed ooze of social sensibility. Children will not thrive by the invention of a new vaccine if mothers are not convinced of that vaccine’s value—and those mothers are less likely to be convinced if they are poorly educated, which is why they need to be at the centre of development. The grand challenges’ change of direction thus makes sense.

And yet, what made the Gates’s original challenges such a refreshing approach was precisely their specificity. The whole bureaucratic apparatus of global health and development, from foreign-aid agencies to charities to the World Health Organisation is signed up to the idea of children thriving and of women and girls being at the centre of development. No right-thinking person believes these to be bad ideas. But they are often fuzzy ideas. If the Gates Foundation can bring to them specific proposals to improve matters, as it has tried to do with disease, then its change of tack may blossom. But if the Grand Challenges programme loses that specificity, and gets buried in the groupthink which pervades the field of international do-goodery, then a valuable alternative approach will, from a scientific viewpoint, have been lost.

via The Economist

Dallas Nurse Tests Positive for Ebola | October 12, 2014

Texas Health Presbyterian Hospital. Photo: Joe Raedle/Getty Images

A Dallas health worker who helped treat the Liberian man who died of Ebola last week has tested positive for the virus, according to state health officials. “We knew a second case could be a reality, and we’ve been preparing for this possibility,” said Dr. David Lakey, the Texas health commissioner. “We are broadening our team in Dallas and working with extreme diligence to prevent further spread.”

The identity of the worker was not disclosed, though CNN confirmed she is a female nurse working at Texas Health Presbyterian Hospital, where Thomas Eric Duncan, the first person to be diagnosed with Ebola in the United States, died last week. The nurse, who is in stable condition, was isolated on Friday night when she reported a low-grade fever.

via The Daily Beast