Square One

I couldn’t help posting this ballad by Richard Lehman from this weeks edition of his incisive summary of the “big five” general medical journals in BMJ’s doc2doc blogs:

A Ballad for Obama

When Massachusetts blew it
We bit our lips and hid,
We said he couldn’t do it,
But then he went and did.

The lobby men seemed cosy
On profits from the sick,
But out strode Dame Pelosi
And gave her troops some stick:

At sight of such a muster
Republicans turned white:
They dropped their filibuster
And lost the will to fight.

All hail, Barack and Nancy!
The world shares your delight:
Americans may fancy
Health is now theirs by right.

I thought I’d have you listen in on this IM conversation I had with a friend from medical school, Simon Adebola, about science, science illiteracy and biomedical science in Nigeria/Africa. Simon blogs at iInitiative.

Simon Adebola: So tell me, what is new in the nebulous world of cells transmitters and neurobiology?

Seye Abimbola: Nebulous world?

Simon Adebola: Just teasing. But wait, let’s see how well you can guard your territory. Imagine I thought it was nebulous and even went a bit further to say that science could be tricky and the analysis dodgy.

Seye Abimbola: …and you’d be perfectly right. That is indeed the true nature of science and the bravado and hubris of science in its more modern history is a loss and the way science has fed public imagination with promises of its powers is also unfortunate… That said, it is still the only way we know by which we can grasp the mysteries of  the natural world, hence the need for constant doubt and skepticism, from the makers and the consumers of science alike.

Simon Adebola: Wait a minute, you remind me of this Oxford Prof Jerome Ravetz. He wrote on post normal science, citing much of what you just stated above. It could be that much of what we call hard facts, especially in modern science is not as factual as we tend to want to make our journal editors, peers and larger public believe.

Seye Abimbola: Journal editors and peers are often conniving partners in the business… and unfortunately, the scientifically illiterate public and newspaper editors just take it in, and spread it… and it backfires some times, with the recent example of Climate Science. Climate science had an agenda and I am suspicious of any science with an agenda and unfortunately that is what much of science is today.

Simon Adebola: Well, all writing, I was taught, has an agenda, and that virtually spoilt films and entertainment for me because I then acquired a magnifying lens and sometimes it descends much lowers to an agenda for money. Science like religion has proven not to sit comfortably with the kind of scrutiny it has gotten. They both would rather prefer to be seen as being infallible and yet no enterprise with humans at the helm should be seen as such

Seye Abimbola: It is troubling how money and agenda drives a lot of research, including medical research and how unfortunately no one beyond the club is even able to really scrutinize. When I was at the BMJ (British Medical Journal) I had a different impression of how science worked. There was the image of science in its most perfect, ideal sense, and although it showed that there was a lot of crap science and studies going on, it didn’t quite ring home that it was a given in “the holy of holies of intellectual objectivity” (Wole Soyinka).

Simon Adebola: Being a strong believer in objectivity and experimentation (I find it truly fascinating) I wonder what the scientific community can do to regain its credibility.

Seye Abimbola: I don’t think it will happen unless we redefine our index of academic credit and the way science is funded – number of papers in peer reviewed journals is a bad idea and funding according to result – often number of papers or positive result – is killing science. It forces scientists to want to say something, when there isn’t anything to say, creates publication bias, unnecessary data analysis et cetera.

Simon Adebola: Sometimes it is like the case of a serially abused individual. Concurrently ignored and used by those they hoped would care about them – politicians and to a lesser extent industry. Over at Cuba (Forum 2009, Global Forum for Health Research) there was this palpable inferiority complex in the research community, a complex not devoid of pride, seemingly crying to be heard by policy makers. As they say in Yoruba, it is a thief who knows how to trace the footprints of another thief on a rock. Once the politicians/policy people see through the credibility flaws, they just would rather use, rather than trust the research community. What would you recommend to improve the assimilation of science into policy?

Seye Abimbola: There’s a lot that is wrong about how science is presently done and how it feeds into policy. I’ve been thinking a lot about policy these days…Ultimately what we need to do is improve scientific literacy. I wouldn’t mind suggesting a model that has scientists, not necessarily practicing, as policy makers in science/medicine…

Simon Adebola: …building a bridge sort of.

Seye Abimbola: Yes, because it’s so easy for scientists to stand on the other end of the divide and send in dumbed down, over-edited, information that lack the nuances, and the element of doubt that comes with science…I’m not happy about the example of Al Gore who has been the most public face for climate change for a long time…It would be a different scenario entirely if he is re-echoing what scientists in the field are saying to the public. However, scientists in the field are the ones trying to re-echo what he is saying by making their data agree.

Simon Adebola: No one is comfortable with the ‘everything is caused by climate change’ line. It gets rancid after a while, with science making the claim on both sides. Ten years ago, science predicted that due to climate change some parts of the world experience drops in snow, for example I heard they said British children would not know what snow was. Now science is proving to us that due to climate change, there would be fiercer snow storms. That breeds the reaction you get when you discover the movie you are watching does not have a plot you want to turn it off, but again you want to see if its plotlessness, is the ingenuity of the director in display, so you hang on watching, hoping it would eventually make sense, somehow.

Seye Abimbola: Again, this is because scientists are not committed to saying the truth the way it is…

Simon Adebola: …and that is the context in which post normal science explores its stance. “Post-Normal Science is a concept developed by Silvio Funtowicz and Jerome Ravetz, attempting to characterise a methodology of inquiry that is appropriate for cases where “facts are uncertain, values in dispute, stakes high and decisions urgent”. It is primarily seen in the context of the debate over global warming and other similar, long-term issues where we possess less information than we would like.” (Wikipedia)

Seye Abimbola: …and again it boils down to scientists feeling a need for that sort of misplaced recognition…

Simon Adebola: …true, opening them up to near destructive abuse. I guess each side just has to make peace with its roles. Oxford would never be Hollywood, or Washington DC, or the Super bowl. Hollywood with its fortune, sports with its fame, and Washington with its power wielding capabilities. The strength of science like you have said would continue to lie in its innovativeness and simplicity once other interests start driving it, that inferiority complex bites in, and self destruction could result. For now we observe the movie, hoping there is a plot. Those profiting off this, increase the hype, the noise, silence the naysayers and hope to bank as much as they can, such that win or lose, at least they have made enough to reward their efforts.

Seye Abimbola: I’m wondering what is there for science in Nigeria… There’s a lot that never happened, despite enormous early promise in Nigeria.

Simon Adebola: There is hope. New minds, fresh minds, need to be trained. We need a reorientation. Science as you know has flourished even when repressed. Galileo, Einstein. It is the commitment that we should hope does not dwindle. The value is in service that would drive a pursuit of excellence, creativity, and better ways of doing things…

Seye Abimbola: In medicine, if we look back to the days of Osuntokun et cetera, they somehow did not, and I suspect due to a lot happening on the political front in Nigeria, manage to build that critical mass that could help sustain scientific productivity. Those guys did and published a lot of great work, good, world class studies and it just didn’t trickle down the generations…and I’m wondering, what can we do? How do we ensure that fresh minds are trained?

Simon Adebola: I hope there can be mega research institutes that will represent a focus on excellent research, openness to innovation, and economically sustainable models where research and innovation lead to productivity and development. I also think scholarships and studentships focused on solving the actual needs in the continent are a crucial need – these should come first. It is just that the selfishness can be acute and sometimes crippling, but we can’t deny the need to keep building capacity.

Seye Abimbola: We are presently finishing up the Build AfReCa! (African Research Capacity) paper for the journal Science. Build AfReCa! Is a very young network of young scientists, mostly Africans in the Diaspora, mostly students trying to work towards improving research capacity in Africa…

Simon Adebola: We need more and more of that, aggressively driving knowledge growth.

Seye Abimbola: We put out a survey in the last quarter of last year to assess the needs of young scientists from Africa and why they might not work in Africa and what might make them want to work in Africa, and their general geographical spread. At this stage, it’s essentially advocacy, creating a voice, an image, some advocacy for the need for funding, coordinated funding for young scientists in sub-Saharan Africa, funded to do great work on the ground in Africa.

Simon Adebola: I think that is crucial and greater seriousness with African journals. We need the equivalent of The Lancet, BMJ and NEJM (New England Journal of Medicine) on the continent…In fact one could talk to some of these journals to help grow stronger journals with greater visibility on the continent.

Seye Abimbola: We will need to work with the model like PLoS (Public Library of Science). It would be nice to have a PLoS Africa…. PLoS is absolutely open access, and online with a good Impact Factor…The tricky bit is that it will be online, but again, internet access in Africa is getting better by the day…so, that can be done.

Simon Adebola: …and daily digests can be sent by email or even SMS gateways alerting of papers of interest…

Seye Abimbola: …the first place to go when looking for good studies from Africa.

Simon Adebola: I am sure we can get funding for that…The Library is online, you register and select your interest. Each time a paper of interest to you appears, based on your selection, you get an SMS with basic info on the paper.

Seye Abimbola: The journal will need an editorial team, a peer reviewer bank, et cereta.

Simon Adebola: This is the kind of aid they should be interested in giving Africa, not more money for corrupt leaders…

Seye Abimbola: Good. Maybe we should put a proposal together…

Simon Adebola: I think we should…once we have the back end defined well, and teams in place… and even though it costs, we can start with donor funding and once we have a critical base of users, we can work on different models to make it work. This would make research awareness go up greatly…

Seye Abimbola:  Thanks. It’s been a great conversation, and I’m tempted to blog excerpts from the conversation on NT.org (Nigerians Talking Science – An IM Conversation).

Simon Adebola: Thanks. Please feel free to do that. It’s been a huge pleasure on my part.

It is itself a surprise to me that we are responding to the issue of the alleged Nigerian suicide bomber/terrorist as if it was totally unpredictable. We want to condemn it, we are disappointed by what Umar is alleged to have done and the added shame and disrepute that has brought upon Nigeria, but it would be wrong to suggest that there are no fundamentalist strains in Nigeria. They abound.

The recent Boko Haram incident, and the way muslims in Northern Nigeria reacted to the 2005 Danish cartoons of Prophet Mohammed (PBUH) by setting churches on fire suggest that we must have been breeding this kind of people, and we are probably more capable of breeding them with possibly little outside influence than we presently imagine.

A series of troubling but interesting events happened in close succession, within the space of two years, when I was a student at Obafemi Awolowo University, (OAU) Ile-Ife. For those who are not very familiar with Nigeria, OAU is arguably the most Yoruba and also possibly the most politically active and intellectually progressive of Nigerian universities.

Obafemi Awolowo Hall (popularly called Awo Hall) is well known as the most politically active, hilarious, fun loving and liberal residential hall within the university. Awo Hall also has a long standing tradition, dating back about twenty years or more, of the free screening of pornography videos in the hall’s TV Room every Friday evening. There is incidentally a make shift mosque just across the lawn from the TV Room in what used to be the kitchen attached to a dinning cafe where students used to eat when the Nigerian government provided free food for university students. The tradition of Friday evening porn predates the existence of the make shift mosque, which according to the university was even an illegal creation in the first place. Suddenly one Friday evening the leaders of the Muslim group in the hall stormed into the TV room and seized the DVD player. The incident eventually degenerated into a free for all fight that resulted in a two-week university closure.

There was another occasion when a girl was beaten up for dressing “inappropriately” while visiting the hall (Awo is a male residential hall). The muslim brothers retreated into the mosque after the onslaught and they wouldn’t allow anyone who wasn’t a muslim to approach for questions and a demand of apopogy. They held sticks and other weapons, prepared to attack the uninvited. It was strange and scary. I had to step in, having been a rather good friend of the Awo Hall mosque as I had been spotted entring the mosque to take part in prayers, and having subsequently attracted a couple of the more senior members of the mosque who tried to convert me to Islam, albeit unsuccessfully. Thankfully, we were able to get them to apologise in the long run, an act that eventually that brought the mattter to rest.

A third one occured when a girl was married off to a fellow student by fellow students within one of Mosques in the university without the knowledge of either party’s parents. The girl subsequently decided to cut off all communication with her family. After several weeks of failed attempts at reaching her, the girl’s parents had to visit the university to confirm what had happened to their daughter. She had been transformed from a regular muslim lady to one that covers her face, she was already pregnant and she wasn’t going to see her parents when they eventually visited.

I once had a “friend,” a Nigerian who told me that he would kill me in the event of a holy war! He wasn’t joking.

Mild as these incidents were, what they show is that for these to happen in the liberal south, at the very bastion of southwestern Nigeria liberalism, you can imagine what possibly goes on in the north where some states already practice the Islamic Sharia legal system.

I don’t think that Umar did what he is alleged to have done simply because he is from a rich, privileged family or from northern Nigeria. He simply had good access to radicalising influences, or is it the other way round? There are thousands of Nigerians, I’m sure, who would go the same way if only they had the same kind of access Umar Farouk Abdulmutallab had, and we should not be oblivious of this important fact as we discuss this unfortunate incident.

It can’t take a joke,
find a star, make a bridge.
It knows nothing about weaving, mining, farming,
building ships, or baking cakes.

In our planning for tomorrow,
it has the final word,
which is always beside the point.

It can’t even get the things done
that are part of its trade:
dig a grave,
make a coffin,
clean up after itself.

Preoccupied with killing,
it does the job awkwardly,
without system or skill.
As though each of us were its first kill.

Oh, it has its triumphs,
but look at its countless defeats,
missed blows,
and repeat attempts!

Sometimes it isn’t strong enough
to swat a fly from the air.
Many are the caterpillars
that have outcrawled it.

All those bulbs, pods,
tentacles, fins, tracheae,
nuptial plumage, and winter fur
show that it has fallen behind
with its halfhearted work.

Ill will won’t help
and even our lending a hand with wars and coups d’etat
is so far not enough.

Hearts beat inside eggs.
Babies’ skeletons grow.
Seeds, hard at work, sprout their first tiny pair of leaves
and sometimes even tall trees fall away.

Whoever claims that it’s omnipotent
is himself living proof
that it’s not.

There’s no life
that couldn’t be immortal
if only for a moment.

Death
always arrives by that very moment too late.

In vain it tugs at the knob
of the invisible door.
As far as you’ve come
can’t be undone.

By Wislawa Szymborska
From “The People on the Bridge” 1986
Translated by S. Baranczak & C. Cavanagh from the Polish

Futurology is at best systematic guesswork, and at worst facile hubris. “Prediction is very difficult, especially about the future,” Niels Bohr (1885-1962) once quipped, but if you think about how successful science-fiction has been, you might be tempted to take Bohr’s piece of wisdom with a grain of salt. Is it really so difficult to predict the future?

HG Wells (1866–1946), one of the earliest writers of science-fiction, most popular of which were The Time Machine (1895) and The War of the Worlds (1898) made many predictions in his life time. He wrote his  most clearly and decidedly futuristic work, “Anticipations: An Experiment in Prophecy” (1901), where he predicted what the world would be like in the year 2000.

He got it right that trains and cars would result in population dispersal, that there would be much greater sexual freedom, that Germany will be defeated, and there would be a European Union. Expectedly, there were many misses: he said there wouldn’t be a successful aircraft before 1950, and that there would never be a successful submarine. For one of the fathers of the science-fiction genre, you expect it would be the other way round.

There was one more thing, partly scientific, he did get right though, which I think he is not being given enough credit for: the Internet, and the eventual creation of Wikipedia. Of course, he didn’t use the Wiki word, but his accuracy was stunning. The following are excerpts from his contribution to the new Encyclopédie Française in 1937, titled “World Brain: The Idea of a Permanent World Encyclopaedia,” reissued in a separate volume World Brain:

A microfilm, coloured where necessary, occupying an inch or so of space and weighing little more than a letter, can be duplicated from the records and sent anywhere, and thrown enlarged upon the screen so that the student may study it in every detail.

This in itself is a fact of tremendous significance. It foreshadows a real intellectual unification of our race. The whole human memory can be, and probably in a short time will be, made accessible to every individual.

Its uses will be multiple and many of them will be fairly obvious. Special sections of it, historical, technical, scientific, artistic, e.g. will easily be reproduced for specific professional use. Based upon it, a series of summaries of greater or less fullness and simplicity, for the homes and studies of ordinary people, for the college and the school, can be continually issued and revised.

In the hands of competent editors, educational directors and teachers, these condensations and abstracts incorporated in the world educational system, will supply the humanity of the days before us, with a common understanding and the conception of a common purpose and of a commonweal such as now we hardly dare dream of.

This concisely is the sober, practical but essentially colossal objective of those who are seeking to synthesize human mentality today, through this natural and reasonable development of encyclopaedism into a Permanent World Encyclopaedia.

If you substitute ‘computer’ for ‘microfilm’, what you have is the internet, and the makings of Wikipedia. There is however another of Wells’ scientific predictions, published in World Brain where he predicted that for an educated citizenship in a modern democracy, statistical thinking would be as indispensable as reading and writing.

Unfortunately, here is another HG Wells prediction failure, one that I would wish above all other scientific predictions was successful. Prediction has always been hubris.

Two weeks ago, it was reported that Arsenal FC (Competing Interest: I am a committed Gunner!) striker Robin van Persie would be traveling to Serbia to see Belgrade-based healer Marijana Kovacevic (Marianna the Therapist) for the horse placenta treatment of his ankle injury that has pretty much, amongst other things, destroyed the season for Arsenal. Frank Lampard, Yossi Benayoun, Albert Riera, Fabio Aurelio and Glen Johnson have also tried her out following reports that Serbia forward Danko Lazovic had been cured faster than expected by the massage that involves fluid from horse placenta.

Kamran Abbasi begins his editorial in this month’s issue of the  Journal of the Royal Society of Medicine titled “The Year of the Horse Placenta” by writing, “We are in the Chinese year of the ox but in the UK this could end up being the year of the horse placenta,” and later says, “This fashion for horse placenta therapy shows how the world of medical science is quickly marginalized by more powerful arguments of politics and money. Here the concern is league position and money, money and television rights deals.”

He ends by reminding us that Bertrand Russell once asked whether it was possible for a scientific society to exist, or if such a society must inevitably bring itself to destruction. In Kamran’s words: “Perhaps he should have asked a simpler question: ‘Is it possible to create a scientific society?’”

I still remember the shock when I realised that the practice of homeopathy was funded within the National Health Service (NHS) in England. I was taking a lunchtime stroll when I came across the Royal London Homeopathic Hospital, which as it turned out was one of the hospitals within the UCL Hospitals NHS trust, which also included the hospital to which the Institute of Neurology where I was studying at the time was affiliated. I almost felt ashamed.

It was particularly shocking because the United Kingdom does have a reputation for science and rationality that is hardly equalled elsewhere in the world. The experience however made it less shocking for me when I got to Sydney, Australia and found lots and lots of alternative practices, with all sorts of interesting and grand names, structured to deceive and confuse with legitimate science. However, I doubt that like in the UK, any is funded from the public purse of Australians.

Two weeks ago, I met a black woman from Jamaica (although born in London and raised in Auckland). She was the first black person I walked up to and spoke with in Sydney, and the first and only person ever to have referred to me as ‘brother’ in the restricted black folk sense of the word. It was rather strange. I had never been a ‘brother’. There are not many in Australia.

We got on the bus together. She had studied ‘alternative/complimentary medicine’ in her youth and had also received training in homeopathy. Much of the rest of the trip was spent discussing the claims of homeopathy, during which she argued that homeopathy was much like vaccination. I was so mad, but out of courtesy I had to change the topic immediately. It reminded me of Raymond Tallis‘ 2007 Sense about Science annual lecture where he said:

…and this is how it is with junk science that borrows the terminology of science, without any sense of its true meaning, and of the massive interconnected hinterland of facts and concepts and even uncertainties behind them.

…and so we have treatments such as ‘reflexology’ which expropriates a well-established, indeed central, concept in biological science, and uses it to label treatments that have no biological foundation whatsoever.

…and ‘homoeopathy’ which, being in Greek, one of the languages of science, sounds very scientific but is based on magic thinking that would shame a six year old child.

…they domesticate terms by uprooting them from a complicated nexus of hard-won concepts.

Whenever I see those Sydney shops or offices, what comes to mind is how successful alternative medicine practice/movement is in Nigeria as well, and how they feed on pretty much the same sentiments. I reckon it must indeed be a universal phenomenon. Thankfully, we are not yet at the stage where the Nigerian government will fund an alternative medical practice, but I bet we are not that far either. I am almost certain of it that the movement will soon have a ‘scientific’ arm made up of people trained as much as to be able to throw terminologies around but not quite as much as to have any deep, nuanced understanding of them.

Here is an excerpt from an advertorial on the popular Doctor Akintunde Ayeni of Yem-Kem International Nigeria Limited:

…he [has] invested resources – time and money to visit renowned herbal homes in India, China, Australia, Japan and Pakistan. In similar vein, [practitioners] of alternative therapy in those countries visit him, here in Nigeria, to exchange notes. The result of these research efforts is manifested in the emergence of our three products namely (1) Blood Cure, which a blood purifier and immune boosting herbal medicine (2) M & T Capsule which is an effective herbal medicine for all chronic fever and (3) Energy 2000 which is a powerful herbal medicine for sex ability deficient patients.

The words again: ‘research’, ‘immune’, ‘capsule’, ‘doctor’, ‘discover’, et cetera. It is also interesting that Australia has its place among the visibly oriental countries that Akintunde Ayeni has visited.

John Diamond, who before his eventual death had his hopes of cure from cancer falsely raised by several alternative medicine practitioners did put what would be my summation very beautifully: “There is in reality no such thing as alternative medicine, just medicine that works and medicine that doesn’t…There isn’t an ‘alternative’ physiology or anatomy or nervous system any more than there’s an alternative map of London which lets you get to Battersea from Chelsea without crossing the Thames.”

So how do you define medicine that works? Well, the same way that Artemisinin made its way from the fields of central China to clinics everywhere chloroquine resistant Malaria is treated.

Jenny Doust on Using probabilistic reasoning

Probabilistic reasoning is used when we consider the diagnostic accuracy of tests in our clinical decisions. It is also called Bayesian reasoning, being based on Bayes’ theorem, in which the probability of a hypothesis is modified by further data… We use tests every day to decide whether our patients have a particular disease, but we often ignore the uncertainty inherent in the test results. Only rarely can we define how well a test rules in or rules out a disease. Does this matter?

Richard Smith on Promoting Health Literacy

If we think of health literacy as knowing the treatment for atrial fibrillation or whether to go to the doctor with a sore throat, then doctors are a lot more literate than patients.

If, however, we consider, as many do, health literacy to be the ability to derive and understand the statistical risk of various treatments versus no treatment of a condition from randomized trials and systematic reviews, then doctors are not much more literate than patients. ..

…standard ways of presenting information on medical risk in journals, the media, patient information leaflets, and, indeed, everywhere would be a good step to raising literacy…

If you want to know just how literate (or is it numerate now?) you are, there is a quiz here, here and here.