Square One

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.

Daniel Sokol, medical ethicist and BMJ columnist writes in this week’s BMJ about doctors deceiving doctors. Not many of us can claim that we are not guilty of some subtle form of deception, mostly to advance the cause of patient care. But is it justified? It brings to mind again, performing the futile CPR, a kind of deception to put the mind of a patient’s family at rest in the conviction that we did our best.

Here are excerpts:

A doctor needs a computed tomography scan for his patient. To obtain the scan in good time he feigns concern about a possible pulmonary embolus on the radiology request form. He is also aware that, in the eyes of his consultant, a measure of his competence is how promptly and reliably he can obtain scans. Under interrogation by the radiologist, the doctor embellishes the truth to justify the urgency.

A doctor on a general ward calls the intensive treatment registrar and lies about the patient’s previous quality of life to boost the probability of admission. It is only when the patient arrives on the ward that the truth emerges. Another doctor uses the same tactic to persuade surgeons to operate on a desperate patient.

In anaesthesia, an occasional deception occurs when the surgeon, struggling to operate during a difficult case, asks the anaesthetist to administer more muscle relaxant. The anaesthetist, whose monitoring tells him that paralysis is adequate, acquiesces and injects a dose of saline.

The full discussion is here.

Can we trust traditional peer review? If it’s broken, how might we fix it?

Former BMJ editor Richard Smith, Medscape founder Peter Frishauf, peer review researcher Liz Wager, health policy researcher Alex Jadad, and computer scientist Thomas (Bo) Adler discuss peer review in this podcast by the Journal of Participatory Medicine (JPM).

This stimulating discussion follows two interesting articles on the subject in JPM’s inaugural issue: In Search of an Optimal Peer Review System, by Richard Smith, and Reputation Systems: A New Vision for Publishing and Peer Review by Peter Frishauf.

The podcast and its transcript can be downloaded here.

After several months of trying, former BMJ editor Richard Smith finally has access to his online medical records, being the first of his GP practice’s 8000 patients to demand access. Here is a pithy excerpt from his BMJ blog about what more he would have wanted to see in the records:

It was an anticlimax. My records contain almost no information about me. You’d have no idea from these records who I was, what I did, what I thought, or what I care about. You’d know more about me after two minutes on the world wide web than you would from reading everything in my medical record. It’s probably unreasonable of me to expect my medical records to say much about me, but I’d like them to say more. I would, for example, like them to say something about my values. If, for example, this train I’m writing on crashes and I’m severely brain damaged should the doctors do everything possible to keep me alive? The answer’s no, and I like that to be in my records. I’m also happy for every bit of me that’s usable to be put into others. That should be there too, and the doctors in Cheltenham, where the train might crash, should be able to access the records.

The New England Journal of Medicine recently published an article by Sachin Jain on practicing medicine in the age of Facebook. Here is an excerpt:

The issues raised by access to online media are in many ways similar to issues that physicians and medical institutions have dealt with for generations. Physicians, after all, are members of real-life communities and might be observed in public behaving in ways that are discordant with their professional personas. During medical training, the importance of maintaining professional distance — however much one desires to have a close, meaningful relationship with one’s patients — is taught by educators and reinforced by the use of beepers and paging services meant to shield physicians from their patients. What is different about the online arena is the potential size of the community and the still-evolving rules of etiquette.

Last week’s BMJ has an article sponsored by the Wellcome Trust on online video sharing and patient privacy:

In 18th century London a popular form of entertainment was to tour the Bethlem asylum for a penny to look at the “lunatics.” Similar forms of voyeuristic entertainment have resurfaced and are alive and well today and available free on the internet. While preparing a scientific manuscript on rabies we came across several disturbing videos posted on YouTube showing footage of patients with rabies. In one video of a child with rabies is embedded the text “CrazyShit.com” and “This shit’s for you!” Some of the accompanying comments, posted by viewers, are equally distressing: “Funniest shit i seen all week”; “He’s screaming at a glass of water. IT’S FUNNY!!!”; “Fuck the family and fuck u! u tree huggin hippie. Don’t click on the video if u think its wrong.” These comments are clearly extremely distasteful and show no respect to the patient or his family. We see no purpose in these videos being made available to this audience in this form.

I was invited – quite soon after the then new ER in OAU Teaching Hospital, Ile-Ife was completed about five years ago – by Chibuzo Odigwe to co-write a short article on commission for the studentBMJ about ‘the Nigerian Emergency Department’, which was to go alongside an article on a newly refurbished ER in the US. I remember in our discussions we had to work out a middle ground between ‘telling it like it is’ and being ‘economical with the truth’, and also having quite similar train of thoughts as Damilola Onikepe Owolabi expresses here in this guest blog post on a new ER in the Lagos hospital where she is presently working as pre-registration house officer, written exclusively for Square One:

The New ER in Lagos

Emergency room medicine is the highlight of movie medicine. Glamorous, fast paced, it displays the skills of medicine, its infrastructure and puts its personnel in hero light. Your heart beat doubles in rhythm as you watch every move to save that patient, and as the balance of the scales tilt back towards life, your radial pulse slowly normalizes and with it a compensatory increase in your mind for the value of medicine.

Yes! ER medicine is “it” only it literally doesn’t exist in this country. Internship has been traumatic as I watch countless lives slip out of a world with technology so advanced it lies on the brink of cloning human organs.

For lack of a simple nebulizer a 37 year old asthmatic is no more. And I really have never and probably will not soon see a defibrillator, an integral part of TV ER. Adrenaline to kick a heart back to normal takes at least 15 minutes to procure, and for want of funds to buy a grey cannula, easily correctable shock lingers till the damage cannot be undone.

It hurts so much to know how much you could achieve with simple basic things: drugs, equipment, extra personnel. How does one nurse man a surgery ER with more than 20 patients. And the classic trademark scrubs, forget it! Part of the ghastly experience of watching people barely survive is having relics of bloody stains on any part of you.

The most amazing thing, the federal government-run government hospital where I’m presently interning completed a new ER two months ago. Slowly but gradually it rose and when the commisioning date was set, in typical Nigerian style, work tempo took on a whole new pitch. Painters scrambling about, technicians banging on new split units, it was to be the ultimate A&E. The ceremony ended, the building looked good, painted. The standard marble nameplate was unveiled, and since then all activity has ceased.

Its doors are not yet open and numerous questions abound, like who will staff the new building? There is literally not much more equipment inside to get better work done anyway. This monster shell of a building doesn’t improve our blood bank services. It will not hasten the tardy laboratory technicians to do tests; neither will it fill up syringes with much need resuscitants and antibiotics. It will not defibrillate failing hearts or provide the required number of trained personnel to improve survival. And unfortunately it will not make more affordable to its usual customers what they need to keep on living.

Quite frequently our national policies on diverse things are reviewed. Budgets are re-written for health, and our verbose bureaucrats make numerous promises and pledges. It is quite irksome to see year in and out our problems have not changed: “We need more funding from developed countries, and better means to implement policies.” “We need the statistics of infectious diseases.” We need to train and retrain our personnel please.” These are the lines towed by content of reports from WHO, African Development Bank and other proposals from diverse health organizations.

We have prioritized and re-prioritized amongst re-doing many things, but every time I look around me, I see a system falling to pieces. So as not to be cynical I admit we do indeed have rebel fighters in our midst, people who will improvise, substitute, work until they die, but how much do they really achieve with an almost abject dearth of everything.

My new ER is but a facade of what it should really be because within itself, its architects and managers, it lacks the substance to achieve the reason why it was built which is exactly my problem with reviewing policies in Nigeria. They have become routine, empty words, quixotic promises, sometimes derived from well analyzed data, but unadapted to our local needs.

And even when great minds have worked to customize the solution to our peculiar realities, it seems like what we do is document, give speeches and set up committees. Many defunct committees exist, many noble ideas have never been translated into deeds. We do not need words of change, we need people to get their hands grimy, their thoughts realistic, not to fear the world of politics, and to make decisions and take actions to start off the slow process of change.

In spite of my several competing interests, and its relatively low impact factor compared to its supposed peer general medical journals, the club of the big five including The Lancet, JAMA, New England Journal of Medicine and Annals of Internal Medicine, I still think the BMJ is perhaps the best medical journal for a young clinical/medical/health scientist. While other journals go out of their way to be interractive, it seems to me to be in the nature of the BMJ to be engaging and interractive. It is not unusual, in fact it is rather the rule than an exception, to learn more from the BMJ’s rapid responses to an article on bmj.com than from the main article itself.

Reading through BMJ’s triumphal announcement of their decision to go all the way with publishing only untraedited versions of research articles (BMJ pico) in print, about two months ago, I chanced upon a 2003 BMJ article by Gerd Gigerenzer and Adrian Edwards working at the Centre for Adaptive Behaviour and Cognition, Max Planck Institute for Human Development, which they started out by saying:

“The science fiction writer H G Wells predicted that in modern technological societies statistical thinking will one day be as necessary for efficient citizenship as the ability to read and write. How far have we got, a hundred or so years later? A glance at the literature shows a shocking lack of statistical understanding of the outcomes of modern technologies, from standard screening tests for HIV infection to DNA evidence.”

They dispel the notion that this is due to some inherent innumeracy of mankind, and place the charge at the feet of scientists for not representing data clearly enough. In an example, they explore the difference between expressing information as conditional probabilities and as natural frequency:

Conditional probabilities
The probability that a woman has breast cancer is 0.8%. If she has breast cancer, the probability that a mammogram will show a positive result is 90%. If a woman does not have breast cancer the probability of a positive result is 7%. Take, for example, a woman who has a positive result. What is the probability that she actually has breast cancer?

Natural frequencies
Eight out of every 1000 women have breast cancer. Of these eight women with breast cancer seven will have a positive result on mammography. Of the 992 women who do not have breast cancer some 70 will still have a positive mammogram. Take, for example, a sample of women who have positive mammograms. How many of these women actually have breast cancer?

They found that most doctors could not answer the question correctly when framed in conditional probabilities , but could when presented as natural frequencies.

The BMJ version of the article is here, and if you don’t have access to the BMJ, then there is a free pdf version of the same article here.

There is a also a more recent and comprehensive discussion by Gigerenzer and four others about framing statistical information, which is targetted at a much wider readership here and it is free. Although much longer than the BMJ article, reading it is well worth the time and effort.

You may then want to try out this question from this week’s BMJ quiz.