MPH Master pieces

Is bullying a public health problem?

Don't know the answer to that one, but the resulting distress is clearly a health problem and stopping the bullying could count as primary prevention. So here is a trial with a modest but potentially important result. Cost £58 per pupil, which could add up to £60k in a large secondary school. I can't see it being widely adopted, or am I getting pessimistic in my old age?

Meanwhile I have been reading a book published 40 years ago by Adam Curle, a Quaker who won the Gandhi peace prize. He tells an interesting story about Danilo Dolci who went to Sicily to do some project or other but stayed on because he was 'distressed that the rural people did nothing to resist the power of the Mafia, which dominated and exploited almost every aspect of their lives'. Curle says that Danilo drew a parallel with schools in which a teacher is frightening and domineering - the children are so concerned to stay int he teachers good books that they pay little attention to each other. The way forward is to encourage the children to connect with each other. That changes the whole dynamic of the bully. Likewise the rural poor and the Mafia. Curle comments that it was surprising to many that Danilo was not assassinated.  

Organisational culture

I don't often come across articles from the management literature - this one has a rather simple basic message but some of the references look interesting enough to follow up. One of them is by Stephen Shortell who over the years has published several interesting studies of hospital teams. 

Promoting physical activity

I think the Chief Medical Officer for England recently issued new guidelines on physical activity for the UK population. I say 'I believe' because it's proved remarkably difficult to track down on Google. I read somewhere that this update from CMO shifts the emphasis away from the previous 100% focus on cardiovascular fitness (10 000 steps a day etc) and remembers the old rule of 'stamina, strength and suppleness', perhaps because of the increasing attention to falls in old people. But you do need all three 'S'. 

The equivalent recommendations from the USA are however easy to find. The full suite of documents is massive but this one is quite fun to browse; perhaps more as a lookup for all those things that people have suggested over the years - wearable activity monitors (aka FitBits); stair use prompts; video games etc etc. 

Standing at work

The British Medical Journal is obsessed with putting everything in plain view. So it's interesting to read the peer-review comments on this paper and see also the authors' responses. One of them answers a query which occurred to me - does standing at work really make much difference?

Lead

Sometimes Google lets you down. It cannot, for example, distinguish 'lead' from 'lead', the former being what you want Top People to do so that we can all follow them dutifully, whilst the latter is a toxic substance that you definitely don't want to get in your mouth / digestive tract / blood. 

All of which explains why I can't tell whether this 'Lead Action Card' has been updated recently. It's worth a quick skim. 

British citizen dies of rabies

By an awful coincidence, it was reported today that a British patient who contracted rabies while on holiday in Morocco has died of the disease. I don't want to make any big thing out of a tragedy but it does confirm that you have to be prepared for rare events. 

Rabies

Rabies is almost unknown in the UK but that doesn't mean it can't happen. This is the latest guidance. More detail than you need unless dealing with an incident but it's one of those things which is worth skimming now so that when you do need it, you remember it exists

Cardiac screening of footballers

The death of any young person is a tragedy. When that death occurs suddenly on a football pitch, in plain view of millions of viewers, the tragedy soon becomes a call for action - why was this elite athlete not given a proper medical? How could they have missed a lethal cardiac problem?

The Football Association rose to the challenge and here are the results. It's an impressive piece of research carried out over 20 years. The conclusion, alas, is that screening is most of the sudden cardiac deaths would not have been prevented by screening. Whether it's worth doing anyway is another question. The report doesn't seem to indicate any harms, and given this programme is run for professional footballers it isn't taking resources away from other more effective healthcare programmes. What do you think?

Typhoid

Typhoid update: the balance has changed between treatment (used to be good) and vaccine (used to be useless) for typhoid: see here for the latest thinking. 

Folate

Well! It seems from a news story that the British government is about to introduce folate fortification of foodstuffs. 

The story starts in the 1970s when Smithells, studying neural tube defect, found that mothers of children with NTD had low folate levels. Wald then ran a classic trial which showed convincingly that folate supplements reduced the risk of a second affected pregnancy in a woman who had already given birth to an affected child. It's known that the neural tube forms and closes very early in gestation, and certainly before the mother will realise that she is pregnant - hence any folate supplementation has to be done pre-pregnancy. That pretty much rules out supplements as a population strategy to reduce NTD, except perhaps n the USA where taking all sorts of vitamins and supplements is remarkably common. Hence the idea of putting folate into an ordinary foodstuff - flour. There is a precedent from the success of putting iodine into salt to eliminate goitre and endemic cretinism 

But folate in flour has its opponents. Some people object to anything they dub mass medication; and the folate will of course do no good to any male, or to any female too young or too old for pregnancy. Not only won't do any good, but it may just possible do harm: giving folate to someone who has a deficiency of vitamin B12 (e.g. old people with very poor diets) can precipitate sub acute combined degeneration of the spinal cord. Furthermore, NTD seems to be on the way out anyway - the incidence of NTD has been dropping since the 1970s, presumably due to overall improvements in the availability of salad and green vegetables. (Note that to study NTD incidence accurately you need to add abortions to the birth prevalence - birth prevalence of NTD is particularly high in Northern Ireland because abortion remains illegal there.)

However, as blogged here 10 years ago (this is an ongoing saga) many jurisdictions already fortify flour with folate, and the result seems to be the good without the harm. 

Of course whether a government consumed by Brexit is capable of doing anything about anything remains to be seen.