A smoker outside of a hospital. Photo by Olivia Harris via Reuters

As a final year medical student I have travelled to many different parts of the world on various medical rotations. Common to many of the hospitals that I’ve worked at, however, is a disturbing paradox. Picture a patient draped in their gown, standing outside a hospital with an IV drip in one arm, healing them back to health, whilst a cigarette is held in their other hand, simultaneously undermining this effort being made to heal them. Sometimes smokers come out in masses, found at the footsteps of the doors that lead into the place of healing and recovery. The hospital, just as the patient, becomes devitalized with a plume of smoke blown in its face. Surely something must be done to keep the integrity and purpose of the hospital alive?

Until now, the NHS trust has aimed to solve this problem by building smoking shelters for patients and visitors at several hospitals in the UK. Professor Mike Kelly who works for the National Institute for Health and Care Excellence (NICE) believes it “sends completely the wrong messages. Smoking is not OK, it is deadly”. Indeed, allowing people to smoke on hospital grounds not only goes against the hospitals efforts of promoting and protecting good health, but also encourages patients to continue smoking despite being given medical care. As the World Health Organization identifies, tobacco is the world’s leading cause of premature death, contributing to mortality in 1 in 10 adults. To help prevent the adverse effects of smoking, the underlying causes need to be addressed, which is perhaps through the way we practice medicine itself.

The need for preventive medicine

If a patient comes to the hospital with a fever, we don’t just give them paracetamol, we look for the underlying cause and treat it. Why should smoking-related illnesses be treated differently? “It’s senseless for the NHS to be spending so much time and resources dealing with the consequence of smoking and not addressing the cause in the first place”, says Professor John Britton, chair of NICE guidance development group. As smoking has addictive properties and countless health consequences, it should be considered as a disease and, more importantly, treated as one.

In an ideal world, preventive medicine would be at the forefront of how physicians care for patients. As it stands, simply put, hospital treatment currently consists of medications and surgery. A third element needs to be incorporated into the system of treatment to enable patient recovery to succeed outside of the medical system. Preventive medicine has had much success with the advent of vaccines and screening tools to impede the advancement of disease. Patient-approach smoking interventions could work in tandem with these innovations, thereby preventing patients from further exacerbating their illnesses or becoming ill in the first place.

One way that preventive medicine can be applied is by reaching vulnerable patients within the hospital itself. For example, patients being treated for tobacco-related illness could receive personalised counseling alongside the pharmacologic treatments that are available, such as Bupropion tablets and nicotine replacement therapy. The Centre for Disease Control has published that almost fifty percent of smokers have tried quitting in the past and therefore have the ability to do so again. Asking patients open-ended questions regarding their smoking history and what methods of quitting they have previously found useful empowers patients to do so again with additional supportive methods tailored to their experiences. Identifying the patients that actively smoke should therefore be a basic task of health care staff in order to help and support smokers to quit.

Turning smoking breaks into social breaks

From speaking to family physicians in Canada, it is clear that a more empathetic approach needs to be applied in order to make smoking cessation programs more comprehensive and therefore successful. Indeed, some general practitioners propose meaningful social contact, emotional support and companionship to be offered by health care providers.

Dr. Cathy Faulds, Canada’s family physician of the year (2010) and incoming President of the Ontario College of Family Physicians, illustrates the analogy: “We do not give our alcoholics a place to drink but rather, with compassion, we help them with withdrawal and offer addiction programs.  We should offer the same approach to all patients with addictions including smokers. Lack of readiness to quit should not be the reason we facilitate addictions in the hospital setting”.

One solution could be to offer a friendly room inside the hospital where patients can go at times when they are craving to smoke. By leaving a cigarette at the door, one could be rewarded with a place to socialize. Here patients can distract their hands from the habit of smoking by playing games or crosswords, or pass their craving sensation with a yoga session in order to enter into a more relaxed state of mind. More research into what activities can help to divert patient’s attention away from their smoking withdrawal symptoms would be of great benefit in this regard.

Although smokers have a right to smoke if they wish, clean air is a basic need around the hospital grounds. At the grassroots, there is opportunity for improvement in the delivery of healthcare by focusing on a more holistic approach to prevent the sequelae of smoking. Providing guidance to quit smoking through the use of pharmacological therapy, counseling and support groups could save health care expenditures and ameliorate quality of life. It is about time the medical community extinguishes the hospital’s smoky reception.

Popular opposition – but who’s listening? Photo by cristineagoe via Flickr.

Fracking, “a technique used to break apart the dense shale rock, releasing the hydrocarbons (like gas and oil) contained inside”, is a controversial practice. It has sparked public opposition throughout the world and has been banned in countries such as France and Bulgaria for its potential consequences on human health and the environment. Yet some European politicians have been getting hot under the collar about fracking when politically convenient – and then forgetting all about it when it is not. Romania is a perfect illustration of such politically expedient see-sawing.

In 2011, when in opposition, current Romanian Prime Minister Victor Ponta’s Social Democratic Party (PSD) proposed a draft law demanding a complete ban on fracking, complaining that no studies had been conducted and no legislative framework to regulate the technical conditions for exploring and exploiting shale gas. Yet after gaining power, the PSD-led government rejected its own previously proposed law. Entirely contradicting his previous position on fracking, in January 2013 Prime Minister Ponta emphasised that exploiting shale gas should be treated as a positive solution to increase Romania’s energy independence, since the country continued to pay the highest price for gas compared to Bulgaria, Hungary and other Eastern European countries.

While the Romanian public has amply, repeatedly and ardently opposed fracking and called into questions its government’s moves, the government does not seem interested in responding to its critiques and fulfilling its demands. This situation calls into question the extent to which popular protests can ultimately ensure government accountability, while underscoring the fact that officials might prefer to pursue economic interests at the expense of their voters’ desires, their health and the environment.

In March 2013, Ponta went one step further, affirming that he is in favour of authorising shale gas exploration, and exploitation under appropriate environmental standards, in what he described as an effort to ensure Romania’s energy independence from Russia. Ponta stated: “First, Romania needs to confirm its shale gas resources. We should allow preliminary exploration of the reserves, a process which could take around five years. After that, any future shale gas development should be in compliance with all European and global environmental standards.”

Yet the reality of fracking would hardly be so straightforward. Romanian law does not differentiate between conventional resources, such as coal and gas, and non-conventional resources, such as wind and solar power, and has no procedures to evaluate the impact that shale gas exploration and exploitation can have on the environment.

Despite this, not only has Romania conceded 2.2 million acres to the U.S. energy company Chevron to start exploration drilling, but in May 2013 the Romanian Environment Protection Agency issued shale gas exploration permits to Chevron for two areas situated near the Bulgarian border. These permits allow the company to conduct controlled explosions at a depth of 10 and 15 meters on an area of 1,800 square kilometers, and the company intends to create its first test wells during the second half of 2013. The Romanian government’s support for fracking was further boosted during a recent European Council Summit, when Council President Herman Van Rompuy announced “shale gas could be part of the energy mix in a number of [EU] countries”.

The Romanian population has vehemently and repeatedly protested against their government’s decision to encourage fracking. In Costinesti, one of the conceded regions, 94 percent of the population voted against fracking in a local referendum. Throughout 2012 and 2013, over 8,000 Romanian citizens have come out to protest. In April 2013, meetings and marches were held in many Romanian cities. The protesters decried the government’s lack of transparency and information on the exploration projects. In a sign of solidarity, on May 2013, Bulgarians from the city of Dobrich also organised rallies against fracking in Romania, which would have an impact on their country. In June 2013, Bulgarians crossed into Romania to join their neighbours’ protest against drilling plans. Thousands of Bulgarians themselves had led anti-fracking protests in 2011 and 2012, calling on their government to place a moratorium on fracking.

The Romanian public’s opposition to fracking is part of the global controversy surrounding the practice. The European Parliament issued a report pointing out that the chemical additives used in fracking include “toxic, allergenic, mutagenic, and carcinogenic substances”. Indeed, a popular petition, signed by almost 15,000 Romanians and demanding the banning of fracking in Romania, argues that in areas where fracking has been used the number of grave diseases, including asthma, leukemia, skin cancer and peripheral neuropathy, is sharply on the rise as a result of consuming water from exploitation areas and breathing in contaminated air. And the method of exploring shale gas is no less dangerous than that of extracting them, because advanced exploration also uses fracking, with the only difference being that of scale.

Several European countries have already rejected the practice. France was the first European country to ban fracking in 2011. In 2012, Bulgaria adopted a moratorium on hydraulic fracturing and immediately revoked an exploration permit previously granted to Chevron, invoking insufficient proof of the environmental safety of the practice. The Bulgarian government’s decision came partly in response to the widespread anti-fracking protests held by concerned Bulgarian citizens. Similarly, Denmark, Holland, Ireland and the Czech Republic imposed moratoriums on fracking. In the U.S., several states, such as New York, have also placed moratoriums, while Vermont has banned it altogether.

However, many state governments in the US mirror the unresponsiveness of Romania. Ohio was a site of protests with hundreds or thousands of participants, and over 100,000 Californians signed a petition urging a fracking ban. Just as in Romania, these protesters’ demands have remained unanswered by their representatives. After using Romanians’ protests against fracking to its own advantage while in opposition, the new Romanian government is now turning a deaf ear to the same public. The Romanian government, much like its US counterpart, seems to have forgotten its responsibility to respect and reflect the wishes of its population, expressed numerous times through protesting and referendum. The government has yet to realise that exploiting shale gas only postpones the needed strategic and sustainable shift to renewable energy – and thus that its greatest focus must be developing renewable energy sources for Romania.

Ultrasound Scan: Determining the sex of a baby can also determine its fate. Photo by salimfadhley via Flickr.

There is an old folk song from Uttar Pradesh, India, which beseeches God to protect the supplicant from a monumental injustice. The mournful tune goes, “O, God, I beg of you, I touch your feet time and again/Next birth don’t give me a daughter, give me hell instead.”

Faced with the costs of marriage and dowries for a supposedly non-contributing family member, many parents see daughters as burdens. Recent advancements in sex-determination testing have provided such parents with the necessary technology to remove such burdens, and in 2011, only 917 girls for every 1000 boys were born in India. Thus there are 40 million missing women in India.

Aware that declining sex ratios will have a disastrous effect on the country’s future, political leaders and policymakers alike have highlighted sex-selective abortions as a national problem. In a speech from the Red Fort on Independence Day, Prime Minister Manmohan Singh said, “As soon as possible we have to remove this blot. Our progress will be incomplete till women become equal partners in the growth.”

Sex ratios have worsened over the past 30 years in India, a decline that has been linked to the increasing availability of sex-determination tests, introduced in India in the 1970s. The methods for determining the sex of a foetus include amniocentesis (performed after 15-17 weeks of pregnancy), chorionic villus sampling (normally performed in the 10th week of pregnancy), and the ultrasound machine (used during the 12th week of pregnancy). Of these, the ultrasound, described as “the nemesis of the female foetus in India” by Indian government official, Anna Dani, as it is the least expensive, least invasive, and most portable, consequently making it the most popular of the lot.

Technology Trials

In response to the growing crisis, India passed the Pre-natal Diagnostic Techniques Act (PDNT) in 1994, which prohibits sex-determination. It restricts the use of prenatal tests to diagnose genetic conditions in foetuses and outright bans using them for sex determination, and requires the mandatory registration of genetic counselling centres, clinics, and hospitals. The act also holds women liable to imprisonment or fines if caught using a sex-determination test, even as it acknowledges that a pregnant woman may be compelled by her husband or in-laws to use a pre-natal diagnostic technique. Those working in the clinic or advertising its services can receive up to three years jail time or harsh fines.

Despite its strict criminalisation and severe penalties, poor enforcement has rendered the law ineffective. Studies estimate that between 250,000 and 500,000 female foetuses are selectively aborted each year. Today, there are about 25,000 ultrasound machines in India, of which only 15,000 have been registered. Doctors give the results of sex-determination tests orally, so that there is no paper trail. The lobbying power of the medical community also grants doctors a great degree of immunity. The first conviction for sex-selective abortions was handed down in 2006, more than ten years after the law had passed; to date, only 300 doctors have been prosecuted for violating the PNDT, and only a handful of those have been actually convicted.

Cultural Convictions

Moreover, limiting technology will not work as long as sex-selective abortions amount to economic and social sense. There are considerable economic disincentives for having a daughter, chiefly because of the practice of dowry in northern India.  Since dowry demands increase with the economic well-being of a family, even middle and upper class families are often forced into large debts as dowry payments can be up to US$125,000. Ultrasound clinics have capitalised on this situation, and often advertise their services by advising parents “to spend Rs. 500 now rather than Rs. 5000 later”. In a survey taken in Punjab, the state with the worst sex ratios in India, nearly 80% of respondents listed dowry as the number one reason they aborted a female foetus.

Penalising doctors is problematic because it interferes with their acting in the best interests of their patients. A study found that 64% of abortion service providers were against sex-selective abortions, but viewed it as a necessity since the women they helped would face abuse at home if they gave birth to a daughter. They also believed that they were saving an unwanted daughter from emotional and mental trauma. One of the doctors in the study said that a woman “came to me saying she wanted to know if her fifth child was going to be a girl or boy. I persuaded her to have the child anyway. It was a girl and she died in 6-8 months as they did not feed her well.” The law has also failed to provide women with a safe space; by holding women liable, it has placed them in a double bind. If a woman requests an abortion, she is subject to imprisonment, but if she does not, she may be subject to abuse from her family. Infringing further upon a woman’s autonomy is not the right solution.

Restricting ultrasound technology cannot change the long-standing cultural attitudes that have made sex-selective abortions acceptable in India. Sex-selective abortions will only decrease with the diminishment of daughter devaluation. To do this, the government must focus on enhancing the position of women in Indian society. Creating economic opportunities for women, so that they are able to contribute financially to their households, is one way to weaken the belief that women are liabilities. The government can also provide parents with financial incentives to have daughters, thereby reducing the burden of dowries. For any campaign against sex-selective abortion to be successful, it must address the root of the issue. Fighting the spread of technology, and half-heartedly at that, fails to consider why the problem exists in the first place.

A survey conducted two years after Hurricane Katrina, of 5,406 people living within 20 miles of the Atlantic Ocean or Gulf of Mexico. About half of the respondents had lived through damaging hurricanes, and nearly a third would not evacuate again.

Nearly everybody, when asked if they would evacuate before a hurricane, will say, “Yes.” Very few people pause to deliberate, because the essence of the question as they see it is, “Do you choose life or do you choose death?” Unsurprisingly, most rational people choose life. Yet, in the actual circumstance of being faced with disaster, innumerable people, many of them educated and of sound mind, seem to choose the irrational course of action. What is nearly always overlooked with the aforementioned question, is that it is actually much more complex than asking, “Safety or peril?” Live adaptively or die prematurely?”

In the wake of Hurricane Katrina in the United States, there were 30,000 people in Louisiana who elected not to evacuate, despite the warnings of the government and meteorologists. Reasons for non-evacuation vary widely. One factor that was not listed as an impediment to evacuation was inadequate public warnings or hazard information.  Thus, the public is plenty well informed of the risks, but in deciding, they put their own lives and maybe the lives of their families in peril.

Ecuador’s Example

Tungurahua, Ecuador, in July 2007. Photo by obvio171 via Flickr.

To help understand the mindset of a person facing evacuation, imagine the scene in Baños, Ecuador, in 1999. A nearby volcano named Tungurahua has just rumbled to life, and scientists have advised the government to evacuate 16,000 people from their homes. The big eruption is coming, they warn. Shortly after, seismic and emissions monitors register a jump in activity and sirens blare in the night, waking up the locals. Fumbling with flashlights, they lift their children from their beds and grab the emergency bags, if they listened well enough to pack one. Many of them do not own cars, so they walk four hours to the designated shelter, and they wait. The fortunate ones will have family and friends in other cities ready to take them in, or they may be able to find work elsewhere. This is exceptional, because the majority of Ecuadorians in this area are farmers. Their entire existence is tied together and tethered to the same piece of land.

Soon the shelters, crowded and poorly ventilated, begin to fill with disease. Sickness spreads; with special fervour it afflicts children, the elderly, and pregnant women. The government hasn’t provisioned for the long-term support of so many people, so rations of rice are meagre. The refugees learn that their town has been occupied by the military in order to keep anyone from returning to the zone of exclusion, and rumours of looting whisper among the people. Although the volcano continues to eject fine flurries of ash, the big eruption still has not happened.

In squalid shelter conditions, people begin to alter their situational cost-benefit analysis. Living in an unanticipated amount of discomfort, with real risks to health and well-being, it starts to appear that living in the “danger zone” is preferable. It may be risky, but it is comfortable. In the case of Baños, citizens stormed the city and overtook the military by force, reclaiming their homes. Tungurahua is still erupting today, and the large forecasted event did not occur until 2006.

Fallible Forecasting

Forecasting is an imperfect science; most laypeople understand the burden of responsibility that scientists and governments must contend with in order to make a good decision with limited data, but they still need enough information to make a rational decision to stay or go. Without predicting a disaster, the next best course of action is to clearly communicate the risks and make the safest option the most attractive.

Making recent headlines, the L’Aquila earthquake scandal of Italy is a case study in poor information transfer. Three years ago an earthquake killed 300 people in the seismically active region after a statement from a government representative assured them that scientists weren’t anticipating “a big one”. The locals pressed for a manslaughter suit against six scientists and the government official, and won. Statements from representatives of the prosecution explain that nobody expected scientists to predict the exact time, location, and magnitude of the quake, but they expected clearer communication of risks. They say that without that information, people who would otherwise have left stayed and died due to a false sense of security.

However, based on human psychology in natural disasters and the inherent aspect of “risky behaviour” it seems dubious that the sole reason 300 people stayed behind was because the government told them to do so. In a parallel universe, 300 people were ordered to evacuate L’Aquila and didn’t, because some were worried about leaving their homes unattended, some didn’t want to move into a shelter, and others thought the government would save them if it was precarious enough.

It is resoundingly true from New Orleans, to Ecuador and Italy, to the recent Hurricane Sandy victims in the USA, that people will not always do what the government advises them to do. They will take a risk, because there is so much more at stake than life alone.

Access denied. Published scientific research has traditionally only been accessible through costly subscriptions and individual purchasing schemes. Photo by jmv via Flickr.

Articles vetted by peers and published in academic journals have long been the currency of scientists, serving as the medium through which research findings are shared with the wider world. Access to these articles, however, has never been free. On the contrary, affiliation with a university that purchased expensive journal subscription packages was, until recently, a near requisite for gaining access to the latest scientific discoveries. The only alternative was to buy individual articles from publishers on a one-off basis, usually for a fee of between US$15 and US$30 (£10 and £18) each.

The last decade, though, has witnessed remarkable change. The most recent push from many researchers, librarians, university presses, and even some publishing houses has been the provision of free, open access to published research. Leading the revolution, open-access publishers like BioMed Central and the Public Library of Science (PLoS) have actively defied the old guard of traditional academic publishing houses, making all articles in their journals freely accessible on the web. Submissions to such journals have been rising almost exponentially; just five years since its launch in 2006, PLoS ONE published almost 14,000 articles last year, making it the largest peer-reviewed academic journal in the world.

PLoS ONE published almost 14,000 articles last year, making it the largest peer-reviewed academic journal in the world.

An Open Debate

Such changes in the publishing landscape have not been without controversy. Major scientific publishing houses like Elsevier, with revenues of US$3.2 billion (£2 billion) in 2010, assert that they add substantial value throughout the publication process. Organising the peer-review system, providing editing assistance, and marketing the journals in which academics publish are among the services they claim must be covered. Indeed, the costs of publication are by no means zero; open-access publishers cover such costs by charging researchers – up to US$5,000 (£3,100) in the case of Nature Communications – to publish an article.

Proponents of open science, however, are not convinced. They argue that journal publishers are high-margin businesses which exploit researchers as unpaid reviewers then charge exorbitant rates for access to new research findings. Elsevier’s 37% profit margin last year, they say, is glowing evidence of this injustice. Many of the scientists themselves believe that restricted access is actively hindering faster progress in the discipline; since January, over 11,000 researchers have joined a web-based boycott of Elsevier. “No matter how much value peer review adds” says open science activist Michael Eisen, founder of PLoS, “it cannot make up for the myriad ways in which traditional scientific publishing retards scientific progress.”

Although the movement for open access to published research is growing, practical concerns abound. For one, academic promotion and tenure are still largely contingent on finding one’s name in print in the most prestigious journals a field has to offer. The majority of these are still run by for-profit publishing houses requiring pricey subscriptions. Service to journals in the form of editing or reviewing is also valued highly by universities when looking to promote. Thus refusing to provide such services to closed journals can become a difficult, perhaps career-limiting decision for a young scientist.

Legislative Action

The debate over access has not stopped at online advocacy forums. In December 2011, two members of the US Congress introduced a piece of legislation called the Research Works Act. The bill proposed barring federal agencies from doing anything that would result in the public sharing of research published in private journals. If passed, such a law would have spelled the end of policies like the US National Institute of Health’s (NIH) public access requirement, which mandates that the results of research conducted with public funds be made openly available on its database within a year of publication. Although the Research Works Act was initially backed by a number of large publishing houses, Elsevier formally withdrew its support in late February after intense criticism from the academic community. The bill’s two congressional sponsors have also recently promised not to pursue further legislative action.

An opposing piece of legislation, dubbed the Public Access Act, was introduced in February. Its goal is to expand the public access mandate of the NIH to even more governmental agencies, and to change the time limit for online posting from one year to six months. Non-governmental bodies have begun to take notice as well. In April, the UK-based Wellcome Trust, responsible for funding £650 million (US$1 billion) of scientific research annually, announced intentions to sanction grant recipients who do not make their research findings openly available. The trust has also introduced plans to create a new high-end open-access journal, called eLife, meant to compete directly with prestigious publications like Nature and Science.

Access Granted

In an election year such as this, the Public Access Act is unlikely to make much progress. But the recent legislative back and forth highlights the success the open science movement is having in pushing issues of access into the highest spheres of public policy-making. Publishing companies are no doubt feeling the pressure. Although academic tradition still rests heavily on their side, open science activists have gathered serious momentum.

If nothing else, the movement has been successful in shining a critical light onto the traditional publishing process that has existed, with little change, since the 17th century. For the most part, scientists have been more than thankful for this. Cash-strapped libraries have already begun to drop subscriptions to expensive journals, and open publishers are becoming popular choices for the scientific community. As a result, publishing houses are beginning to prepare for a future that doesn’t exclude the vast majority of individuals from accessing research. For those with trust in the process of scientific inquiry, one thing is for sure. After rigorous testing and a bit of experimentation, the strongest model will ultimately rise to the top.

Nature’s Architecture: The cytoskeleton of mammalian cells that allows them to push and pull on their surroundings. Credit: Wellcome Institute via Flickr.

When astronauts escape gravity their bones become weaker, when body-builders lift weights their muscles grow, and when tennis players train their bones become stronger in their hitting arm.  These are just three examples of mechanobiology, or how living cells respond to forces.

Cell biologists have paid little attention to engineering in the past, but recent findings suggest that it is time to rethink the role of mechanical forces in biology. Forces are thought to contribute to numerous processes from cancer progression to stem cell differentiation and are likely to be instrumental to treating and preventing a number of debilitating diseases.

Early beginnings

In 1892, Julius Wolff, an orthopaedic surgeon and anatomist, made a novel discovery: bone formation responds to physical loading. He found that fractured bones form an architecture different from that of healthy bones that optimises force transmission following structural damage.

This observation suggests that cells can test their mechanical environment and reorganise their structure in response to changing mechanical conditions. Lacking the necessary tools to investigate this process, forces remained under the radar of the scientific community for nearly a century.

Mechanobiology was further pushed aside during the molecular biology revolution in the 1960s, which set out to explain how genes and proteins contribute to biological function.  Researchers focused on developing new tools to better understand biochemical signalling pathways, which describe how chemical signals elicit a physiological response in cells.  Following 50 years of research, significant progress has been made, but it is evident that molecules and proteins cannot fully explain these pathways and biologists have begun to reconsider forces.

In 2006, Dennis Discher, a biophysicist and biologist, made an important discovery while studying the effect of forces on stem cell expression. His team placed mesenchymal stem cells, a type of cell that can differentiate into a variety of cell types, on gels of varying stiffness.

Remarkably, they found that cells that are placed on soft gels resembling the stiffness of brain tissue become neurogenic, those placed on medium stiffness gels resembling muscle become myogenic, and those placed on hard gels resembling bone become osteogenic. This finding highlights the significance of the microenvironment on cell differentiation and its implications for tissue disease and regeneration.

How It Works

Cells are situated in the extracellular matrix of tissues and are exposed to a range of external forces. For example, as we walk, our muscles contract, pushing us forward by transmitting forces to our bones through tendons. Our lungs expand as we breathe and our heart pumps oxygen throughout our body by means of blood vessels.

During this relatively simple task, cells in our muscles, tendons, bones, cartilage, lungs, and heart are pushed, pulled, and twisted. These forces are sensed by cells and transmitted into biochemical signals through a process called mechanotransduction, which lies at the heart of mechanobiology.

Recent studies have shown that cells possess a structure called the primary cilium, a rod-like protein that extends from the surface of most mammalian cells. When fluid flows past these structures the rod bends acting as a sensor that can detect fluid flow, similar to a speedometer attached to the bottom of a boat.

When primary cilia bend, their conformational change induces a biochemical response that is translated into changes in biological function. For example, fluid that has a smooth flow has been shown to prevent an inflammatory response in tissue whereas fluid that is turbulent promotes inflammation.

Cells are furthermore capable of producing internal forces that influence tissue development and cell migration. For this reason cells should be viewed as dynamic structures that are constantly pushing and pulling on their microenvironment rather than as static objects like water droplets, whose movement is dictated by external forces.

Recent time-lapse images have captured how skin cells pull on fibres as they migrate through a matrix. When they encounter a weak fibre they let go and attach to another fibre thereby weaving their way through the construct. This observation suggests that skin cells migrate towards areas of high stiffness and are thought to have implications on scar formation and tumour progression, which are much stiffer than healthy tissue.

Looking Ahead

Cell biology was shaped by the development of enabling technologies in the 20^th century.  Likewise, mechanobiology will rely on the invention of new and sophisticated tools. The recent development of biophysical tools, such as magnetic tweezers, will be key to understanding mechanotransduction mechanisms. Magnetic tweezers are capable of applying piconewton forces to surfaces, that is one trillionth of a newton, and can be used to probe cells to observe their biochemical response.

Although much work is yet to be done in the field of mechanobiology, forces are being used to promote tissue regeneration in the clinic and have shown promising results. For example, over 200,000 amputations have been prevented through the development of a technique called Vacuum Assisted Closure Therapy.

Healing is enhanced by placing a sponge-like material over the wound and applying a cyclic force to the sponge using an oscillating suction pump. Patients undergoing this treatment show enhanced blood vessel generation and cell division due to the micromechanical stimulation of cells.

Forces dominate activities such as breathing and blood flow, but have been shown to play an important role in all cellular functions. Rather than considering forces as a specialised case in biology they should be regarded as an essential part of biological function. With the development of enabling technologies, mechanobiology may dominate the twenty-first century similar to the molecular biology revolution that took place over the past 50 years.

Window to the Universe: The ACT measures the temperature of the microwave sky. Photograph from ACT Collaboration.

The early universe was not a fun place to be. The logical consequence of an expanding universe, first proposed around ninety years ago, is that the universe started in a hot, dense state – the big bang.  This fiery early universe was a soupy mix of protons and electrons. Radiation interacted with the electrons – bouncing around and making the universe appear opaque, for much the same reason that we can’t see into the centre of the sun.

As the universe expanded, however, it cooled, until it was cool enough for atoms like hydrogen to form – the building block from which all other atoms formed.

In this slightly cooler universe, the photons no longer interacted with the electrons and were free to start their long journey through space, eventually reaching us billions of years later as Cosmic Microwave Background (CMB) radiation. The existence of the CMB is a direct prediction of the big bang model – the afterglow of a fiery birth.

Visible to Microwave

While this light was incredibly hot when it started its journey towards us, the expansion of space has stretched the light to long, microwave wavelengths, and cooled it dramatically: the temperature of this radiation is less than three degrees above absolute zero. And yet this cold, microwave light unlocks the secrets of the universe.

In order to measure the distribution of the temperature of this microwave light on the sky, an extremely dry site is needed. The Atacama Desert in northern Chile proved to be ideal: at 5,190m above sea level and with less than a few millimeters of rainfall per year, the site is atmospherically stable and provides an excellent view of the sky. It was therefore chosen as the home for the Atacama Cosmology Telescope (ACT), which began its survey of the sky in 2007, and continued until 2010. Unlike telescopes that ‘point’ at certain known objects on the sky, ACT is a survey telescope, scanning the sky repeatedly and making a map of the radiation above it. In doing so, it takes a picture of the baby universe.

By looking at the photons that have been travelling to us from the early universe, we are basically looking back in time to the infancy of the universe, which started 13.7 billion years ago. The detection of this radiation earned Penzias and Wilson the 1978 Nobel prize. After its detection, scientists began to measure and analyse the CMB radiation, and in particular to measure its energy spectrum. The Cosmic Microwave Background Explorer, which turned 20 in April, was the first probe to measure the spectrum of the CMB. The pioneering work of the scientists who led that search was again given the nod of the Nobel committee in 2006, when George Smoot and John Mather shared the prize. Measuring the temperature of the CMB, and how that temperature changes as a function of position on the sky, tells us how uniform the universe is.

While the universe started out as an incredible uniform ‘soup’, it was the tiny ripples in the density of the universe that would grow to form the structures we see today. Just as a small snowfall can start an avalanche, so tiny over-dense regions in the universe grew under gravity, becoming more and more dense over time and collapsing to form large structures. This growth is extremely sensitive to how much of the various components of the universe, such as dark matter and dark energy, are present. The CMB, light from the nascent universe, allows us to understand the ‘birth conditions’ under which our universe began.

Massive Cluster Shadows

While we use the CMB light to illuminate early times, the photons that have been travelling towards us for over 13 billion years have also been interacting with all the stars, galaxies, and clusters of galaxies along the way. Hot gas in the clusters of galaxies far away cause photons to scatter, with large clusters effectively casting a ‘shadow’ compared to the light normally seen from CMB.

Cosmic Juggernaut. Dubbed El Gordo, this cluster was detected with by looking for ‘shadows’. Photo credit: ESO/SOAR/NASA

ACT is specifically designed to detect large clusters, and El Gordo (or “fat one” in Spanish) scooped the top spot recently for the largest cluster in the universe. El Gordo is composed of two separate clusters that have collided with each other at several million kilometers per hour. This collision can be seen in the X-Ray image, where the blue colour traces the hot gas in the cluster, which clearly shows a ‘wake’ as the two clusters merge and combine. Felipe Menanteau from the University of Rutgers in New Jersey led the ACT search for this goliath, and was delighted to be able to find “the most massive, the hottest [cluster], which gives off the most X-rays of any known cluster at this distance or beyond”.

ACT has studied the sky for three years and is now in the process of being upgraded to have even more sensitive detectors capable of measuring not only the temperature of the CMB, but also the amount of polarisation in the radiation. The next few years will provide more data, more exciting discoveries, and more challenges as we strive to push the limits of our understanding to greater and greater depths, and to smaller and smaller scales.

In 2012 the world of free online education, particularly in the field of computer science, has expanded and evolved beyond recognition. Collectively the Khan Academy, Codecademy, Coursera and Udacity offer 10 different free computer science courses. Udacity is one of the most recent start ups. Created by ex-Stanford professors, they have enabled free online education to become comparable to the university class room experience for the first time. Although the models of teaching differ between each company, they offer the same thing – an education where the only barrier to learning is access to the internet. This education revolution will no doubt have great implications for the developing and western world.

In the developing world, 115 million children under the age of 12 do not receive an education. Of these children 3/5 are girls and the likelihood of a child attending school correlates strongly with family wealth. In many countries primary and high school education is not free and many parents cannot afford to educate their children, with those that can often favouring their sons. The potential for these free online education courses in the developing world is immense. Through not charging fees or enforcing a strict classroom timetable online courses have the opportunity to remove the poverty, class and gender barriers to education. As with traditional class room education, these courses will help individuals become better educated, enabling communities to lift themselves out of poverty and experience the associated benefits, including better health, increased life expectancy and immigration opportunities.

In the developing world, free education has implications not only on an individual level but also country wide. Certainly, it is computational developments such as the Rural Telemedicine project in the Aravind Eye Hospital, Southern India that are furthering countries development. Educating individuals in computer science will enable these developments to be sustained without requiring outside intervention or aid.

The rise of online education also has the potential for impact in the western world. Indeed, it will make it far simpler for individuals living in rural areas to access educational resources and provides people with the opportunity to study at their own pace alongside a full time job. In the UK approximately 50% of people study at university, however the advent of new online education courses has the potential to increase this number greatly, possibly creating an (or furthering the) educational class system. Many believe an education class system already; that an Oxbridge or Ivy League education sets you apart from other degree educated individuals. Online degree courses will have to fit into this already existing system, potentially becoming a separate additional educational tier. In order for free online education to have the most impact on the western world it needs to gain the support of both the general public as well as businesses. Without public and business support, these online courses will remain at the bottom of the educational class system, below that of the traditional degree. Many of the online providers are already attempting to boost their standing within both communities. For example, Udacity and Coursera ensure that all their teaching staff have had previous experience in lecturing at well known universities. In addition, Udacity has recently announced their intention to run testing centres for individuals who wish to obtain official credit for the course to make them more desirable to employers.

In summary, online education has great potential to revolutionise learning and have a large impact upon society, with the biggest potential for social change being in the developing world. Maximising impact in the western world relies on generating buy in from the public and business sectors. Online education providers will have to focus on this first before this revolution can achieve its full potential.

Grim Realities: A tuberculosis-infected lung. Photo from CDC.

In 2000, the Lancet published an article highlighting the failings of North Korea’s health care system, ranking tuberculosis (TB) as the highest public health concern in North Korea. In 2010, the prevalence rate of TB in North Korea was 399 per 100,000 people, which is alarming given that Ghana, another developing country with the same population of 24 million, has a prevalence of only 106. The amount of infected individuals is more than three times higher than that of South Korea and China.

TB is a highly infectious disease needing professional diagnosis and treatment. The situation in the country only compounds the problem, as even 20 years after a famine reportedly killed about 3.5 million people, malnourishment is still rife. A weakened body increases susceptibility to the disease.

On a more positive note, North Korea’s history with international agencies and non-profit organizations to target the elimination and prevention of this disease has been cooperative. ‘One victory was the construction of a laboratory which has the capability to diagnose drug-resistant TB strains. This idea was formulated in early 2007 by John Lewis, a professor at Stanford University, who considered engaging with North Korea from a different angle, by helping them with their TB epidemic. Given the infectious nature of TB, this was undoubtedly a matter of international interest, and it received much positive reception worldwide.

TB Cooperation

Soon afterwards, public health officials from North Korea and experts at Stanford University met several times, initially at Stanford and then later at Pyongyang, North Korea’s capital. The project, led by epidemiologist Sharon Perry, was named the US-DPRK Tuberculosis Project, and its success was the result of collaboration between Stanford School of Medicine, Christian Friends of Korea (a U.S. non-governmental organization), the WHO South-East Asia Regional Office in Delhi, and North Korea’s Ministry of Public Health.

The willingness of North Korea to engage with US academics and specialists is a good sign. Not only has North Korea’s Ministry of Public Health chosen to engage the US in this issue, but it has also been working with the WHO South East-Asia Region Office in Delhi for over ten years. A grant from the Global Fund has cured 31,000 TB patients in North Korea since 2010, achieving the second highest performance rating available. The Eugene Bell Foundation, a non-profit organization registered in both South Korea and the U.S. has worked with North Korea for over 50 years to help control their TB epidemic.

International Interests

This engagement is crucial not only because TB is infectious but also because drug-resistant strains are continuously evolving. The international community must continue to support North Korea with this issue as the consequences of ignorance are potentially catastrophic. If a drug-resistant strain unresponsive to current drugs were to evolve in North Korea, it could easily spread rapidly through the small channels of tourism and trade, as well as the sporadic flow of defectors across the border with China.

It is problematic that public health is routinely left out of any sort of discourse on North Korea. However, throughout the upcoming year, as countries with or without formal international relationships with North Korea re-evaluate their diplomatic stances, policymakers should keep in mind the dangers of ignoring the state of the health system. This knowledge can be a crucial factor in setting up a better framework for how humanitarian aid really affects the people of North Korea.

Involving public health in foreign policy is complicated, especially when it involves a process as delicate as persuading North Korea to phase out its nuclear capabilities. However there have been other cases of success by other countries, for example Brazil’s exportation of its successful HIV/AIDS combating model to other developing countries has increased its access to international markets.

At the very least, employing healthcare diplomacy in North Korea through official channels is a useful way of showing compassion to a people who are taught as schoolchildren that contact with the outside world should be avoided. It would be a small but positive step towards effective engagement with North Korea, one of the world’s most isolated countries, and could potentially cause negotiations to end more positively than they have done in the past.

For the first time since 2001, international funding for HIV is falling

In May 2011, scientists announced that people living with HIV who adhered to treatment were 96% less likely to pass on the virus, based on results of the HPTN052 randomized control trial. Other trials have also demonstrated that antiretroviral drugs and male circumcision have significant protective effects for people who are not HIV-positive. Economic modelling undertaken by the U.S. Centres for Disease Control demonstrates that substantial investments in Sub-Saharan Africa will not only significantly reduce the incidence of HIV but also offset the cost of scaling up treatment and care by almost 60%. In its 2011 global report UNAIDS set goals of zero new infections and zero AIDS-related deaths – targets that they believe are achievable in the not-so-distant future. In a letter to partners, UNAIDS Executive Director Michel Sidibé urged that “together, we can make this the defining decade, the decade that signals the beginning of the end of AIDS”.

Brake on Progresss

Ironically, for the first time since 2001, international funding for HIV is falling. The two largest international donors, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, have both recently revealed worrying retrenchments. At the end of 2011, in an unprecedented move, the Global Fund announced that it was cancelling its next round of funding due to the failure of wealthy governments to deliver on their commitments. Also, despite promising to work towards the realization of an “AIDS-free generation”, the Obama administration has proposed an 11% cut in funding to the PEPFAR program next year. By reducing or even flat-lining investments in expanding treatment access, donors are threatening to pull the brakes on this fight.

When asked about the reasons for this reneging on aid commitments by wealthy nations, Dr. Jennifer Cohn, international HIV policy expert and Assistant Professor in Infectious Diseases at the University of Pennsylvania said: “I think some has to do with the global economic downturn, but it also has to do with donor fatigue and the fact that governments view foreign assistance as expendable.” According to Cohn, this back-pedalling by international donors is already having an effect on some of the most vulnerable states on the continent. In 30 African states, donor funds account for more than 70% of expenditure on HIV treatment and care. In countries like Uganda and Mozambique, caps have been imposed on the numbers of people that can be put on treatment, and there are reports of a shift in donor funds from recurrent expenses to one-off investments.

A moral obligation

While governments in low and middle-income countries must most certainly be held accountable for increasing domestic resources to address the pandemic within their own borders, some believe that donor governments have a moral obligation as well: “The reality is that those cuts, as devastating as they are to these communities, will never balance the budgets of the richest countries in the world. They are not necessary cuts. Fundamentally, they are political choices. African communities have become collateral damage in an effort by some donors to attempt to step away from a commitment that they made as members of the international community. I think that our challenge as a global social movement to promote universal access to HIV treatment, to freedom from TB and protection from Malaria, as well as the human right to health, is to ensure that they don’t get away with it”, said Asia Russell, Director of International Policy for a U.S.-based HIV advocacy organization called the Health Global Access Project.

While activists around the world are enraged by recent retrenchments, Russell expressed hope that civil society could ensure that donors do the right thing: “We know that the cost of doing the wrong thing is astronomical. It is morally, politically and economically untenable. I think that is why even a sceptic can understand that, although we are facing a moment of acute challenge, this threat is something that is imminently surmountable.”