The choice between rail and road:perspectives from Delhi
This week I started a 3-week research trip to India, based at the Centre for Chronic Disease Control in New Delhi. Yesterday I rediscovered the joy of train travel. My morning began with a ride on the efficient Delhi metro at 6.15am. The service is state-of-the-art in South Asia, and in my view, compares very well with similar services in many high-income countries. Alongside the option of driving, sitting on the train from Delhi to Chandigarh was not only much more relaxing, but I actually had the time to take in the views as we travelled through colourful North Indian villages.
Contrast this with the situation on India’s roads. Even in urban centres such as Delhi, the chaos of road traffic makes you wonder at how survival statistics are not worse. India has a higher rate of road traffic accidents (RTAs) than anywhere in the world, according to the World Health Organisation’s report last year, with 14 people dying every hour on the road. Globally, RTAs make up a third of unintentional injury deaths, with double the death rate and three times the burden of disability in low-middle income countries compared with high-income countries, which are less able to cover the huge economic and social costs. Children are more likely to be victims, and RTAs are projected to be fourth leading cause of death in 2030.
One recent post-mortem study from Kolkata found that a staggering 63.1% of deaths were due to accidents, mostly on the roads. The dire circumstances which can result from RTAs are shown by a case report from Jaipur, India, simply titled, “An unusual presentation of head injury: teeth in brain”.
Interestingly, an analysis from the UK estimated that walking to and from stations accounted for 65% of the overall door-to-door risk of being killed on rail journeys; with the rail system itself accounting for only 21% of the risk. In other words, it is the risk of the road which causes deaths on trains in England as well. There are calls for better data globally, since only 20 countries have the high-quality data needed to accurately estimate mortality from RTAs but I think I have read enough. I will use the train whenever possible. The urgent message for Indian policymakers is that a comprehensive policy for road safety is required and fast.
Beyond trials and looking to prevention. Notes from AHA 2011
Since the early trials of beta-blockers and thrombolysis, or “clot-busting” drugs, in cardiovascular disease, the American Heart Association Scientific Sessions and other international cardiology meetings have been dominated by highly-anticipated “late-breaking” or “hot trials” sessions. During these talks, thousands of conference attendees would clamour to hear the results of trials of new drugs reported for the first time. As well as being highly talked about, they greatly influence projections of how the drug will perform in the real market: akin to a stockmarket floor for pharma. Today new drug trials are still by the dozen, but difficult economic times, increased regulation of pharma and wider and quicker dissemination of results may be changing the role of these sessions.
Aside from the trials, three messages are coming through loud and clear from this year’s meeting in Orlando. First, although the best-attended sessions are still the trials of new interventions and drugs for the range of cardiovascular disease, the number of talks devoted to primary prevention and primordial prevention is growing. In other words, prevention of the development of disease and prevention of the development of risk factors of disease, respectively
Second, there is a shifting focus on risk factors as continuous exposures over the whole lifespan. For example, we have talked about “pack-years” of smoking for a long time, i.e. an individual’s lifetime exposure to cigarette smoke. Rather than looking at arbitrary cut-offs for risk factors such as hypertension or high cholesterol, it may make more sense to look at the burden of that risk factor over their lifespan, and in combination with other risk factors.
Third, in the aftermath of the September UN high-level meeting, there is an increasing recognition of the global health aspects of heart disease and stroke. In a session chaired by Professor Sir Magdi Yacoub, eminent cardiac surgeon and long-term activist for improved health services for heart disease in low-income countries, a researcher from Mozambique showed the huge disease burden how feasible screening for common heart diseases can be, even in rural settings.
All three of these changes are welcome and signal gradual, encouraging paradigm shifts among both researchers and health professionals to look at the bigger picture of prevention and population approaches to cardiovascular disease.
Age ain't nothing but a number
Yesterday’s news hero was 100-year old Fauja Singh who finished the Toronto Waterfront Marathon to enter the Guiness Book of Records as the oldest man to ever complete a marathon. After reading so much about obesity, lifestyle risk factors and the chronic disease epidemic, it is great to hear that this Sikh gentleman has reached his age and maintained his fitness by sticking to ginger curry and tea.
Age and the “elixir of life” seem to be the theme of the news this week. Scientists fully decoded the genome of the world’s oldest woman who died in 2004 at the age of 115 years. This lady had no signs of dementia whatsoever and her good health has led to hopes that her genome will provide clues to her longevity. A herring-rich diet may have had something to do with it.
Ageing research is big money and a big priority. At the National Institutes of Health (NIH), over US$2.5 billion will be spent on ageing research this year, and the UK has been strengthening its ageing research portfolio and networks for the past few years. Scientific journals have blossomed around the search for life-prolonging knowledge. Did you know there was a journal called “Rejuvenation Research” ?
In clinical trials and research studies, if a difference is detected between two groups of individuals, often the first step in analysis is to “adjust for age”. In plain English, that means if we get rid of the differences between two groups which are just caused by differences in the ages of the individuals in the two groups, then we can assess if there are any other differences. It has always seemed counterintuitive to me that we do not also routinely adjust for sex, ethnicity, education, socioeconomic status and any number of other risk factors which can cause differences between groups of people.
With the make-up of our societies shifting more in the direction of elderly populations with increasing chronic diseases, the focus of research is shifting to how age itself contributes to disease processes and how we might reverse age-related processes. But are we focusing too much on just one factor? Age is undoubtedly a major contributor to many diseases and their underlying development but we cannot look at age in isolation. Fauja Singh and other healthy ageing adults reach their old age due to the complex interactions between genes, environment and chance, like every disease that medical science has so far uncovered. So to just look at his genes for the answer or for everybody to start on a diet of ginger curry does not make sense to me.