Alcohol services reaching 'crisis point', report warns

Services for people struggling with alcohol dependency have reached “crisis” point, according to a new study.

A lack of sufficient investment and not enough staff left many health professionals concerned about the state of the sector, the report found, adding that it “cannot survive” without additional funding.

Only 12 per cent of the 154 health professionals surveyed by recently merged Alcohol Concern and Alcohol Research UK felt that resources in their area were sufficient.

More than half of respondents (59 per cent) felt the situation had become worse over the past three years, with residential rehabilitation facilities hit the hardest.

Cuts to services of between 10 per cent and 58 per cent were also reported.

The study, which will be launched on Tuesday at the All Party Parliamentary Group on Alcohol Harm said: “Substance use treatment services in England are, it appears, facing a crisis.”

“The challenges facing alcohol treatment services are numerous and, in many cases, acute.

“They are, undoubtedly, a consequence of funding cuts which have gone beyond what a functioning system can sustain if the goal is the meaningful reduction of harm to individuals, families and communities.

“Alcohol services cannot survive at their current level of funding.”

In England, there are around 595,000 people in need of specialist support for dependency on alcohol.

 Around 108,000 people receive treatment, according to a study by the University of Sheffield in 2017.

It is thought approximately 200,000 children are cared for by someone with a drinking problem.

The report calls on the government to develop a national strategy for tackling alcoholism, “plug the gap in treatment funding” and order a national review into staffing problems.

Dr Richard Piper, CEO of the new charity formed by the merger of Alcohol Concern nd Alcohol Research UK, urged those in charge to act now. 

She said: “Around 595,000 people in the UK are dependent on alcohol. It’s clear that the government must develop a national alcohol strategy to address the harm they and their families face, and include treatment at its heart to reduce the suffering of the four in every five who currently do not access the services they need.

“This report shows very clearly what action is needed and we urge policy-makers, practitioners and service providers to join together to implement these recommendations to help the hundreds of thousands of people who are in desperate need of support.”

Press Association contributed to this report. 

منبع مطلب : http://www.independent.co.uk/news/health/alcohol-services-uk-alcoholism-report-support-government-a8330181.html

Labour MP John Woodcock suspended from party after sexual harassment allegation

High-profile Labour MP John Woodcock has been suspended from the party after an allegation of sexual harassment was levelled against him.

Mr Woodcock, a prominent critic of Jeremy Corbyn’s leadership, was accused of sending inappropriate texts and emails to a former staff member from 2014 to 2016.

The MP for Barrow was made aware of the claim in December last year and told the Sunday Mirror who first reported the allegations at the weekend that he “does not accept” the claims.

But on Monday, a Labour Party source said: “John Woodcock has been suspended from the Labour Party pending due process.

“It would not be appropriate to comment further on an ongoing case,” they added.

The Huffington Post reported that Labour’s governing body – the National Executive Committee (NEC) – had decided in 2017 to refer the case to the party’s disciplinary body.

Mr Woodcock added on Sunday: “I was made aware in December last year that a complaint made against me was being referred to Labour’s national constitutional committee as a potential breach of the party’s policy on sexual harassment.

“I do not accept that charge but know the complaint must be thoroughly and fairly investigated.

“I have not yet been notified of any date for a hearing and was following the party’s guidance that the process should remain confidential to reassure potential victims that they could make complaints without being exposed to unwelcome publicity.

“Therefore I do not intend to discuss details of the issue ahead of any hearing.”

The Independent has contacted Mr Woodcock for comment on his suspension.

منبع مطلب : http://www.independent.co.uk/news/uk/politics/john-woodcock-suspended-labour-why-mp-investigation-sexual-harassment-allegation-a8330126.html

Mentally ill subject to 'physical violence and verbal threats' while held under Mental Health Act, finds report

Mentally ill people are being subjected to “distressing experiences” including physical violence and verbal threats while detained under the Mental Health Act, a government-commissioned review has found.

A report on the interim findings of the review, commissioned by Theresa May last October, warns people held under the act are vulnerable to “potential coercive mistreatment”, which can lead to physical and psychological harm.

The Mental Health Act 1983, which covers the assessment, treatment and rights of people with a mental health disorder, has come under scrutiny after it emerged growing numbers are being detained under the legislation.

The review, which will publish its formal recommendations for the government in autumn this year, has so far carried out a survey of more than 2,000 people and conducted new research as well as discussions with service users and carers.

Interim findings show that while the act can save lives, many held under it are subject to mistreatment, with two-thirds of those who expressed a strong view saying they were not treated with dignity and respect.

“It is concerning that people often do not feel safe, treated with dignity or that their human rights are respected whilst detained,” the report stated. 

“The inherent power imbalance means detained patients are vulnerable to potential coercive mistreatment, abuse and deprivation of human rights, leading to physical and psychological harm.”

It went on to say: “Throughout all of our engagement with service users and carers, we have been made aware of a wide variety of distressing experiences including but not limited to, experiencing or witnessing physical violence, verbal abuse and threats, bullying and harassment, sexual predation, pain-based restraint, coercive reward and punishment systems for access to open air, leave or family contact.”

The review also highlighted that people of African and Caribbean heritage in particular were detained more than any other group, and highlights that services “do not always take proper account of people’s cultural circumstances and needs”.

“Our focus groups with participants from BAME communities overwhelmingly told us they felt there was a lack of cultural awareness in staff and a need for culturally appropriate care. They also expressed concerns about racism, stigma, stereotyping and overmedication,” it stated.

The researchers suggested the NHS should play a bigger role in healthcare services in police custody, saying the care of people in cells is “as much an issue for health and social care as it is for police”. 

“We will consider whether NHS England should take over the commissioning of police custody healthcare services, or otherwise create a plan so that people in police custody get better care, and faster transfers out to NHS and social care services,” the report stated.

The findings also pointed to issues arising for children and young people being placed in hospitals far away from their families or detained during their time at school, resulting in delays in their education.

Presenting the interim findings, Professor Simon Wessely said: “People with the most severe forms of mental illness have the greatest needs, and continue to be the most neglected and discriminated against. 

“Furthermore, they are also the group who are the most likely to be subject to the influence and powers of the Mental Health Act. We have an opportunity to replicate the advances made for people with common mental illness for those with more serious conditions.”

Danielle Hamm, associate director of campaigns and policy at Rethink Mental Illness, said in response to the interim findings: “This landmark review confirms what we have long known: that there are serious problems with the Mental Health Act. 

“People who have been detained under the act have been telling us how it fails to protect their rights and dignity, and how they are kept out of decisions about their own care. Today is an important validation of this and a much needed call to action.

“In recent years we have seen a welcome increase in mental health awareness. However, the rising tide hasn’t lifted all boats. The review makes clear that those severely affected by mental illness, such as people living with schizophrenia or bipolar disorder, who are more likely to be held under the act, have been dramatically underserved.

“The review’s interim report has clearly set out the need for change and it should be required reading for politicians, whose task now must be to commit to reform this important but outdated legislation.”

منبع مطلب : http://www.independent.co.uk/news/uk/home-news/mentally-ill-mental-health-act-detained-physical-violence-threats-treatment-a8329891.html

More than 1,000 people could die if England doesn't mirror Scotland's alcohol pricing reforms within five years, warn campaigners

More than 1,000 lives could be lost if England fails to mirror Scotland’s sweeping reforms to alcohol pricing within five years, campaigners have warned.

Medical leaders have joined with a leading children’s organisation and a homelessness charity to call for minimum unit pricing (MUP) to be implemented south of the border.

The changes, coming into effect in Scotland on Tuesday, will drive up the price of bargain booze by setting a floor price below which a unit of alcohol cannot be sold.

It is hoped the move will curb alcohol related death and illnesses, while reducing crime and lessening the burden excessive drinking places on the health service.

The Alcohol Health Alliance UK (AHA), a group of more than 50 medical organisations including the British Medical Association, Royal College of GPs and Alcohol Concern, launched an intervention with the Children’s Society and homelessness charity Thames Reach on Tuesday.

They said that a delay of five years could lead to more than 1,000 people dying in England from alcohol-related problems.

MUP would not affect bars and pubs in England, instead pushing up the price of cheap supermarket vodka and super-strength lagers which are popular with street drinkers and other vulnerable groups, the group said.

Chair of AHA Sir Ian Gilmore said: “Cheap alcohol is wrecking lives and livelihoods in England as well as Scotland.

“There are more than 23,000 deaths a year in England linked to alcohol and many of these come from the poorest and most vulnerable sections of society.

“Minimum unit pricing will save lives, cut crime and benefit the public finances. At the same time, pub prices will be left untouched and moderate drinkers will barely notice the difference under MUP.

“Any delay in implementing MUP in England will only cost lives and lead to unnecessary alcohol-related harm. We urge the Westminster government to act now.”’

As of Tuesday, the floor price for alcohol will be set at 50p per unit, meaning a pint of beer containing two units will have to cost at least £1, while a nine-unit bottle of wine will be a minimum of £4.50.

Chief executive of Thames Reach Jeremy Swain said: “Cheap, high-strength ciders and super-strength lagers are responsible for more deaths among homeless people in the UK than either heroin or crack cocaine.”

He added: “Minimum unit pricing would significantly raise the price of these damaging products, creating a strong motivation for the vulnerable, dependent drinkers we support to move to weaker, less damaging drinks. Without doubt, this change will diminish the extreme health problems experienced by dependent drinkers in our projects and ultimately, save lives.

“We call on the Westminster government to act now to ensure minimum unit pricing is implemented in England urgently.”

Sam Royston, director of policy and research at the Children’s Society, said: “We know through our research and direct support for children that parents’ alcohol misuse can tear families apart, is linked to domestic abuse and children living in families affected by mental ill health or facing homelessness.

“There is clear evidence that minimum unit pricing targeting the cheapest alcohol reduces consumption and harm. This can only help to reduce the devastating impact problem drinking by parents can have on families.”

PA

منبع مطلب : http://www.independent.co.uk/news/uk/home-news/scotland-alcohol-minimum-unit-pricing-1000-people-die-bma-royal-college-of-gps-aha-a8329621.html

Marco Rubio admits Republican tax bill benefits corporations much more than average Americans

A prominent Republican says that the tax cuts passed late last year are not helping American workers nearly as much as members of his own party have predicted.

In an interview with The Economist, Senator Marco Rubio said that he has not seen evidence that corporations are behaving the way the Republican Party predicted when trying to promote their tax cut bill. Instead of investing in their workers, corporations are mostly using their tax cuts to buy their own stocks, Mr Rubio claimed.

“There is still a lot of thinking on the right that if big corporations are happy, they’re going to take the money they’re saving and reinvest it in American workers,” Mr Rubio said in the interview, published late last week. “In fact they bought back shares, a few gave out bonuses; there’s no evidence whatsoever that the money’s been massively poured back into the American worker.”

Democrats, including the communications director for Senate Minority Leader Chuck Schumer, seized upon the remarks, noting that the statement is similar to what Democrats have been saying about the tax breaks for months.

The Democratic position — that the tax cuts are mostly being used to buy back stocks — has largely been cornered by Republicans who note that companies have used their breaks to give workers bonuses, wage increases, and to make new capital investments.

“There is no more eloquent critic of Marco Rubio’s voting record than Marco Rubio,” Seth Hanlon, a former special assistant to President Barack Obama tweeted.

 

 

Matt House, the communications director for Mr Schumer, tweeted to note that Mr Rubio was basically saying “exactly what Democrats have been saying about the tax bill for months”.

The tax law pushed for and passed by Congress cut the corporate tax rate permanently from 35 per cent to 21 per cent, while offering tax breaks to Americans that are set to expire after a certain period of time.

Mr Rubio, who had pushed for the corporate tax rate to be cut to 25 per cent, had threatened to vote no on the bill if the child tax credit was not expanded. He later voted for the deal after the credit was epanded.

A spokesperson for Mr Rubio said Monday that Mr Rubio has “pushed for a better balance in the tax law between tax cuts for big businesses and families, as he’s done for years.”

“As he said when the tax law passed, cutting the corporate tax rate will make America a more competitive place to do’ business,” the spokesperson continued, “but he tried to balance that with an even larger child tax credit for working Americans.

Mr Rubio had previously expressed concern that the bill was too kind to corporations.

منبع مطلب : http://www.independent.co.uk/news/world/americas/us-politics/marco-rubio-tax-bill-benefits-corporations-stock-buyback-a8330281.html

Car insurance premiums fall for first time in two years

The average price paid for motor insurance has recorded its first quarterly fall in two years, according to insurers.

Despite the drop, average costs during the first quarter of 2018 were the highest that the Association of British Insurers (ABI) has ever seen at this time of year.

The ABI’s latest Motor Insurance Premium Tracker found the average price paid for private comprehensive motor insurance was £478, down £13 on the final quarter of 2017, as well as being the first quarterly fall in premiums in two years.

The index, which started in 2012, measures prices consumers pay for their motor insurance, rather than quotes.

The ABI said £478 is the highest average premium it has recorded for the first quarter of any year.

It marks a £14 increase on the same quarter last year.

The ABI said the price of motor insurance is subject to seasonal trends and average motor insurance premiums can fall in the first quarter of the year due to new car registrations in March, which boost demand for motor insurance, leading to more competition.

It said the Civil Liability Bill, which makes changes to the personal injury compensation system in England and Wales, may also have contributed to a more pronounced fall in the first quarter of the year.

Rob Cummings, the ABI’s assistant director, head of motor and liability, said: “While this small fall in the last few months gives some relief to motorists, it is in line with seasonal trends and the underlying cost pressures from things like personal injury claims remain.”

He continued: “The Civil Liability Bill now going through Parliament will fix a broken system and help millions of motorists whose premiums had been going up and up over the last two years.”

PA

منبع مطلب : http://www.independent.co.uk/news/business/news/car-insurance-premiums-fall-for-first-time-in-two-years-a8329751.html

How to make pasta with smoked salmon, watercress and horseradish

Pasta with smoked salmon, horseradish and watercress

Prep: 5 mins
Cook: 10 mins
Serves 4

300g penne pasta
Finely grated zest and juice of 1 lemon
1tbsp cream horseradish sauce
150g low fat Greek style yoghurt
Salt and freshly ground black pepper
100g pack watercress, roughly chopped
100g smoked salmon, finely chopped

Cook the pasta in a large pan of boiling salted water until it is just tender – about 10 mins. Drain the pasta in a colander and return it to the pan.

Add the lemon zest and juice, horseradish, yoghurt and plenty of ground black pepper, then stir to coat the pasta. Add the salmon and watercress and gently stir to mix. Divide between four plates with more watercress on the side if liked.

Recipe form watercress.co.uk

منبع مطلب : http://www.independent.co.uk/life-style/food-and-drink/recipes/pasta-smoked-salmon-watercress-ingredients-cooking-instructions-a8329306.html

The mysterious Cambridge library tower, supposedly full of banned books, is opening to the public

It has inspired long running myths – notably that it hides a stash of Victorian pornography – is home to 10 storeys of books, has given rise to some dark tales of famous literature and has dominated the skyline of one of the nation’s most historic university cities for almost a century. 

At 157ft tall and 17 floors, Cambridge University Library’s tower can be seen for miles around but has largely kept its secrets to itself and its contents (approaching one million books) have given rise to much speculation.

But now in a new free exhibition, Tall Tales: Secrets of the tower, we reveal some of the truth about what the great skyscraper really holds.  

Just over a year ago, the first question at my interview for the job of Cambridge University librarian asked about the importance of a legal deposit – or copyright – library. 

The factual answer is that, by law, it means we are entitled to receive a copy of every book that is published in the United Kingdom and Ireland. But the answer that speaks to my passions as a librarian and archivist, is that it means we are home to a collection that tells the remarkable story of our national life through the printed word. 

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In the exhibition, which opens on 2 May, we lift the lid on two centuries of popular publishing in the UK, received under the Copyright Act and held in the tower since the building opened in 1934. 

Victorian toys and games jostle for a place with colourful children’s books, Edwardian fiction in pristine dust jackets and popular periodicals. Once considered of “secondary” value to the main academic collections, the tower collection is a treasure trove for today’s readers and researchers.

At the time they were published, librarians would never have considered these books important. Many were ephemeral, populist, mainstream scribblings not worthy of the notice of Cambridge scholars, and so banished to the tower.

It’s a marker of how little was thought of the books that no thought was given to future browsing by author or subject, and they appear to have been placed in the sequence simply in the order in which they arrived in any one year. 

Today, this makes for quite surreal bedfellows with, say, an edition of War and Peace elbowing for position next to a Dull Thud (a long-and-probably-best-forgotten murder mystery). But in terms of social history, it’s fantastic. 

You can literally stand in front of a given year and see exactly what was published. This must be the academic equivalent of being a child in a sweet shop; an experience the exhibition tries to recreate for visitors with a towering pillar of 1,950 books with the serious and the quirky side by side.

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The benign neglect of these books had other unexpected benefits. It wasn’t until the early 20th century that the potential of the dust jacket (a term that derives from its original role as a purely utilitarian paper wrapper used by 19th-century booksellers to protect ornate leather bindings) as art began to be recognised. 

Through the 1920s, the illustrated jacket became established as a vibrant area of the applied arts. Most libraries discarded these paper wrappers on purchase. But Cambridge, opting for efficient minimum handling, did not, a decision we can delight in today. 

This probably makes the tower collection unique – unusual even among its peers in the legal deposit libraries of Oxford, Trinity College Dublin, the British Library and the National Libraries of Scotland and Wales.

Looking around the Tall Tales exhibition, the changing fashions through display of book jackets is striking. The Mediterranean colours of Ernest Hemingway’s The Old Man and the Sea, the darker tones of William Golding’s The Pyramid, or the action and adventure of Ian Fleming’s Casino Royale – with artwork by the author himself. 

You can’t go up into the university library tower without a trip down memory lane, especially if you, like me, were a bookish child. 

I’d forgotten, until I spotted Five Fall into Adventure (1950), my excitement aged seven of devouring all my father’s dog-eared copies of the Famous Five. What a guilty pleasure to see those old friends again in the exhibition. 

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Perhaps you might not expect to find the original series of the Mr Men in a university library, but aren’t you glad these much-loved characters will still be here in hundreds of years, representing one of the most successful picture books of all time with sales of over 100 million copies in 28 countries worldwide? And to think it all began when Roger Hargreaves’ son asked him what a tickle looked like. 

Preserving the documentary heritage, which is what the UK and Ireland copyright libraries do for the nation, is about retaining the breadth of what is published. There is a suspicion that Cambridge’s strength of “secondary” holdings from the mid-19th century onwards came about not so much because of a positive desire to collect (as is now the case) but because it was easier to accept every book than to make decisions on each item. 

But there are signs of selectivity on “secondary” periodicals of the period, driven by space, and that selection reflects the taste and social judgements of the time. We have The Girl’s Own Annual (in the exhibition), but not the less respectable Victorian title Tit-Bits, which ran for 80 years from the 1880s. We only started taking the Beano in 1976 (about the time I began waiting for it to drop through the letter box so I could read Dennis the Menace), although it started between the wars; but the Eagle – a more middle-class magazine for children – we have from its first issue in 1950. 

The space issue is a serious one. In 2000/01, Cambridge University Library was receiving about 1,600 printed books a week (85,000 per year) and about 1,800 serial parts (newspapers and so on). Even with 17 floors, a growth rate of two miles a year is far from sustainable. 

To help meet our responsibility as part of the national collection, we have just opened a brand new book store in nearby Ely. It doesn’t have a tower but it does have more than 100 kilometres of shelves reaching 11 metres high (imagine two giraffes). 

Legal deposit also moved into the digital age on 6 April 2013, when new legislation for electronic deposit came into force. Since then, we’ve received a little over 250,000 ebooks on deposit and 270,000 printed books. 

There is also now a Non-Print Legal Deposit UK Web Archive, which includes millions of UK websites and surely must be the digital “tower collection” of popular ephemera for the future. Ironically, under the terms of current legislation, this internet treasure trove can only be accessed in the physical reading rooms of the copyright libraries, despite its electronic format. 

What, finally, about the Victorian pornography? It has long been a student myth in Cambridge that the library’s tower is where the more risque books are hidden away from prying eyes. 

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While the exhibition debunks this story, works of a sexual nature do come into the library and for many years were secreted away in a collection that came to be known as the “Arc” (from the Latin for “secret things”). 

The Arc used to be stored in the safety of the librarian’s office. Today the remainder of the Arc is in the vaults and the majority of modern additions are books that have been withdrawn from publication for legal reasons, like libel. 

And in my office, no more forbidden books but a print of a rare suffragette poster, one of 14 originally shelved in the tower until recently on display in the library to mark 100 years of women’s suffrage. Times do change and, as the second female Cambridge university librarian in 600 years, these symbols do matter. 

This year, for the first time, the rainbow flag flew from the iconic library tower to mark LGBT+ history month and show that our city and university are places where people can be themselves without fear of discrimination. 

The Cambridge University Library is the work of architect Sir Giles Gilbert Scott, who also gave us the much loved red telephone box (the design of which is mirrored in the library’s tall windows), Battersea Power Station, and the Bankside Power Station (now Tate Modern). 

It’s an irony of the exhibition that the tower, home of so many cultural riches, was an afterthought, not in the original plans. Philanthropist John D Rockefeller, who generously provided much of the funding for the building, felt it needed a bold statement to reflect its academic standing. 

Tall Tales hopes to make the secrets of the university library welcoming and open to all visitors. The treasures we’re proud to display provide a rare insight to a wealth of ephemeral and popular literature that little survives today outside of the copyright libraries. 

The exhibition is a testament to the importance of legal deposit – both print and now electronic – which has been part of English law since 1662, helping to ensure our nation’s publications, and thus intellectual and cultural history, is collected and preserved for all future generations.   

Tall Tales: Secrets of the Tower is open until 28 October 2018. Dr Jessica Gardner is Cambridge University’s librarian and director of library services@CamUniLibrarian

منبع مطلب : http://www.independent.co.uk/news/long_reads/cambridge-university-library-tower-banned-books-opening-copyright-a8325196.html

The long and expensive fight to eradicate polio

For more than a quarter of a century a group of a few hundred experts based in Switzerland has been masterminding the most complex medical campaign of all time – to eradicate polio, the nerve-destroying virus that has caused death and disability on a terrifying scale.

Working out of an anonymous office block in Geneva, headquarters of the World Health Organisation (WHO), they have recruited more than 20 million vaccinators worldwide who have administered more than 10 billion doses of oral polio vaccine to more than 2.5 billion children. They have scoured city slums and mountain villages, toured war zones and refugee camps, reached nomadic tribes and jungle communities and have chased the virus to the brink of extinction.

Success is now tantalisingly close. There has been a greater than 99.9 per cent drop in the number of cases since 1988, when the Global Polio Eradication Initiative was launched and 1,000 children worldwide were being paralysed by the disease every day. More than 13 million people have been saved from severe paralysis and a generation of children has been protected from devastating disability and death. The virus is holed up in a few communities straddling the border between northern Pakistan and Afghanistan, where it is making its final stand. With one last push, it could be gone for good. 

But the campaign has not been quite the success that some have suggested. On 24 October 2017, World Polio Day, the UK Department for International Development (DFID) – a supporter of the eradication campaign – set out the progress achieved in a series of tweets:

“New polio cases in 1988: 350,000.”

“New polio cases in 2016: 37.” 

“A 99.9 per cent drop in less than 30 years.”

No one can deny the extraordinary scale of this achievement against a disease that has been the scourge of mankind for centuries. In 2017 there were just 21 confirmed cases of infection with wild polio virus causing paralysis worldwide, another record low. The disease that was endemic in 125 countries in 1988, including huge swathes of South America, Europe, Africa and Asia, is now endemic in just three – Pakistan, Afghanistan and Nigeria. 

But while DFID’s tweets were not inaccurate, what they omitted to say was that we have been on the brink of eliminating the disease for the whole of the present century. In little more than a decade between 1988 and 2000, the number of cases fell by 99 per cent. In the near two decades since then the programme has striven to eliminate that final 1 per cent. Again and again, it has failed. 

From 2000 to 2010 cases hovered between 500 and 2000 a year. Enormous effort was expended to chase the last ones out and spending rose to $1bn a year. But the virus evaded its captors. Since 2010, the numbers have begun to creep down again. Yet it is still hanging on. Nigeria, declared polio-free in 2015, recorded four cases in 2016, caused by a virus that had been circulating undetected for five years in Borno, in the north of the country. 

The final 1 per cent has proved remarkably resistant. “We can end polio for good,” DFID tweeted in October, a refrain that has been repeated by all partners involved for almost two decades. But the programme has missed every deadline it set itself for eliminating the disease – in 2000, 2004, 2009, 2012 and 2016. Some critics allege it has become a lifestyle, not a mission.

Why did the polio eradication programme stall? And can it still succeed? Some say that if it does so, it will rank as mankind’s single most ambitious accomplishment. But the answer to the second question depends critically on the answer to the first. 

A virus that has existed for millennia

Poliomyelitis, also called infantile paralysis, has existed for thousands of years. By the early 20th century it was one of the most feared diseases in industrialised countries. Outbreaks occurred regularly across the world until the 1950s, paralysing hundreds of thousands of children annually and causing panic whenever new cases were detected. 

In his novel Nemesis, Philip Roth describes the arrival of polio in Newark, New York, in the summer of 1944. No one understands how polio spreads and as children succumb, panic and paranoia grow. Neighbours of sick children demand they be quarantined, a local hot dog joint is shunned and a mentally disabled man called Horace is accused of being a carrier.  

The polio virus infects nerve cells, destroying muscle function and eliminating tendon reflexes, especially in the legs, leaving the victim severely paralysed. In the worst cases it spreads into the brain stem, destroying the nerve cells that control breathing and swallowing. Survival then depends on artificial ventilation – thousands were treated in iron lungs in the 1950s – until the acute phase of the illness is past. 

It is an intestinal virus that penetrates the lining of the gut and becomes lodged in the lymph nodes. There it causes fevers and stomach upsets, and passes back into the faeces. It can survive for up to 60 days outside the body, and in the absence of good hygiene and sanitation it can contaminate drinking water.

The introduction of effective vaccines in the 1950s and 1960s brought it under control and in 1988, the WHO conceived the idea of a campaign to eradicate it for good, to ensure no more children were crippled for life. Billions of dollars have been spent, millions of volunteers recruited and billions of children immunised as the battle has been carried to the remotest corners of the globe. 

2018 could be the year that it is ultimately driven to extinction. But if history is any guide, the final push will demand a superhuman effort. Past attempts to eliminate diseases have almost all failed. In his book Better, Atul Gawande recounts how in the early part of the 20th century billions of dollars were spent on successive campaigns to eliminate hookworm, yellow fever, yaws (which causes purulent skin ulcers) and malaria – all without success.

The shining exception was the battle against smallpox, eradicated in 1978 following a mammoth campaign that was, even so, much simpler than the one against polio. Smallpox is marked by a distinctive rash. When it occurred, a team could be dispatched to vaccinate everyone the victim may have had contact with, in a technique known as “ring immunisation”.

The same method is not available with polio because for every case of paralysis there are at least 200 – and possibly as many as 1,000 – who suffer, at worst, a fever and an upset stomach. They soon recover but remain silently contagious for weeks after their symptoms disappear. Ring immunisation would require a huge target area. And as the oral vaccine does not always “take”, especially in children with diarrhoea whom it may pass straight through, repeat vaccination is required.

India’s achievement

Vaccination is the cornerstone of the polio eradication strategy. The target is to deliver at least three doses of oral vaccine to every child within the first year of life, and to keep repeating for all children under five to ensure none miss out. The vaccination programme in each country is a huge logistical operation. Worldwide, more than 20 million volunteers are involved in repeated sweeps as many as 10 times a year. The easiest areas were cleared of polio many years ago. Those still infected are places where eradication is most difficult, because of conflict, political instability or hard to reach populations with poor infrastructure. Moreover, as the number of cases falls, finding them becomes more difficult. 

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The virus can hide away, travel hundreds of miles and then spring out. Corruption, insecurity and poor management are its aids. Every last drop has got to be squeezed out – even if the programme is down to the last dozen cases it is not down to zero. No one knows what that will take. 

Confidence that it can be done comes from India’s success in eliminating the disease. The last case of polio in India was recorded in 2011. In one of the most chaotic, densely populated and deprived nations on earth, that is an astonishing achievement. 

The centrepiece of the Indian campaign is the national immunisation days (NIDs), begun in 1995, around which all other activities are organised. They are still held regularly to ensure it does not return – most recently on 28 January 2018 – even though the last case of polio in India was recorded almost seven years ago.

The aim is to vaccinate 172 million children under five on a single day, employing 2.5 million vaccinators who are moved in 155,000 vehicles (including boats, elephants and camels) carrying more than six million ice packs (to keep the vaccine cool) and supplying more than 700,000 vaccination booths – set up in hospitals, on street corners and out of the back of cars. The NID is followed by a five day mop-up phase in which vaccinators move from house to house, following a meticulously planned route, seeking out those missed. 

To see how it is done, I travelled to India for The Independent in 2013 to accompany two neighbourhood workers, Poonam and Mamta, on an earlier national immunisation day as they made their rounds in the Madipur district of Delhi, squeezing through narrow alleyways, pushing past dogs and children while dodging buckets of waste and ducking under electric cables. 

Poonam clutched a ledger with names and addresses and Mamta carried the insulated box containing the vaccine nestled on a bed of ice – half a dozen vials each enough for 20 children. They had 400 houses to visit over four days with a fifth day reserved for “mopping up”.

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As they knocked on doors, or called to upper floors, summoning families by name or simply with the words “Polio drops!”, dark-eyed children emerged from cell-like rooms, ready to receive their medicine in a ritual that had become routine.

The secret of India’s success is contained in the two-inch thick ring binder I found laid out on Dr Sucheta Bharti’s desk, the vaccine coordinator for Madipur, in a dimly lit office in the Jagwan Ram Government Hospital. Beside her on the floor, dozens of insulated boxes containing vials of vaccine on a bed of ice were standing ready to be loaded into 15 vehicles to be distributed to 160 vaccination booths across the north-west of the city. 

The ring binder held the “microplan” – hundreds of pages of coloured maps that detailed every corner of the district, with its allocated health workers. Here was identified every dwelling in the neighbourhood in a triumph of bureaucratic planning. The yellow section marking the slum we had just visited contained 18,000 houses covered by 28 teams of vaccinators, each with their designated route.

“Each paralysed person is a burden on themselves and on society,” Dr Bharti said. “This is the only programme that has reached to every doorstep. We have the vital statistics [for the country]. We can use this for anything.”

The major players

The polio eradication programme relies on the support and financial backing of a range of partners, led by the WHO. The key donors are Rotary International, the US Centres for Disease Control and Prevention, Unicef and the Bill and Melinda Gates Foundation who together have raised more than $16bn. 

By the mid-2000s, with the programme going nowhere, they were becoming restive. The programme was spending $1bn a year and supplying hundreds of millions of doses of vaccine across the affected countries – yet making no progress. There was frenetic activity but little analysis of what was holding up the programme’s advance. Its leaders believed they just had to push on.

Bruce Aylward, the charismatic director of the programme, was a talented leader who had been in post for 10 years and was known as Mr Polio. But there were complaints that there was too much power in his hands, he was not taking account of other partners and was driving on with the same methods he had used for years. He left the programme in 2014 to take charge of the WHO’s efforts against the ebola outbreak in West Africa.

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Unicef’s role was to obtain the vaccine, ensure it was kept cool throughout its journey, educate families about the importance of vaccination and ensure they were helped to attend. The emphasis had been on delivering the vaccine rather than communicating around it. 

The Centres for Disease Control in Atlanta was accustomed to dealing with outbreaks of, for example, Lassa fever. Their role in the polio campaign was to analyse data and send out field workers as advisers but Tom Frieden, their go-getting director from 2009-17, was critical of the programme’s performance.  

Rotary International had been in the polio eradication drive from the beginning and had raised a lot of money. They too were critical of the eradication efforts in some countries but their focus was on fundraising and they became agitated about the criticisms becoming too widely known because of its dampening effect on their supporters. They had begun planning celebration parties around the world in 2012 in anticipation of the end of polio and when it emerged the target might be missed they received thousands of emails from worried supporters. 

Bill Gates had made the eradication of polio his personal mission and invested hundreds of millions pounds as well as raising hundreds of millions more from other donors. It was clear that he would not allow it to fail. The Gates Foundation had many senior staff with expertise in vaccine-preventable disease. But he too had doubts about the leadership of the programme. 

What the eradication programme lacked was a rigorous analysis of its shortcomings. It needed a hard look at what it wanted to achieve, how to build confidence, what levers worked and how to motivate frontline staff. 

Reaching every last child

In 2010, Margaret Chan, then director-general of WHO, decided to act. She established an independent monitoring board (IMB) of international experts to hold the programme to account. The board, chaired by Sir Liam Donaldson, former UK government chief medical officer, quickly discovered all was not well. Discontent was growing with the lack of progress but the partners felt unable to challenge the programme’s leaders, particularly health ministers who were representatives of their member states.

An early IMB report contained a killer statistic: the number of missed children worldwide – 2.5 million – who had never had a single dose of vaccine. It pointed out that the programme could run 10 campaigns in a country but if the same 500,000 children were missed each time, repeating the campaign wouldn’t help. The programme’s slogan was “Every last child” so the IMB titled its report “Every missed child”.

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Reaching every child in each country posed huge challenges – mapping the houses, monitoring the vaccination teams, maintaining the supply lines, with all the potential for errors, poor practice and corruption. But no one at that stage was asking if it was being done right. At their weekly meetings, the programme leaders in the WHO were focused on technical issues – how many children were being vaccinated. They did not ask how they could improve the quality of the programme. 

A frequent defence offered was the security situation. In some areas the polio programme had become toxic. It was not helped by the Bin Laden episode – the CIA had used a fake hepatitis B vaccination campaign as cover to obtain vital DNA evidence that helped locate Osama bin Laden before he was assassinated – or by the reenactment of those events in the Hollywood blockbuster Zero Dark Thirty, where, for reasons known only to the filmmakers, the hepatitis B campaign was replaced by a fake polio campaign. 

Dozens of vaccinators had been killed in Pakistan, Afghanistan and Nigeria, because their activities were seen as part of a Western conspiracy. (A mother and daughter administering polio drops were shot dead in Quetta in the south-west of Pakistan in January 2018.) Everyone recognised that the courage and commitment of the vaccinators was remarkable and the programme owed it to their memory to succeed. But even in these areas, good management was key. 

In 2012 there was a window of opportunity in the endemic countries when the programme had access to all the children it needed to reach. It very nearly succeeded – but corruption, and the poor quality of the vaccinators meant it didn’t happen. It was not security but the delivery that was at fault.

In North Waziristan in Pakistan, the Taliban temporarily opened its doors in December 2012 and the programme was a few months off halting the virus and might have succeeded if it had seized the moment. Then there was a huge orchestrated uprising with 12 vaccinators killed. The window had been missed.

The lesson of that failure was that unblocking the security issues and creating a window was not enough. There had to be a properly managed programme ready to seize the opportunity. In North Waziristan it wasn’t properly managed – and it failed. 

In Afghanistan, the programme leaders complained that beyond the security issues they did not know what the problems were. A team was appointed to conduct an independent review which found the programme was good at negotiating access with the Taliban. But once the vaccinators got in, the review team discovered they were underage, missing lots of houses, and the cold chain – which ensures the vaccine is kept cool from depot to delivery – was not working. All the basic things were going wrong.

Security nevertheless posed an immense challenge. There were also darker political forces in play. There was a suggestion, though it was only hinted at, that in the wider geopolitical agenda, something might be given in return for something else. Drone attacks, for example. Would the terrorists back off for long enough to allow polio to be eradicated in return, say, for the suspension of drone attacks? It was never made clear. 

One factor was critical to success: ownership. Some countries – India, for example – had taken ownership of the problem but others hadn’t. India made polio a priority because it was sensitive about its reputation as a 21st century nation. But it didn’t work for Pakistan where there was evidence of massive corruption. Supervisory managers were pocketing funds which had a hugely damaging impact. The government was thought to be unembarrassable. 

What turned things around in Pakistan was the appointment of a senior official brought in as the prime minister’s adviser on polio who grasped the nettle. It was decreed that all vaccinators had to be over 18, each team had to have at least one woman and each had to have one government employee to increase accountability. From that point, Pakistan’s programme began to make progress. Having stalled for years, the numbers started coming down again.  

In its December 2017 report the IMB commended the “strong political engagement and leadership from all levels in Pakistan” but warned the targets were “incredibly complex”. 

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In August 2017, the government of Balochistan allocated an extra 1000 vaccinators and 300 technicians and there were signs of progress. The proportion of female community health workers, who can find missed and hidden children, had been increased to 88 per cent and the number of vaccine refusals had been reduced from 1500 in 2016 to 400 a year later. 

However, the small border community of Killa Chaman, which accounts for 70 per cent of polio cases in the region, is one of the most dangerous places in the world. It is difficult to get staff to go there. In late 2017, a district police officer was killed. The IMB said: “The border town is a hub of insecurity, illicit activities and community resistance.” In Quetta, 100km to the south, a woman and her daughter were shot dead in January 2018 while administering oral polio drops. 

There are further hotspots in Karachi, where campaign fatigue has produced a backlash, and in the twin cities of Rawalpindi and Islamabad. In slum areas, where all amenities are practically non-existent, people ask: why the focus on polio? Why not on other health services?

In Afghanistan concern is centred on 15 districts in Kandahar and Helmand in the south with a population of just over one million. They account for 90 per cent of polio cases in the region – owing to periodic inaccessibility, vaccine refusals and a high-risk mobile population. Yet even here there is progress. The proportion of missed children in Kandahar has been reduced from 13 to 6 per cent. 

Nigeria delivered a grievous shock to the programme when polio recurred in Borno in 2016, after the country had been declared polio-free. No new cases have been detected in the months since August 2016, but insecurity in the region, large cross border movements and a patchy immunisation campaign have left the IMB “deeply concerned”. Between 160,000 and 230,000 children and 30-40 per cent of settlements remain trapped by Boko Haram. “Unless there is a breakthrough to reach those areas the entire polio programme is at risk,” it says.

An outbreak of monkey pox has set Nigeria afire with rumours that the government vaccination campaign is the cause, undermining public trust. Political engagement has also waned.

Overall, the IMB warns of a “pervading sense of fatigue”. Poor quality programmes in key areas, a “worrying number” of inaccessible populations, and unreliable data are additional concerns. “The polio programme seems to have hit a wall, familiar to athletes in endurance sports in the final stages of a race,” it says.

A public health emergency

Back in 1988 at the launch of the eradication programme, the plan had been to drive out polio by improving routine immunisation, which protects children against a range of diseases from infancy, and add in additional “vertical” campaigns (focused on polio alone) where necessary. The strategy proved successful in the easier countries but in others, with less well established routine programmes, more vertical campaigns were needed. 

Over time the view developed that the routine programmes were never going to deliver, so the focus switched to the additional vertical campaigns. That was where a number of the problems – with management, political alignment, and communication – originated. 

By 2014, 10 countries had active polio outbreaks and, under pressure from the IMB, the director-general of WHO, Margaret Chan, declared the international spread of the virus a “public health emergency of international concern”. That enabled the coordination of an expansive international response, including measures requiring travellers from the worst affected countries to be vaccinated to prevent the virus from crossing borders. A WHO emergency committee was established which meets every three months to reassess the situation. At the Centres for Disease Control in Atlanta, an emergency operating centre was established that is normally activated only in a flu pandemic. 

Yet the programme itself did not respond to the heightened sense of urgency. The people running it had secured their funding and the problems they faced – terrorists – were completely outside their control so they couldn’t be held to account for them. They seemed to say: “Well, this is going to take a while now.” They slipped into complacency. 

Eliminating a disease is not like any other project. By common consent it is an incredible thing to be trying to do and is untested. So the programme could always defend itself by appealing to the scale of the challenge it faced. 

When it ran into difficulties the donors were more forgiving. Instead of saying, “You asked for $10bn and said that would be enough, so that’s it, no more”, they said: “We accept it is hard and you have some really tough challenges – have another $10bn.”

The great worry now is that the programme has run out of ideas. The IMB speaks of a “pervasive sense of fatigue and low spirit”. Some leaders have even wondered privately whether eradication is possible. Yet the goal is now so close that the pain of slipping back to a state where there were thousands of cases is impossible to contemplate. 

The programme is too big to fail. 

Preparing for the endgame

As the campaign enters its final phase, preparations have begun for the endgame. One challenge of using oral polio vaccine to eradicate polio is that when cases fall very low there will be a small number of cases caused by the vaccine itself. The oral vaccine contains a live, but weakened virus which replicates in the intestine for a short time while producing an immune response. During that period it is also excreted and in areas of poor sanitation it can spread in the local community. This has advantages because it offers protection to other unvaccinated children through “passive” immunisation, before eventually dying out. 

However, in areas where vaccination coverage is low, the excreted virus can circulate for a longer time, undergo genetic changes and, very rarely, develop into a form that can paralyse. This has happened in the past year in Syria, where there were 74 cases of circulating vaccine-derived poliovirus in 2017, after vaccination levels in the country dropped from 80 per cent to 40 per cent. There were also 12 cases in two outbreaks in the Democratic Republic of Congo (DRC).

The programme in Syria responded by vaccinating 355,000 children up to August 2017 in the governorates of Deir Ezzor and Raqqa where the continuing violence has devastated the health service and severely disrupted the routine immunisation service. Previous outbreaks of vaccine-derived virus have been rapidly stopped with two to three rounds of high quality immunisation campaigns and are regarded as less serious and more easily contained than outbreaks caused by the wild virus. But the impact on public trust when it becomes clear that the last cases of polio are to be blamed on the vaccine itself, can only be guessed at. The anti-vaccine conspiracy theorists will have a field day.

In order to avert more outbreaks like the ones in Syria and the DRC as eradication approaches, the oral vaccine containing the live virus is being phased out and replaced by an injectable vaccine which contains a killed virus. This inactivated polio vaccine confers longer lasting immunity than the oral vaccine (which may not “take” in a child with diarrhoea) but it does not spread protection to others, is more expensive and more complicated to administer, and requires trained healthcare staff to give it.

About 30 per cent of countries worldwide have so far switched to the injectable vaccine with the rest to follow once transmission of wild polio virus has been interrupted. There is a global shortage of the vaccine and stocks are being directed to countries in greatest need.

There is a bigger risk: the impact on health services in the most vulnerable countries once the last case of wild polio is eliminated and funding of the programme is wound down. Ending polio is the first challenge. Disassembling the enormous global organisation established over decades to do it, is the next. As the IMB has put it the “high-profile, assertively top-down enterprise now needs to turn the entire juggernaut around as it prepares to put itself out of business”. 

This is already starting. The programme currently spends $1bn a year, of which 90 per cent is directed to the 16 most vulnerable countries. It has 30,000 staff on substantive contracts and a workforce of millions within local communities who are either volunteers or paid on a daily basis. Funding has already declined by $330m in the last year and a further drop of $300m is expected by 2019. 

Some governments have woven polio-funded staff and infrastructure, built up over 30 years, into nearly every aspect of their public health systems. Their withdrawal could have a severe impact on health services in some of the world’s poorest countries, affecting their ability to respond to disease outbreaks. The WHO itself is threatened – around 20 per cent of its budget comes through polio programme donors. 

It would be a cruel irony if the success of the greatest medical campaign of all time were followed by the collapse of public health services in the most poverty stricken parts of the world. 

In South Sudan, for example, a country that has suffered through a catastrophic civil war and is among the poorest countries in the world according to the UN Human Development Index, the polio programme currently pays for 673 staff. They would be lost without careful transition planning.

Ethiopia has a polio budget of $39.8m which will drop to $4.6m in 2019, an 88 per cent cut in three years. Countries like these which are expected to take over the staff and infrastructure currently paid for by the polio programme are under great pressure. 

When the transmission of wild polio virus is deemed to have been interrupted there will be three years at least before the remaining endemic countries – and thus the world – can be declared polio-free. Maintaining vigilance, with the highest quality surveillance activities and the most thorough vaccination programmes will pose an immense challenge, with the potential of catastrophic outbreaks ever present. It will be a very hazardous time because of the large numbers of “missed” children in the mobile populations in Pakistan and Afghanistan, the trapped and inaccessible populations in Nigeria, weaknesses in surveillance systems and low levels of routine immunisation. Yet the temptation to celebrate prematurely will be intense. 

For some, however, it is already too late. In January 2018, Ghulam Ishaq, a shopkeeper from Karachi, was pictured on Instagram by National Geographic holding his daughter, Rafia, aged four. One of Rafia’s legs was shown withered by polio, the other encased in plaster after it was broken by a car she couldn’t dodge.

“I didn’t trust the polio vaccine,” Ghulam said. 

منبع مطلب : http://www.independent.co.uk/news/long_reads/polio-world-health-organisation-eradicate-disease-prevention-international-development-a8323541.html

How artificial sweeteners are linked to diabetes and obesity

The ConversationMany countries have introduced a sugar tax to improve the health of their citizens. As a result, food and drink companies are changing their products to include low and zero-calorie sweeteners instead of sugar. However, there is growing evidence that sweeteners may have health consequences of their own.

New research from the US, presented at the annual Experimental Biology conference in San Diego, found a link with consuming artificial sweeteners and changes in blood markers linked with an increased risk of obesity and type two diabetes in rats. Does this mean we need to ditch sweeteners as well as sugar?

Sweeteners are generally “non-nutritive” substances meaning we can’t use them for energy. Some of these compounds are entirely synthetic chemicals, produced to mimic the taste of sugar. These include saccharin, sucralose and aspartame. Others sweeteners are refined from chemicals found in plants, such as stevia and xylitol. Collectively, sweeteners are being consumed in increasing amounts with most diet or low-calorie food and drink containing some form of non-nutritive sweetener.

Combating or fuelling the obesity crisis?

Artificially sweetened foods and drinks have become popular largely due to the growing worldwide obesity crisis. As sugar contains four calories per gram, sweet foods and drinks are normally highly calorific. In principle, by removing these calories we reduce energy intake and this helps to prevent weight gain.

Increasingly, however, evidence suggests that consuming artificially sweetened products might be associated with an increased risk of being overweight or obese, although this is controversial. If true, it suggests that using sweeteners is fuelling, not fighting obesity. Research has suggested that consuming lots of artificial sweeteners scrambles the bacteria in our gut, causing them to make our bodies less tolerant to glucose, the main building-block of sugar.

The new research, from the Medical College of Wisconsin and Marquette University, looked at some biological effects of sweeteners in rats and in cell cultures. They wanted to know if artificial sweeteners affect how food is used and stored. These are called metabolic changes and the research combined many different aspects of metabolism to build an overall picture.

The team also looked at the impact of sweeteners on blood vessel health by studying how these substances affect the cells that form the inner lining of blood vessels.

The scientists gave rats food that was high in either sugar (glucose or fructose) or calorie-free artificial sweeteners (aspartame or acesulfame potassium). After three weeks they saw significant negative changes in both groups of rats. These changes included the concentrations of blood lipids (fats).

They also found that acesulfame potassium, in particular, accumulated in the blood and harmed the cells that line blood vessels. The study authors state that these changes are “linked to obesity and diabetes”. These results suggest that consuming sweeteners change how the body processes fat and gets its energy at a cellular level.

Limit your intake

What does this mean for the average consumer of artificial sweeteners? As the study was performed in animals and not humans it would be wrong to draw firm conclusions about what might happen in people. The findings of the study do, however, add to the growing body of research that suggests that sweeteners are not benign alternatives to sugar.

The European Food Safety Authority suggests a daily limit to most artificial sweeteners of around five milligrams per kilogram of body weight, per day. With so many foods including artificial sweeteners now, it is relatively easy to reach this limit.

It is important to note that not all sweeteners are equal. This recent study focused on artificial sweeteners, like most of the research that has identified negative effects. Some sweeteners are associated with health benefits.

Stevia, for example, has been shown to improve blood pressure and glucose tolerance, while xylitol has been shown to help prevent tooth decay. This means that choosing the type of sweetener that you use may be more important than choosing a sweetener over sugar.

It is likely that the best advice is the blandest: everything in moderation. There is no such thing as good or bad food, only good or bad amounts. Maybe avoid consuming too much of either sugar or sweetener, especially in drinks.

James Brown is a senior lecturer in biology and biomedical science at Aston University; Alex Conner is a senior lecturer in biomedical sciences at the University of Birmingham. This article was originally published on The Conversation (www.theconversation.com)

منبع مطلب : http://www.independent.co.uk/life-style/health-and-families/artificial-sweeteners-linked-diabetes-obesity-health-a8319291.html