Onwards to a new obsession

As some may know, I've spent the last 5 months as probably the only unemployed doctor in Singapore. For various reasons relating to the ministry of defense/ministry of health, I've been waiting (and waiting), for a decision regarding the future of my medical career.

In any case, I've been keeping sane by studying for my USMLE (man, those American M.D.s have it tough), and getting deeper into a pastime (that I suspect has now become an obsession): Coffee.

So, I had brought my good old Gaggia Classic over from Australia, together with the budget-friendly Sunbeam E0480. Frustrated at the fact that the freshest beans were 1/2 - 1 h away, I bought a Gene Cafe and starting roasting. My budget Sunbeam soon starting dying, so I made a (huge) jump to the new-kid-on-the-block, the Ditting Vario! To make sure that I'm been squeezing every possible cent out of these machines, I attended roasting classes, cupping classes, and latte art classes (all this on top of what started me off in the first place - Cynthia's gift to a barista class).

Now I subject my friends to tasting coffee that is not just under/over extracted, but also to coffee that is possibly underroasted or charred to a crisp. Surely it (the coffee) can only go up from here ;).

Book review: The Demon Under the Microscope, By Hager

As human beings, we have relatively short memories; we have largely forgotten what life was like barely 90 years ago, when human lives were far too often cut short by relatively simple infections (by today's standards). Most of us have lost touch with the time when epidemics of "childbed fever" meant that almost all women giving birth in the hospital would die from infection; when a simple blister on the toe could lead to deadly, incurable bacterial sepsis.

Hager's book is an excellent reminder of how far we've come. It is largely narrative history, written with the aim of communicating the processes and ideas that led to the development of sulfa (the world's first true antibiotic), rather than a straightforward chronological account.

Hager begins right at the start, when microscopic world was first discovered, and how it led to the development of germ theory. He carries us through the development of antiseptic use and serum therapy, moving us from a time where surgeons merely placed their instruments on any convenient table, to a period when theatres were constantly filled with aerosolised antiseptic blown from a bellows.

The real start of the show, however, is Nobel Prize winner Domagk (and of course his much neglected chemists), who led the clinical research that culminated in the discovery of the antimicrobial properties of sulfa. Their pains and toils are remarkably communicated by Hager, giving us a definite sense of disappointment after years of unfruitful research. At the same time, due credit is given to other parties involved in the discovery - including French researcher Forneau.

The stories doesn't just stop at the discovery of sulfa - Hager also gives us an account of how the FDA and a haphazard medicinal drug market was transformed overnight into a well organised, highly vigilant industry.

All in all, this is a fantastic book - not just for an insight into the discovery of sulfa, but the ideological and scientific struggles surrounding the idea of a antimicrobial "magic bullet", and the challenges that sulfa placed forth to the world - that of the need for careful, well designed and executed clinical drug research. Most of all, this is a book that reminds us of where we've come from, where we are now, and raises question of where we are headed, in our constant battle with the microscopic enemies in our midsts - an issue particularly pertinent with worrying trends in bacterial resistance.

OK, lets get this out of the way

There's been a post circulating around on FaceBook, entitled "Scientists Cure Cancer, but No One Takes Notice". To be honest - it's unproven science at best, a load of rubbish at worst. Here's why:

1. The author of the article doesn't know what he/she is writing about, and scientific terms are thrown around in a nonsensical manner. For example, mitochondria are NOT cells - they are cell organelles (little organs in the cell). Sure, there is a theory that a million gazillion years ago when we all lived in a soup that they were infective bacteria, but that's a separate story. A more significant error is the fact that glycolysis does NOT produce lactic acid - it is an essential cellullar process that provides pyruvate, the substrate used for the cell to generate energy. Shut off glycolysis, and you kill ALL cells, period. Lactic acid is produced via a different mechanism (more on this later).

2. The original research paper proper (from the website) dates back to 2007, and is more a hypothesis than anything. What the original researchers are suggesting is this: cancer cells grow at very high rate, and and hence have high energy needs. Most of this energy has to be produced via anaerobic respiration (probably due to ineffective angiogenesis), hence producing lactic acid in the process. To maintain the high energy requirements, the rate of pyruvate production has to increase (so glycolysis needs to occur at a faster rate).

The researchers propose to use DCA to suppress glycolysis, thereby cutting down the rate of anaerobic respiration. This essentially cuts off the energy supply to the cancer cells and kills them. The theory is that other cells are not AS affected because they are much more energy efficient (aerobic respiration) than cancer cells, and thus do not require high rates of glycolysis.

Sounds like a good theory, and explains why cells such as lung cells are not damaged in early experiments. However, there are other cells that are pretty energy demanding - such as neurons - which may explain why DCAs side effects include neurotoxicity. Also, the researchers also seem to be proponents of the Warburg hypothesis - that lactic acid is the cause of cancer - an idea that has fallen out of favor due to genetic discoveries.

3. Some good results are seen in vitro, but the real test of a drug is in vivo. DCA has so far gone through Phase 1 and 2 testing - which means that it seems to be relatively safe, and that there seems to be the possibility of benefit from the drug. However, there are no Phase 3 study results available (which is where we get REAL information on whether the drug actually has a benefit, and how great a benefit/harm).

IE: The science behind this hypothesis ranges from reasonable to rubbish, and DCA as yet is unproven in cancer treatment and actually has significant known side effects. I wouldn't be asking any doctor to prescribe this for me, anytime soon.

On Rising Healthcare Costs - And Why I'm Not Buying Opposition (or PAP) Promises

As a medical doctor, I read with concern claims by the opposition that rising health costs are the fault of "government mismanagement". Even more worrying were promises by the opposition to provide cheaper medical care (with one politician reminiscing of low healthcare costs in the 70s and 80s), with plans such a welfare scheme put forward by some parties, as if this were an end-all solution.

The reality is that healthcare is getting exponentially more expensive, by processes beyond the control of any government. The “cheap and easy” gains in health outcomes, such as vaccinations and sanitation, have been already been achieved. With demographic shifts reflecting those of first world countries, Singapore would soon be facing increasingly complex healthcare issues that require new, and often expensive, solutions. These would include an ageing population, with people living longer and developing more illnesses associated with old age (such as dementia, cancer and arthritis). Recent economic analyses from the US have demonstrated that any cost-saving from addressing preventable illnesses will be offset by these unavoidable “diseases of old age”.

Rapid advances in technology also mean that medical care today is a far cry from medical care from yesteryear (especially from the "good old 70s"). We have a larger number of more powerful drugs to treat conditions, many of which are being detected with more sophisticated tests. Technology has revolutionized medical practice, such as fibre-optic imaging in keyhole surgery. However, all of these advancements involve significant R&D costs, into the millions of dollars, which are then transferred to the end-users. By positioning ourselves as a medical hub, Singaporeans effectively now have access to these latest developments. However, if we want to continue to enjoy the latest pharmaceuticals or the most advanced imaging and surgical techniques, we will need to face the burgeoning costs associated with them.

What this means, is that healthcare is becoming more expensive at a rate never seen before, bringing the issue of healthcare costs to the forefront in many political debates around the world (the most recent, and perhaps significant, are the healthcare reforms in the USA). The best minds from around the world have sought a solution, but no easy answer has yet been found. Ultimately, the costs have to be borne by someone – in Australia and the UK, the governments have borne the costs through a welfare system. However, this is translated to significantly higher taxes for the people (close to 50% for some categories!) Even then, these governments are frantically searching for a way to curb the ballooning healthcare expenditure that is pushing the countries deeper into debt (as a friend of mine says – health care expenditure is basically a black hole). On the other hand, the USA has attempted to use a free market approach in an attempt to drive healthcare costs down via competition. Unfortunately, this has backfired for a number of reasons, leading to even basic healthcare being out of reach of a significant proportion of the population.

We should thus take any blanket promise of lower healthcare costs with a grain of salt, being aware that there is no simple answer to this complex issue. As the election draws close and more promises are being made, we should be wary of such utopian offers, realizing that there is no magic bullet to ease the pain of rising medical costs.

My 2 Cents, on probably the only topic I'm familiar with.

Sing Chee

Book review: Unscientific America by Mooney and Kirshenbaum

In this book, Mooney and Kirshenbaum (I'll just refer to Mooney from now on) address the key issue of scientific illiteracy - the decline of scientific awareness and engagement with the public, and the dangerous implications it has for the future. He splits his chapters up into key topics - describing the current situation, how we got here, the issues behind the decline in various disciplines (eg: science in culture, science in movies, science in schools), hot topic issues such as the new atheism, and what can be done about it all.

I really want to like much more than I did, for good reason - it's centred on an issue that I'm (somewhat) interested in: scientific illiteracy. Mooney shares the same desire as I do - that people become more aware of the wonderful progress being made in scientific fields, that science conciously becomes a integral part of society, and that more people take consider pursuing science as a career path for the sheer love of it. In my case, my career direction (As a doctor) was most impacted when I was barely 10, by a "Book of Science" (that I still have) which contained some of the most marvellous pictures of the human body (dissected down to the level of vessels). I think my parents must have thought I was crazy to have placed "B.Science/Arts (combined)" right after "MBBS" on my university course preference list (I do have a crazier medical colleague who put B.Education as his second choice). So for sharing this passion, and communicating it in a easy and readable manner, Mooney scores some points.

But why doesn't this book score higher? Well, Mooney loves the scientific process no doubt, but underlying his entire book is a very questionable stance on what "science" is, and it's relation to the rest of society. Take for example, Mooney's discussion on the nature of science - which he describes as the description of an objective reality, compared to the humanities, which make a fool of reality. (He tries to be fair to the humanities, but he still comes across as poo-pooing them. Eg: His chapter on science and entertainment starts with a mockery of the idea that movies don't need to follow the natural order) He more or less completely dismisses post-modern philosophy in a few sentences, without showing evidence of engagement with some of the serious epistemology challenges it throws to scientific research. Even Stephen Hawking, in his new book The Grand Design, makes an admission that traditional "realism" is no longer a tenable position, not in light of post-modern philosphy, but in the context of new knowledge of the quantum world.

In addition, he repeated uses the word "science", like it were some holy grail - he says "we must fund science/protect science/encourage science", but never really deals the whole question of "what is science" - is it a concept, a philosphy, a defineable entity? He writes in such a way that one could be mistaken for thinking that science is a god to be worshipped, and that anyone who doesn't recognise that is a moron.

It is this "holier -than-thou" attitude, masked by what seems like a false sense of humility (he repeatedly says "Scientists are somewhat at fault to, for not doing enough to make sure things are done the proper way"), that marrs the entire book. For example, he complains that in politics, decisions are made not on careful analysis, but rather on ideology and political belief (well, surprise surprise, but ideology and political belief does form the entire framework on how we perform our analysis).

There is ultimately no clear outline on what exactly accounts for "Scientific literacy" is, and what differentiates it from scientific illiteracy. For example, he mocks things such as the Reagan "star wars" project as examples of stupidity, but then heaps praise upon projects that were once "Dreams" but have become reality (eg: space flight).

Scientific America is a book that for all intents and purposes addresses a key issue, not just in America but all over the world, even in Singapore (despite our world record science and math scores, how many of our students can actually apply critical scientific thinking to problems?). But ultimately, it comes across as too much of a kopitiam whinge, than a well thoughtout engagement with the key issues at hand (although there some points that shine through).

Review: 6 Feet Over

This book should be entitled - "adventures in the apparent physical manifestations of the afterlife". In this book, Roach approaches the issue claims of experiences of the afterlife as a skeptic, looking at the evidence closely and with a healthy dose of salt. She comes away, unsurprisingly, as a....skeptic.

To understand why, you only need to look at the central topics upon which she focuses. These range from reincarnation (she goes to india, interviewing experts on the topic and sitting in on interrogations of supposed "reincarnated persons"), to investigating mediums (And the ectoplasm craze), before capping it off with an examination of near death experiences.

The only firm conclusion that she can come away with is - there really isn't any. This is due to a number of factors - mostly related to poor evidence, but also the nature of the object of study (ie: if an event is uniquely supernatural, occurring not at fixed pattern but at the whim of invisible beings, one cannot perform a quantitative study, and can only remain in the domain of qualitative science).

Peppered with hilarious remarks, many finding inspiration from the loose nuts she finds on her journey, this is a great read, for both believers and skeptics alike.

Review: 13 Things That Don't Make Sense

Brooks writes about 13 "anomalies" in the scientific world that refuse to fit into our nicely formulating theorems and paradigms. His writings can be largely grouped into two subsets - physics and biology (with chemistry interspersed along the way). For the former, he looks at issues such as dark matter and evidence of changes in universal constants (Eg: the speed of light). For the latter, he explores matters such as the placebo effect and the quest for a working definition of "life".

As I read this book, I couldn't help but have a stirring within me - a love for science in it purest, curious form, and an amazement at the marvels and curiousity of the creation. You see, One of my favourite books of all time is a guide to science by Isaac Asimov; Asimov's explanation of the world of physics left me in awe - I fondly remember discussions I had with friends on how relativity, amongst other things, had so many strange and marvellous implications for our understanding of the world. I remember spending nights in high school trying to wrap my head around quantum theories (who can forget Shroedinger's cat).

Why mention all this? I feel that this book embodies that philosophy in its approach to science - an inquisitive nature that revels in the challenge of discovering why the world works the way it does. Brooks at more than one point evokes Kuhn and his discussion of crisis leading to the (now cliched) paradigm shift, and he does it with good reason - Brooks is arguing at many of these anomalies in science just don't fit with our current paradigms, and could potentially force a complete rethink of our current systems. In short, look at the world around you, and don't be afraid to ask questions if things don't make sense - not with a fear that everything will collapse if you do, but with a confidence that somehow, someway, we'll come up with an even better way of explaining the world around us.

I don't know about you, but I find the thought of doing that strangely exciting.