Category: medicine

  • Why some viruses are so difficult to stamp out

    Why some viruses are so difficult to stamp out

    The United States is fighting an unexpectedly big measles outbreak, with hundreds of cases in the state of Texas alone. Health experts expect it will last for a year or longer, because the virus has a long incubation period — people can be infected for days before they begin to show symptoms. That, in turn, means it can spread silently.

    Another virus that’s spreading silently right now is polio. Tests of wastewater around the world have turned up alarming levels of the virus, notorious for paralyzing children, in Afghanistan and Pakistan, according to the World Health Organization (WHO), but also in Europe, in Spain, Poland, Germany, the United Kingdom and Finland.

    These two viruses should not still be around. They only infect human beings, and mass vaccination campaigns have been ongoing for decades to try to wipe them out. And the medical profession keeps coming so close to success. 

    And where do these viruses come from that keep returning despite our attempts to wipe them out? The answer is from us — from other people.

    Smallpox is the only human disease to have been completely eradicated. That was done with a dedicated global vaccination effort in 1972. Because the smallpox virus doesn’t infect any other animal, there wasn’t another place for it to survive and come back to reinfect people. 

    The same should be true for measles and polio, but war, disruption, poverty and a mistrust of vaccines make it difficult.

    Where viruses hide

    So even as vaccine campaigns come close to succeeding, the viruses can still hide out in unvaccinated and undervaccinated people. Travel and human contact do the rest to keep both measles and polio circulating. When an infected traveler hits a community of unvaccinated people — say a neighborhood of ultra-Orthodox Jews in London or a rural West Texas county full of vaccine skeptics — a contagious virus such as measles or polio can take off. 

    With both measles and polio, it takes immunization rates of more than 90% to protect a population. When rates drop below that, a community becomes vulnerable to outbreaks. A virus can take hold and spread among people, picking up steam.

    That’s happened in Pakistan and Afghanistan with polio, where efforts to reach remote populations fall short because of geography, conflict and mistrust. And in Gaza, where continuous Israeli attacks have destroyed virtually all healthcare facilities, United Nations agencies have struggled to vaccinate Palestinian children against polio outbreaks. 

    Polio is also complicated because of the different vaccine types. One of the vaccines is given orally, and it’s made using a live, but weakened, form of the virus. This gives good immunity but in rare cases the virus can mutate in someone’s body and return to infectious strength — becoming what’s called vaccine-derived virus. 

    A follow-up vaccination with a second type of vaccine made using a fully killed virus will protect against this, but when vaccine campaigns can’t be completed, vaccine-derived viruses can emerge.

    How viruses spread

    In Europe, no cases of polio have been seen, but wastewater evidence suggests the virus is surviving in people’s bodies, and could burst out to cause sickness if it gets to someone unvaccinated. Polio spreads via the fecal-oral route — in contaminated water, via poorly washed hands, on surfaces and also via sneezes and coughs.

    Fully vaccinated communities are safe but in 2022, an unvaccinated man in New York State became paralyzed after he caught polio. Investigation showed a vaccine-derived strain had been spreading quietly in the state.

    Measles is the most infectious disease known and that makes it particularly hard to eradicate. In a podcast interview I did for for One World, One Health, Dr. Peter Hotez, a pediatrician and vaccine scientist at the Baylor College of Medicine, explained just how infectious it is. 

    “If someone has measles, and especially before they get the virus and stop feeling very sick, they’re releasing the virus into the atmosphere,” Hotez said. 

    Even if they leave the room, that virus will linger in the atmosphere for a couple of hours.

    “So you can walk into an empty room that has the measles virus from someone who was there a couple of hours before and become infected,” he said, noting that one measles patient will infect up to 18 other people.

    A virus reemerges.

    Nine out of 10 unvaccinated people who are exposed to the measles virus will become infected. What is disappointing to public health experts in the latest U.S. outbreak is that so many people have become infected when measles was eliminated in the United States in 2000 and in all of the Americas in 2016.

    But pockets of people who are not vaccinated against measles can act like tinder. The spark is usually a traveler who goes to a country where measles is still common because vaccination rates are low — usually due to poverty. 

    In a November 2024 report the WHO said that measles is still common in many places, particularly in parts of Africa, the Middle East and Asia.

    “The overwhelming majority of measles deaths occur in countries with low per capita incomes or weak health infrastructures that struggle to reach all children with immunization,” the report said. Measles kills more than 100,000 people a year, mostly children. But before the vaccine was introduced in the early 1960s, it killed 2.6 million a year.

    The COVID-19 pandemic badly hurt all childhood immunization efforts, WHO and other global health authorities say. Routine childhood vaccines have not caught back up to where they were before the pandemic, leaving children and adults susceptible to vaccine-preventable diseases including measles and polio but also meningitis, hepatitis, tetanus, cervical cancer and rotavirus — a disease that causes diarrhea and vomiting in babies and young children. 

    The retreat of the United States from global health efforts — the dismantling of the U.S. Agency for International Development, its plan to cut $1 billion in funding to Gavi, the Vaccine Alliance, and its withdrawal from the World Health Organization — will further weaken global vaccination, experts say.

    And that means many more children will likely die who might otherwise live healthy lives. 

     

    Three questions to consider:

    1. How can vaccines help prevent the spread of diseases?

    2. What role should personal choice play in being vaccinated against deadly diseases?

    3. How can global cooperation help in fighting the spread of disease?

     

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  • Diversifying medicine by widening participation

    Diversifying medicine by widening participation

    Medicine is an elite profession, traditionally dominated by white, male, middle- or upper-class people, frequently from medical families.

    In 2014, the Medical Schools Council (MSC) created a Selection Alliance (SA), and published Selecting for Excellence (SfE), to address inequities in access to medical degrees in the UK for those from “widening participation” backgrounds.

    Fostering Potential: 10 years on from Selecting for Excellence , published in December of 2024, reports on progress made, with welcome achievements that are testament to the commitment of the community. The report rightly notes that focus on widening access has meant support for diverse students once they commence studies has been neglected.

    Recently, medical student activism – #LiveableNHSBursary , and #FixOurFunding – have highlighted the peculiar funding situation medical students find themselves in , and the financial pressures they experience during their studies.

    Fostering Potential asserts that WP needs to be reconceptualised away from a deficit framing of individuals as lacking ambition or aptitude to excel, to understanding lack of participation as the product of systemic and institutional failures around inclusion. For me, one of the main barriers to success for students from a disadvantaged socio-economic background studying medicine is the degree was designed and developed for a financially comfortable student. Its current structure excludes students from diverse backgrounds, and part of this is financial.

    The earnings gap

    One might argue that the financial hardship experienced by student medics is the temporary cost of what will become a lucrative career. However, once qualified, doctors from a lower socio-economic background will experience an average class pay gap of £3,640. This means their degree is both harder won and less remunerative.

    Current research and initiatives on financial barriers to success mostly treat money as a discernible object that can be quantified. It is a thing we either have enough of, or not; something we earn for ourselves as individuals. Hence proposed solutions tend to focus on maximising individual students’ abilities to earn alongside studies, while recognising that lack of time due to part-time work or caring responsibilities means some students cannot take advantage of extracurricular career development opportunities.

    I find this contradictory and suggest it misses a key point – money is also a relationship; it shapes our experiences of the world far beyond how much we have. It is a condition of success, not a result of it. Developing support for a student from a financially disadvantaged background should be informed by research that explicates how poverty impacts students’ opportunities to learn and exploit the advantages higher education allegedly offers.

    A student’s-eye-view

    I lead a project at Lancaster Medical School called Medicine Success, providing funds to mitigate the hidden costs of a medical degree for students from diverse backgrounds – purchasing a stethoscope, professional attire and funding the compulsory elective.

    Five years of project evaluation data reveal much about the role money plays in students’ sense of belonging and success. A student’s-eye-view of the degree reveals how unexpected its hidden costs are, how difficult it is to cover the cost of living and studying without financial support, and how choices about career development are constrained by cost. Further, the data shows students with scarce resources are keenly aware of how wealth is a vector of exclusion and inequity shaping their experience of the degree differently to their wealthier peers:

    Receiving these funds made a massive difference as it took me by surprise how much of a financial burden studying at university was. It seems that every aspect of it requires you to spend money that you don’t have and I feel at times it’s not all inclusive (2nd year, 2024)

    Their evaluations of the funding show that money transforms our lived experience of the world, and in turn, shapes our thoughts and feelings. They explain how scarcity can impact mental health and mental bandwidth, and the funding alleviates financial anxiety and paid-work commitments so they may focus on their studies.

    But it means more than just being able to afford essentials, it means being able to participate equally and with pride in their degree in comparison to their wealthier peers. This directly impacts self-esteem and addresses feelings of unworthiness or lack of belonging.

    A good example of this is the professional attire fund:

    I know professional attire might not seem serious but not having the right attire when it’s necessary leads me to overthink about how I’m dressed and feeling insecure during sessions. It’s often to the point where instead of focusing on learning I can’t help but to think about my appearance. (1st year, 2020)

    It is well-established that class can be read through a multitude of symbols. Respondents describe how their “lower” social status feels revealed through clothing, making them feel insecure in the learning environment. Students relate having their cheap and tired-looking clothes pointed out to them by peers, others worried about wearing the same outfit every day and what that said about their finances, while some feel that their patients have less respect for their opinion when they don’t present well-dressed. Meanwhile, ill-fitting clothing and shoes also interfere with the ability to focus on studies, causing pain and making long shifts additionally exhausting.

    Widening participation initiatives that focus on belonging from a social, cultural or academic skills perspective miss this crucial element – money. One student articulates a point made repeatedly by many of their peers:

    Funds like these make students like myself feel more heard and seen and gives us the opportunity to come from a lower socio-economic background and not feel as if we don’t belong here simply due to lack of finance. It gives us the confidence and the ability to work hard for what we want as we know there is always support available for students like us. (1st year, 2022)

    Recipients of Medicine Success funding attest that financial support levels the playing field with their more privileged peers in numerous, significant, and yet, subtle ways. Providing financial support is essential to make the learning environment, social activities, and career development accessible to students from all backgrounds. Belonging is in part financial; you can’t participate fully without money.

    Wider Context

    Recent reports show that the government is making a loss on student loans due to higher interest rates . This means private lending institutions are making a profit from the scheme funded by tax-payers and graduate repayments. In Why We Can’t Afford the Rich, Andrew Sayer explains that our current political system “supports rentier interests, particularly by making the 99 per cent indebted to the 1 per cent” , in which wealthy people are less likely to earn money through paid work, but accrue wealth through financial activities. The student loans scheme is one example.

    Higher education is presented as a means of social mobility, while extracting wealth into a financial sector that shores up its and its investors power. It does so by making already poor people pay to access education but without the conditions to participate fully. The promise of breaking the cycle of poverty with a university degree is so powerful that it deflects attention from what is really happening, despite extensive evidence that education has yet to prove itself as a solution to class inequalities. For these reasons, even with WP policies, HE has financial injustice embedded within it, resulting in deleterious effects on students’ mental health, degree experiences and outcomes.

    I see this as an example of “financial trauma,” defined by Chloe McKenzie as “the cumulative effect of being required to experience economic violence, financial abuse, financial shaming, and/or (chronic) financial stress to attain or sustain material safety”.

    Social mobility is a problematic term; it requires individual people to increase their position in an established hierarchy that is itself integral to maintaining socioeconomic inequality. This is why I welcome the MSC’s push to reconceptualise improving participation as a systemic issue, not one focussed on changing individuals to fit into the status quo. At the same time, we must apply this thinking to financial barriers to success, by recognising that money is far from a private issue but a matter of justice.

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  • What’s all the flap about bird flu?

    What’s all the flap about bird flu?

    Avian influenza has scared doctors and scientists for a generation. But its arrival in the United States might finally give the H5N1 bird flu virus the combination of factors it needs to cause a global pandemic.

    Those factors include a new carrier; dairy cattle; a regulatory system that protects farmers at the expense of human health; and a government bent on taking down an already weak public health infrastructure.

    The H5N1 avian influenza virus making headlines around the world — and driving up the price of eggs — in the United States is no youngster. It’s been around since at least 1996, when it was first spotted in a flock of geese in Guangdong in southern China.

    Since then it has spread around the entire world, tearing through flocks of poultry in Asia, Europe and the Americas and wiping out birds and mammals on every continent, including Antarctica. H5N1 bird flu only rarely infects people but as of the end of January 2025, the World Health Organization reported 964 human cases globally and 466 deaths, although many milder cases are likely to have been missed.

    Vets and virus experts have had their eyes on H5N1, in particular, for decades. It didn’t look like a serious threat when it killed geese in 1996. But the next year the virus caused an outbreak in people just over the border from Guangdong in Hong Kong.

    It infected 18 people and killed six of them before it was stopped. That got people’s attention. A 30% fatality rate is exceptionally high for a virus — something approaching the mortality of smallpox.

    Mutations and swap meets

    The virus gets its name from two prominent structures: the hemagglutinin, or H designation, and the neuraminidase, or N. All influenza A viruses get an HxNx name. The current circulating viruses causing human flu misery right now are H1N1 and H3N2, for example, as well as influenza B, which doesn’t get any fancy name.

    But influenza viruses are exceptionally mutation-prone, and even the extra designation doesn’t tell the whole story about the changes the virus has undergone. Every time a flu virus replicates itself, it can make a mistake and change a little. This is called antigenic shift. As if this wasn’t enough, flu viruses can also meet up inside an animal and swap large chunks of genetic material.

    The result? The H5N1 viruses now circulating are very different from those that were seen back in 1996 and 1997, even though they have the same name.

    This is what’s been going on over the past 30 years. H5N1 has been cooking along merrily in birds around the world. So, after the 1997 outbreak, not much was seen of H5N1 until 2003, when it caused widespread outbreaks in poultry in China. Researchers discovered it could infect wild waterfowl without making them sick, but it made chickens very sick, very fast. And those sick chickens could infect people.

    The best way to control its spread among poultry was to cull entire flocks, but if people doing the culling didn’t take the right precautions, they could get infected, and the virus caused serious, often fatal infections. Doctors began to worry that the virus would infect pigs. Pigs are often farmed alongside chickens and ducks, and they’re a traditional “mixing vessel” for flu viruses. If a pig catches an avian flu virus, it can evolve inside the animal to adapt more easily to mammals such as humans. Pigs have been the source of more than one influenza pandemic.

    Pandemic planning

    In the early 2000s, scientists and public health officials took H5N1 so seriously that they held pandemic exercises based on the premise that H5N1 would cause a full-blown pandemic. (Journalists were included in some of these exercises, and I took part in a few.)

    But it didn’t cause a pandemic. Vaccines were developed and stockpiled. Pandemic plans were eventually discarded, ironically just ahead of the Covid pandemic.

    However, flu viruses are best known for their confounding behavior, and H5N1 has always been full of surprises. It has evolved as it has spread, sometimes popping up and sometimes disappearing, but never causing the feared human pandemic. It has not spread widely among pigs although it has occasionally infected people around the world, as well as pet cats, zoo animals, wild seals, polar bears, many different species of birds and, most lately, dairy cattle.

    It’s this development that might finally be a turning point for H5N1.

    For a virus to start a human pandemic, it must acquire the ability to infect people easily; it must then pass easily from person to person; and it must cause significant illness.

    Competing interests

    So far, this hasn’t happened with H5N1. It has infected 68 people in the United States, mostly poultry or dairy workers. Mostly, it causes an eye infection called conjunctivitis, although it killed one Louisiana man. But it is spreading in a never-before-seen way — on milking equipment and in the raw milk of the infected cattle.

    “The more it spreads within mammals, that gives it more chances to mutate,” said Nita Madhav, a former U.S. Centers for Disease Control and Prevention researcher who is now senior director of epidemiology and modeling at Ginkgo Biosecurity. I interviewed her for a podcast for One World One Health Trust. “As it mutates, as it changes, there is a greater chance it can infect humans. If it gains the ability to spread efficiently from person to person, then it would be hard to stop,” Madhav said.

    And while some states are working to detect and control its spread, the federal government is not doing as much as public health experts say it should. Two agencies are involved: the U.S. Department of Agriculture (USDA) and the Centers for Disease Control (CDC).

    Dr. John Swartzberg, a health sciences clinical professor emeritus at the University of California, Berkeley said in an interview with the UC Berkeley School of Public Health that the USDA is charged with two responsibilities that only sometimes work in concert.

    “One of the responsibilities they have is to assure a healthy agricultural industry for the United States,” Swartzberg said. “The second responsibility is to assure safety of the human beings who consume agricultural products in the United States.”

    More information, not less, is needed.

    Dairy farmers feared they’d lose money if their farms were identified as sources of infection. And it’s a lot more expensive to cull cattle than it is to cull chickens.

    “And I think what we’ve seen with this bird flu problem is that the USDA is tilted in favor of protecting the industry, as opposed to protecting the health of humans,” Swartzberg said. “CDC is also involved, but the CDC has no authority to go into states and tell them what to do. It has to be done state by state.”

    On top of that, U.S. President Donald Trump has ordered the CDC to take down websites reporting on avian flu and other issues. He is withdrawing U.S. membership from WHO, crippling the ability to coordinate with other countries on controlling outbreaks of disease.

    He notably tried to suppress reporting about Covid during his previous presidency and promoted unproven and disproven treatments.

    His newly confirmed Health and Human Services Secretary, who will oversee CDC and other agencies charged with human health, Robert F. Kennedy, Jr, is a vaccine denier, proponent of raw milk and has no public health qualifications.

    The stubbornness of people in the United States doesn’t help. When public health officials warned against drinking raw milk last year, raw milk sales actually went up.

    “Food safety experts like me are just simply left shaking their heads,” Donald Schaffner, a Rutgers University food science professor, told PBS News.

    The big fear? That in flu season, someone will catch both seasonal flu and H5N1, giving the viruses a chance to make friends in the body, swap genetic material and make a deadly new virus that can infect people easily.

     

    Three questions to consider:

    1. How can politics affect public health risk?
    2. How does public understanding and trust affect the risk of disease?
    3. Countries often blame one another for the spread of disease, but should they?

     

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  • The barriers that must be removed for degree apprenticeships to meet NHS workforce targets

    The barriers that must be removed for degree apprenticeships to meet NHS workforce targets

    The recent notion that level 7 apprenticeships will be ineligible for support from the apprenticeship levy has caused consternation amongst training providers, especially in healthcare.

    Training providers and employers are urgently seeking clarity on the government’s position – the current “announcement without action” leaves stakeholders unclear about next steps and further risks the reputation and role of apprenticeships in skills development.

    The development of advanced roles in health or shortened routes to registerable qualifications significantly relies on level 7 apprenticeships. The NHS Long Term Workforce Plan is full of examples of how advanced and new roles are needed now and in the future.

    Once again, decisions are being made by the Department for Education without consulting or collaborating with the Department of Health and Social Care, which means that questions are left unanswered. It is not the first time that training providers and University Alliance have called for joined up thinking and, unfortunately, it certainly won’t be the last.

    Expansion of opportunity

    Health apprenticeships at the University of Derby started small with level 5 provision about ten years ago (subsequently expanding to levels 6 and 7) – we could not have foreseen the enormous expansion of opportunity both in health and other industries that would follow.

    I am proud to say that “I was there” when the nurse degree apprenticeship standard was approved in 2017 – the culmination of two years’ collaboration between the Nursing and Midwifery Council, government, Skills for Health, employers and training providers.

    There were challenges, but we made it, and it opened the door to transformation in how healthcare professionals are educated.

    A bumpy road

    But the journey remains bumpy, and apprenticeships seem to be experiencing a particular period of turbulence. New research conducted by the University of Derby on behalf of University Alliance demonstrates the need for change in how the levy is utilised, the importance of partnership working, and the support that those involved with apprenticeship delivery need in order to secure successful outcomes.

    While the NHS Long Term Workforce Plan of 2023 is itself being refreshed, we can be confident that apprenticeships will continue to have a significant part to play in workforce development. However, our new research has shown how and where employers and training providers need support to make this happen.

    Employers told us how expensive they find it to support apprenticeships, with apprentice salaries, backfill and organisational infrastructure contributing to the financial burden. We know that apprentices need significant support through their learning journey, taking time and investment from employers.

    To make apprenticeships truly successful, the support required is over and above that normally expected in healthcare programmes, yet apprenticeships are specifically excluded from the NHS Healthcare Education and Training tariff. This feels like a double whammy – no support from the tariff and no flexibility in how the levy could be utilised differently, meaning that the responsibility remains with the employer to resource.

    Equally, training providers reported the additional activities and responsibilities associated with the delivery of apprenticeships. The University of Derby has recently successfully completed its inspection by Ofsted. The week of the inspection required input from teams across the University, but the enduring responsibilities of compliance and record keeping make this a continuous activity for a skilled and specialist team.

    The Education and Skills Funding Agency then came hot on the tails of Ofsted – while this is not unexpected, it has again required teams from across the University working long hours to be audit ready. These inspections have served as a reminder of the regulatory burden placed on training providers, especially in healthcare.

    A matter of commitment

    Today marks the start of National Apprenticeship Week. At the University of Derby, we are hosting a week of activities and events, encouraging aspirant apprentices and a range of employers to come and find out more about what apprenticeships can do for them. It is heartening to hear that the number of young people coming to the campus this year has more than doubled since last year’s event.

    Finally, the word is beginning to spread about apprenticeships, and we find school leavers are increasingly well informed about their post-16 and post-18 options.

    The week’s events will be ably supported by our employer partners and apprentices, truly reflecting the partnerships that have developed over the years. These partnerships take a significant amount of investment on all sides – anyone in the vocational education and training world will know that strong partnerships take time and effort to build and maintain. But even the briefest of conversations with apprentices will tell you that it is all worth it. Their confidence, passion and knowledge (their skills and behaviours too) shine through. In a city like Derby, the awareness of the positive difference you are making not only to the apprentice, but also to their family and friends, is never far from your thoughts.

    It is difficult to know how the advent of Skills England will impact the pace and scale of reform, but the present inertia may set the country back – and it certainly will if a blanket approach to level 7 apprenticeship funding is adopted, and lack of join-up between DfE and DHSC remains the status quo.

    National Apprenticeship Week 2025 has the potential to be a force for good – and should be the week that all stakeholders commit to making a difference.

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