An organizing principle for cancer therapeutics

As knowledge of the human genome advances, physicians are finding ways to tailor cancer prevention and treatment to specific molecular targets, according to Richard Klausner, M.D., director of the National Cancer Institute. Speaking at grand rounds in February on The Taxonomy of Molecular Targets, Klausner said, “I think we are beginning to see ways that we can organize the extraordinary complexity of genetic change in cancer.” The challenge for oncology and general medicine, he said, is to develop a usable, meaningful phenotypic database. “We are going to have a hard time developing successful therapies if we can’t understand the targets we’re looking at.”

The uneven distribution
of health care

Wealth is more concentrated in Latin America and poverty rates are four times those of countries with similar gross domestic products, said David Brandling-Bennett, M.D., deputy director of the Pan American Health Organization, speaking at grand rounds at Epidemiology and Public Health in February. That adds up to poor health care for large segments of the population. “We are not attending to the needs of those who are the neediest,” he said. Governments, he continued, must ensure that basic health services of adequate quality are provided equitably. Of the $2.3 trillion spent on health care annually around the world, 90 percent is spent in industrialized nations. “We are not addressing the issue of disparity in health.”

Where Harley Street crosses Fleet

As editor of The Lancet, Britain’s leading medical journal, Richard Horton, M.D., finds himself straddling two worlds. “Editors have one foot in the perfumed halls of academia and the other in the sewage-strewn gutters of the press,” he said in April at the 52nd annual meeting of the Associates of the Cushing/Whitney Library. His journal’s readership is a broad clinical audience. Only 300 of the 6,000 manuscripts submitted each year are published, Horton said, and they must meet journalistic as well as scientific criteria. When they find their way into the hands of the lay press, misinterpretations can have unfortunate results. One study published in his journal described a possible link between submissiveness in women and lower rates of heart disease. The resulting newspaper headline? “Put down that rolling pin, darling, it’s bad for your heart.” Another press report, however, led parents to the mistaken belief that childhood vaccinations could cause developmental disorders. “There was a panic, a serious drop in the uptake of the vaccine,” Horton said. “The effect was catastrophic.”

Linking HIV care to socioeconomics

Many interventions aimed at stemming the spread of AIDS miss the point, says Tom Peterman, M.D., chief of the prevention studies section at the Centers for Disease Control and Prevention. They assume, he said during a talk to Yale AIDS researchers in March, that individuals are in control of themselves and their environment. But in this country the disease is increasingly associated with high rates of poverty, homicide, teen pregnancy, drug abuse and other sexually transmitted diseases. “It is hard to ignore race and racism as a factor in public health in the United States,” he said. “It is a pretty consistent finding that income inequality, more than income, determines health.”

Communicating in the clinic, across cultures

Language and culture can come between patients and caregivers, sometimes with disastrous clinical consequences, said Glenn Flores, M.D., co-director of the Pediatric Latino Clinic at Boston Medical Center. “Culture affects clinical care,” Flores said during his talk in March, “Culture and Patient-Physician Relationships: Achieving Cultural Competency in Health Care,” sponsored by Y-NHH Ambulatory Services. “It affects outcomes and it affects quality of care.” He cited the example of a physician who failed to grasp the severity of a Mexican girl’s abdominal pain because her parents spoke no English. After two return visits to the emergency room she was diagnosed with peritonitis. In another case, a mistranslation led to suspicions of abuse and a mother’s uninformed consent to turn her daughter over to child welfare officials. Caregivers, he said, must be familiar with the language and culture of their patients. “What is not going to work,” he said, “is to say, ‘Let’s all be sincere, let’s hold hands and sing ‘We Are the World.’ We need to have a more diverse work force.”