Flu-express, Bermuda: a drive-by vaccination programme

I probably shouldn’t be surprised to read in Bermuda news that flu vaccination sessions are being held over the next few weeks, but on some level I suppose I had associated flu with inclement weather, rain, dark evenings, hot lemon and blankets. Seasonal flu, northern hemisphere November to March, and the annual flu campaign – why not in Bermuda, it is in the northern hemisphere, does have a winter season and is very much not isolated from the world. It just hadn’t occurred to me.

My next thought was “should I have one?” For several years now I have “qualified” for a vaccination in UK – first as a health care worker and then as a health “hazard” (aka “person with chronic illness” as the more politically correct term) so where do I stand on Bermuda?

How do I approach answering this?
Some background:
The virus:

Influenza Virus (image: wikispaces-microbiology 2009)

Influenza is caused by a virus, an orthomyxovirus. There are types A,B and C. Seasonal flu is commonly from types A or B. All viruses will have special characteristic protein molecules sticking out of their coat and these are used to further classify flu viruses – type A flu viruses will have varieties of H proteins and N proteins (haemagglutinin or neuraminidase). The proteins themselves will differ and at least 16 different H proteins have been identified so far. So different strains of virus will have names, such as “H3N2“, which was the main one causing seasonal flu last year. Others in the news have been “H1N1” that caused the 2009 pandemic or “H5N1” which was an avian flu virus that jumped the species barrier to infect a human in 1997.

The viruses can change the proteins they display, akin to wearing a different hat, and this can happen if two strains meet each other in the same victim. A virus can only reproduce inside a living cell but if two or more are trying to duplicate in the one cell then it’s inevitable they will make mistakes and get stuck together with wrong or different proteins, so creating a new strain. While most strains prefer one species to infect, some can make a leap, such as when “swine flu” viruses because capable of infecting a human. This all makes keeping up with the new strains extremely difficult and is the main reason why we have to have a flu vaccination every year – the strains circulating can change quickly.

The vaccine:
The vaccine is reconfigured every year according to data from a worldwide surveillance programme that informs WHO which strains are in circulation. Commonly the vaccine consists of 3 strains ( 2 type A and one B) but from last year in some places four strains (2A and 2B) have been used. Northern hemisphere vaccines will often be different from Southern ones, it all depends on which viruses are predominant in the areas.

Vaccines are given just before the anticipated season, i.e. October or April. In tropical regions the picture is less distinct as the illness can occur year round without pattern so guidelines for vaccinations here are still being developed.  Bermuda is not tropical, it has seasonal flu in the winter just like UK, Europe and much of US.

Seasonal vaccination is 70-90% effective at preventing disease. It is slightly less effective in the elderly but where they do contract influenza after vaccination the severity of the illness tends to be much reduced.

The injected vaccine does not contain live viruses. It is not possible to contract flu from the vaccine. That may not fit with the tales you hear – but it is fact. Some people do feel unwell after vaccinations, which could be due to an inflammatory response, but it isn’t flu itself and will not have the bad sequelae that may follow flu infections.
The illness:
Worldwide each year there will be around 3-5 million cases of severe influenza and 500,000 deaths. Those figures need some context: there are just over 2 million new cases of HIV infection worldwide each year; worldwide there are around 100,000 new cases of melanoma. Just because flu is common doesn’t mean it is not serious.

Pandemics occurred in 1889, 1918, 1953 and 1968. Did they reach Bermuda?  Official reports from the island government claimed no cases of influenza on Bermuda in 1889-90 but at the time there was a Swedish ship quarantined off-shore with dengue fever that was later found to be influenza brought across from Cuba. It would be surprising if the island had escaped from the 1918 pandemic but I haven’t yet found a source for the data. WHO unfortunately does not list Bermuda as a separate country, rather it seems to be included as part of the Pan American Health Organisation (PAHO) which makes some sense given its proximity but none given it is a British Dependency. Neither US nor UK hold statistics for Bermuda, but maybe they don’t exist (triangles and all that)
In Bermuda:
Between 2000 and 2008 the average annual incidence was 744 cases per year.
Bermuda has used seasonal flu vaccination since the 1970s and coverage for the over 65s is around 60%. That figure isn’t all that good – Chile and Cuba claim a 100% uptake in the elderly and WHO were aiming for 75% coverage by 2010. In UK financial incentives for practices boosted uptake to above 80% but there doesn’t seem to be an equivalent drive in Bermuda.

One report on the drive-in flu campaign next week stated that it cost $10 for the vaccine, but in smaller print suggested those in health groups at risk should first get a prescription from their GP. I haven’t had to pay for any prescriptions yet on the island, they seem to be covered by insurance, but to see a GP the co-pay is $40 and I don’t know of you can get a prescription without a consultation – it might seem easier to pay the $10 at the drive-in.

The report also implies you don’t actually have to get out of your vehicle to have the injection – so much for the “sit in the waiting room for 10 minutes afterwards” advice we always gave patients in case they fainted or felt unwell. I think I would still suggest you don’t drive off immediately!

Conclusion:
All this makes me feel a little nervous – it’s different from what I normally do, I don’t know the rules, it’s not a familiar process. The publicity assumes a degree of knowledge, and although I know I do need one I am less clear on how I actually go about getting one. Are ex-pats entitled to the $10-government-subsidised vaccines? Should I book an appointment with my GP? Can I attend a drive-thru even if there isn’t one in the parish where I live?

Unusually for one of my blogs I have generated more questions that the ones I set out to answer. I am tempted to hide behind the low incidence of flu on the island – 744 is less than 1.25% of the population so in daily life I am unlikely to encounter the virus. But I am catching a plane back to UK at Christmas and that changes everything. If I don’t meet a virus on the plane then one of my relatives will probably introduce one with the presents or the turkey. So somehow I have to conquer my anxieties and join the queue for a Bermudian flu vaccination!

Please may I have your kidney?

Today, September 4th is the American National Polycystic Kidney Disease Awareness Day (PKD)

It’s important to me because I have polycystic kidney disease.

Poly = many
Cystic = fluid filled spaces

In essence, instead of containing healthy functioning nephrons, the kidneys become non-functioning organs composed of many cysts.

There are different types but the more common is Autosomal Dominant PKD. 1-2 people in every 1000.

It’s genetic, inherited – I was born with it. My mother had it, her father, his mother … That’s as far back as we know.
“Autosomal dominant” means the abnormal gene is not on the X or Y chromosomes but on one of the others, and that having just one copy alone means you are affected. It also means there is a 1 in 2 chance (50%) that you will pass the gene onto your child.
If you are quick thinking you will have realised that for each of my children there was a 1 in 2 chance that I passed it on to them.
They know that. It’s a story we all live with even if it’s one I haven’t often told.

What happens is that over the years the kidneys, which are designed to filter and maintain a chemical balance in the blood, struggle and eventually fail.

Academically I find the physiology behind all this quite fascinating, but maybe that’s a defence mechanism by which I avoid the more emotional aspects of certain kidney failure.

The overwhelmed kidney gets confused and sends out messages that raise the blood pressure and that just makes the whole situation worse. The PKD patient will encounter antihypertensives early on and, although you know they are a “good thing”, you sometimes wonder if they don’t make you tired and slow. It’s a complex picture, other parts of the body step up in an effort to correct the disequilibrium but, not designed to do the work of a kidney, they muddy the field even more.

In medical school we were taught that a body can lose up to 90% of kidney function and still “go on”. It may mathematically be so, but I suspect that most patients with chronic kidney disease will experience some indication of impairment quite a bit before they reach the 10%-left-point. Nowadays the measure of renal effectiveness is the estimated glomerular filtration rate (EGFR). The downward curve below 60 is arguably more predictable than the stars, at least the astrological ones if not the astronomical. When it falls below 15 then you probably need some outside help: dialysis or transplant. Dialysis is just a holding measure.

Today in Britain there are 5616 people on the kidney waiting list. Actually phrasing it that way, on a waiting list, somehow distances it from the reality – there are 5616 people waiting for a kidney. So far this year there have been only 478 deceased donors. Just 703 kidney transplants have been performed this year. The numbers don’t compute perfectly because some donated kidneys aren’t usable and then some patients are fortunate to have living donations. But over 5000 people go to bed at the end of each day disappointed, more than disappointed, desolate.

On Bermuda the figures are smaller but tell a similar story. In fact it may be a sadder version because only 4 or 5 Bermudians each year will be lucky enough to have a kidney transplant. This week the dialysis unit on Bermuda will keep 160 people alive. Most of them will not get that longed for telephone call to tell them an organ match is waiting. Last year one of them did get the call but she couldn’t get to Boston in time for the operation and the kidney went to someone else.  It is too painful to imagine how she must have felt. 

Joseph Murray (1919-2012) was the surgeon who performed the first successful human kidney transplant, December 23rd 1954. He worked at Brigham Hospital in Boston. For this and subsequent work in the field he received the Nobel Prize for Medicine in 1990. In 2012, coincidentally and sadly the year Joseph Murray died, my daughter, then a medical student at SGUL, was involved in the development of a teaching case for their new approach of using PBL (problem based learning) and virtual patients for the delivery of the ethics curriculum. The virtual patient was named Joseph Murray. The scenario involved organ donation, permissions, dealing with relatives – if you want to try working through the case it is freely available, even has a video (look out for the patient’s mother – closest I will get to an OSCAR)

I was at home yesterday and in the unforgiving midday heat I sought respite inside and without any guilt at all sat watching TV. My selection, via AppleTV/UnblockUS/BBCiPlayer was a programme on tissue and organ procurement, The Human Tissue Squad.

It left me wondering just how organ and tissue donation works on Bermuda. Clearly it isn’t a big enough country to run it’s own procurement programme and there are no facilities for transplant surgery on island. So what happens?

Since proximity to US dictates a link to American healthcare, even though actually a British Overseas territory, Bermuda is part of the New England Organ Bank. So Bermudians can be organ and tissue donors – forms from doctors, TCD and post offices. But there must be huge logistical problems with a 3 hour flight each way to Boston, the closest transplant centre. In US and UK the donor-recipient distance has an effect on allocations and on outcome.  

I was surprised to read about the differences in allocation processes between US and UK. In the States the system is to be enhanced to include a donor index which acknowledges that some kidneys are better than others for factors not relating to the specifics of tissue matching. Bluntly, the non-smoking-kidney will probably be better suited to the new job description.

A person where I once worked had a strange way of paying a compliment with “That’s a nice jumper. Can I have it when you die?” We all laughed, politely, if a little nervously.

Yes, you can have all my jumpers when I die – I won’t have much use for them myself.
But, you know that kidney? Can I have it when you die?

2:30 (or finding a dentist in Bermuda)

I have been very brave and I am going to tell you about it for two reasons – one is that I want sympathy and two is that when I needed it the information was sorely lacking.

Wednesday night I was up with toothache. Ibuprofen and paracetamol did work after a while but I awoke with an unpleasant feeling of dread mixed with guilt. I knew the pain would return, not because I am clever, but because I have had it niggling on and off for several weeks and done nothing about it, hence the guilt.

Actually I had almost done something about it – I did find the telephone number of a dentist in Hamilton, but …..

I swallowed some more ibuprofen, cleaned my teeth for twice the recommended 2-minutes, ate breakfast on the other side of my mouth and tried my best to ignore it. Eventually there was no hiding my discomfort – my husband was oh so nice, but I still snapped back at him when he told me “You need an emergency dentist”. Excuses flew through my mind in one last attempt to avoid this – cost too much / hate making phone calls / insurance – but even as I heard myself pathetically claiming “It isn’t as bad as it was” I knew I had reached that point.

I am going to make it easy for those of you who have floundered on my blog because you have toothache in Bermuda:

RING King Edward Memorial Hospital on 239 2009

Ask for the phone number of the duty dentist on call

Ring that number!

It really is as easy as that. I made the call at 2:10 (2:30 would have been funnier, but I couldn’t wait, it was starting to throb again) and saw the dentist at 3pm and was home again by 4pm.
I would joke that the only bit that hurt was the bill but even that was really not too bad.

I am a little embarrassed to say I had two teeth extracted, it sounds like I have never bought toothpaste. I guess, like many, I did not take as much care with my teeth as I now wished I had, and I dread visits to the dentist in part because I anticipate being told off and lectured. But the dentist I saw yesterday did not lecture me, grimace at me or otherwise make me feel uncomfortable – he was gentle and kind, and, even better, he stopped my toothache. 🙂

So what if you just need a regular dental check and aren’t yet at the stage of mixing painkillers with red wine and denial? That may not be quite so easy. For a routine appointment with a new dentist you are looking at a 5 month wait as a new patient. Not many of the dental practices have websites. The best starting place is probably the Bermuda Dental Association

On the page helpfully titled “Find a Dentist” they have a list of 20 dentists who are taking new patients but, looking closely, the list was last updated in 2009 – come on, it is now 2014!

My daughter was aghast that the wait could be that long – she felt the whole population of Bermuda could be seen in that time, the maths does compute. I don’t know why it takes so long, I have contacted several practices and they give a similar story. (I suggest phone is best as few responded to email enquiries and only the newer practices have a web presence.)

All dentists on Bermuda are Bermudian – the Dental Board will sanction work permits only for specialists, such as a periodontologist, certified dental assistants or sometimes for a dental hygienist. There are a few government dentists who cover school children and prisoners with sentences longer than two years. In a surprisingly technological approach the Bermuda government produced The Tooth Team,  a short YouTube video  – sadly it has only had 154 views in 4 years. School dental health seems much the same as in UK, a dental nurse does screening of specific year groups and a letter home advises on what needs to be done. Children can be treated free but I understand most are seen privately using parental work health insurance.

Dental health insurance might be a recent phenomenon in UK but here it is an expected benefit from your employers health policy. I was extremely grateful for that yesterday – a total bill of $299 was reduced to my own liability for $130 which was the co-pay and emergency fee. I suspect it would have amounted to not much less back home. The dentists will also deal directly with the insurance company on your behalf so the hassle factor is virtually eliminated. For larger bills and restorative work it is advised to get an estimate approved in advance.

I found another blogger who talked about Bermuda dentists in 2010, she gives some helpful information. Her experience was perhaps not quite so good as mine was in the end, but I am grateful to her for blogging about it since it gave me a place to start when trying to solve my problem.

So today I am sipping soup, trying to distract my tongue and using salt mouthwashes as advised. I am grateful he didn’t suggest clove oil, black pepper, red bananas (really?) or stems of the castor oil plant.

 

On my doorstep this morning

Bufo marinarus

I thought it was an ornament, that the landlord had been round in the night adding to the inventory.

This is Bermuda’s only toad (as in only species):  Rhinella marinara, after Linnaeus in 1758 – commonly called a cane toad, but also known as :

• Bufo agua Clark 1916
• Bufo marinus Mertens 1969
• Bufo marinus Schneider 1799
• Bufo marinus marinus Mertens 1972
• Bufo strumosus Court 1858
• Chaunus marinus Frost et al. 2006
• Bufo marinis Barbour 1916
• or: bufo toad, giant American toad, giant toad, marine Toad, Suriname toad, crapaud, kwapp, maco pempen, Maco toro, Aga-Kröte

They were brought onto the island by Captain Nathaniel Vesey.

Captain Nathaniel Vesey

The Conservation Bermuda website confidently states that he imported 24 toads from Guyana in 1885, but it may not have been so precise as all that – this is an extract from a book written in 1917 by the Bermuda Biological Station for Research:

Interview with Captain Vesey reported in Science, 1900

It is a direct quote from Science N8  Vol XIII No 322 p 342 which notes that a survey undertaken in 1884 on Bermuda found no amphibians at all on the island. Frederic Clayton Waite wrote the article in Science and he was a Harvard trained Professor of Zoology at Ohio State University.  I found some of his other work of particular interest – way back in 1908 he argued for less didactic teaching in the medical student curriculum and more hands-on experience, though he favoured anatomy and histology experience and I might favour patient experience.  He advocated the dissection of cats, dogs or rabbits as a precursor to human anatomy  (not to be encouraged at home).

Frederick Clayton Waite, Professor of Zoology (with ideas on medical education)

Back to the toad. Where was I?

Over time several species of flora and fauna have been introduced into Bermuda, usually well-intentioned, but sometimes with less than ideal outcomes (Ladybirds to eat aphids that necessitated Jamaican anoles to eat the ladybirds, then Kiskadees to eat the lizards etc. I think I mentioned this back in July last year when talking about ants and cockroaches)  Well the introduction of toads seems to have been successful – with voracious and opportunistic appetites they eat all sorts of insects and roaches, crickets, millipedes and snails. It could have gone terribly wrong because there are no natural predators above the toads on the island.  In fact worldwide they are considered tasty morsels by very few species – maybe one or two snakes eat them if they have to.  Probably because the toads secrete a poison from their parotid glands when squeezed and this not only tastes foul (I am told) but can actually cause death if ingested by dogs or cats.  The Invasive Species Compendium database informs that:   The toxin causes extreme pain if rubbed into the eyes  – who would even test that hypothesis? 

Captain Vesey was probably before his time since now there are many instances of these toads being introduced to control crop pests.  He was a member of the colonial parliament representing Devonshire Parish.  The ships that the master mariner sailed includes: Eliza Barss 1857, a barque W P Chandler c1860, the Sir George F Seymour,  Atlantic, a clipper called Ceylon of Boston, a brigantine Lady of the Lake and an appropriately named brigantine Devonshire.
It does seem however that what Google remembers him for is bringing toads to Bermuda!

Now this toad has one more interesting fact  – it was once used for pregnancy testing!

Sources disagree on the process – the Invasive Species compendium describes injecting a woman’s urine subcutaneously into the toad then if she is pregnant the toad will produce sperm in its own urine.   While the Welcome Institute states that African clawed frogs (Xenopus) were used,  and the procedure was to inject the woman’s urine into the leg muscle of a female who then was induced to lay eggs if the woman was pregnant. The former was called a Bufo test but the latter called a Hogben test.  Britannica supports the Xenopus frog while Wikipedia the Bufo toads.  After googling for ages I have found a 1948 article in Nature  where using the male Bufinus toad is described – with the benefit that you can reuse the toad in as little as five days.  The research is interesting – after establishing the theory worked using the isolated hormone hCG, then they used 60 pregnant women and all 60 had positive tests using this method,  which would seem to make it more accurate than todays pharmacy tests – but the paper omits details such as how pregnant the women were and whether controls were used.

It is tea time now, not that I have been writing this all day, but it did keep me entertained on an unusually rainy Sunday afternoon.  We will not be eating Toad in the Hole, nor playing it, nor watching it.  🙂

 

Bermuda Onions

The story goes that Governor Daniel Tucker had onions brought to Bermuda in the ship Edwin in 1616 because he was an enthusiastic farmer.  This fact appears in  lots of places:  Bermuda-attractions, Tuckers Point and news articles. But is it true?

• Daniel Tucker was Governor of Bermuda in 1616-1619….. √
• Daniel Tucker was a planter in Virginia when called to be Governor… √
• He came to Bermuda aboard the ship George…..√
• There was a ship “Edwin”  in 1616….√
• Edwin sailed from England to Bermuda, then to West Indies and back to Bermuda….√

The next sentence is complicated:

• Virginia Bernhard, in her book Slaves and Slaveholders in Bermuda, 1616-1782,
• wrote that 
• Governor John Henry Lefroy, in his book Historye of the Bermudas or Somers Islands
• wrote that
• Nathaniel Butler in a manuscript now in the British Museum (Sloane MSS750)
• wrote that
• the ship Edwin brought to Bermuda “One Indian and one Negroe”

……….  but nothing about onions!
True, he mentions   “plantans, suger canes, figges, pines, and the like,”  so maybe some onions were in the mix.

Bermuda Onions, Botanical Gardens

 

It probably isn’t possible to find out exactly so we will have to believe the current version of history: onions arrived on Bermuda very early on.  It is true that by the mid 19th century onions were a significant crop for the island: in 1844 some 332,735 lbs were exported.  By 1875 the figure was around 4000 tons.  The merchant seamen were nicknamed “Onions” and Bermuda itself “The Onion Patch”.  

You might be wondering why they are so popular and its to do with the mild but sweet taste, probably the combination of soil, sun and water, but I have found three journalist articles saying there is “some magic in the soil”.  A gardening website said to grow onions one should use lots of potash and water and if you harvest at 50 days you get Spring onion-style onions with green tips, but leaving for 120 days gives you larger bulb keeping onions.  It also suggested sowing onions in between rows of other vegetables because they protect from aphids and carrot flies  (after googling for an image of a carrot fly I am not sure I will eat carrots for a while)

Naturally the medical aspects of onions interests me – I didn’t know that freshly cut onion has 10 minutes of antibacterial action so has in the past been used for grazes, wounds, beestings, boils and bruises – note for any junior doctors reading this: probably not approved by the GMC!   In India and China onion has been used to treat cholera and dysentery – 30g onion with 7-10 black peppers ground together and given every few hours.  Onion contains potassium, vitamins A and C and sugar without fat so it might just work on any gastroenteritis.  There are also some interesting studies ongoing in Texas on whether onion can inhibit colon cancer.  The best study I found (in terms of I like the conclusion not that I have analysed the technical aspects of the study) is from Queen Elizabeth College, London, that has found adding fried onions to steak and chips reduces platelet clumping and so could be good for cardiovascular problems!

This book was written years ago and you will have to come to Bermuda to get a copy – $12 at the Trustworthy Shop – has every onion recipe under the sun, or so it seems.  How about strawberries, onions, toasted almonds with lettuce and yoghurt poppy seed dressing?  Or an onion egg sandwich: 1 chopped Bermuda onion, hard boiled egg and 1 cup mayonnaise with chopped parsley, salt and pepper on decrusted bread.  For the National Trust researchers meetings Margie brings the most delicious egg sandwiches and I am wondering if this is the secret!

So I have covered history, medical and cookery – which leaves onion art?  This will make one of my daughters smile – onions are one of the few things I can draw.

 

Bermuda Samples

Almost hidden away on the top shelf of the Bermuda reference section of the library is a small book that one might easily overlook – just 5 inches tall in mid-blue cloth-covered hardboard with various stamps inside indicating it once occupied a shelf in Somerset Library and was for 14 day loan only. Sadly it is now never borrowed and possibly rarely read, “Bermuda Samples” by William Zuill sits between a volume of island-inspired poetry on one side and a large “Bermuda Development Plan for 2000” on the other.

William Zuill put this book together in 1937, selecting extracts from the Gazette (was Bermuda, now Royal) between 1815 and 1845.  His choice suggests an eclectic mind and definitely a sense of humour:

• From November,1816 a warning to women wearing low-cut dresses that an “elderly gentleman of venerable appearance and correct manners” was imprinting their bare shoulders or backs with a “stain similar to that from lunar caustic” the words NAKED BUT NOT ASHAMED; washing would not remove it so the ladies were forced to cover it up with more respectable clothes.  [Lunar caustic is silver nitrate, used in the past to treat warts and in photographic developing, it darkens on exposure to light. My thoughts on reading that were that the elderly gent was not so correct in his manners.]

• From June 1818, a letter to the editor bemoans latecomers to church services, for lying in bed on Sundays was “un-Christian-like“. The writer continues to comment on lowering of standards that permitted “ladies at the breakfast table in night or dressing gown” and “men with chins like a pigs back”.  [which I took to mean unshaven but was less clear as to whether this was lamentable at breakfast time or in church]

The selections that caught my eye were cures or remedies for various illnesses.

• March 31, 1829, Cure for Consumption:  In the month of May gather flowers from the thorn bush and boil two bunches of blossoms in half a pint of milk. Let it stand until it is about as warm as milk from a cow. Drink it first thing in the morning and take a walk immediately afterwards, if the weather is favourable, and a cure will soon be effected. [Maythorn or hawthorn has its main effects on the heart and is unlikely to do much to help TB, but it might be beneficial to cholesterol levels] 

• July 19, 1823, To remove pins and bones: Any person who may swallow a pin or the bone of a fish will find almost instant relief by taking four grains of tartar emetic dissolved in warm water and immediately afterwards the white of six eggs. So effectual is this remedy, that it has been known to remove no less than twenty-four pins at once. [who would swallow 24 pins?] [tartar emetic is antimony potassium tartrate, nasty stuff once used for treating alcohol intoxication, known as an emetic since the middle ages. The egg white protein would protect the patient to a degree from poisoning by binding with the antimony. ]
• July 3, 1832, Recipe for Cholera: 1oz of cinnamon water, 35 drops of tincture of opium, 1 drachm spirits of lavender, 2 drachms tincture of rhubarb.  [1 drachm or dram = ⅛ fluid ounce or approximately one teaspoonful.  If it is a solid measure then 1 drachm = 3 scruples or 60 grains, almost 4grams. I rather suspect the opium might slow the diarrhoea but the rest is just to make it taste pleasant. ]

• April 1, 1834, Simple Cure for Consumption: this distressing complaint which carries of so many of our valuable young men annually has been cured by a very simple remedy, viz:- the inhaling of the gaseous perfume of chloride of lime. [ Consumption = TB. Chloride of lime is calcium hypochlorite and was used then to bleach laundry, now for swimming pools; the gas given off would be chlorine but is not going to cure TB] 
• April 21, 1835, Cure for the whooping cough: Take one fourth of a pint of sweet or olive oil, the same quantity of common leeks, cut them fine and simmer them moderately two or three hours; add honey to make it palatable; half a teaspoon full a portion for an adult if taken four or fibre times, it will in a few days remove this distressing disorder. [Cabbage water was also a well-known remedy for coughs] 

The final sample that caught my attention was a report from December 1840 documenting the occurrence of ice “a full quarter inch thick” on the low lying ground in the central parishes of Bermuda. Unbelievable?

Dr Luke Blackburn

Munificent or Malefactor?

It was 1864 and Bermuda faced an epidemic of yellow fever.  Not for the first time, more than five outbreaks had devastated the islanders, in 1817 it had taken 213 people from St George’s town alone.  They had tried refusing landing to ships that carried disease and buried the victims in separate cemeteries, but they were no closer to a solution.

The illness began with fever, aching and weakness. Then briefly you might feel slightly better, but the short-lived reprieve was followed by jaundice and bleeding with progressive liver failure.   Vomited blood is customarily black as coffee-grounds and the stools become loose, tar like and offensive.  Few recovered from this point, kidney failure following rapidly and death usually within 10 days. Altogether pretty unpleasant.

Man with yellow fever
Image from Wellcome Library

Pages from Nineteenth Century Textbook

 

 

 

 

 

 

 

 

This was all going on during the American Civil War and although Bermuda was officially neutral it did play an important role in blockade running to enable trade with Southern states (for more on this you should visit The Globe National Trust Museum).  Amidst all the politics and fast ships, along came Dr Luke Pryor Blackburn.

You need some background in order to judge him fairly, he features on many websites, some clearly written to support the guilty verdict. I mean to be balanced but as I began to write that I realised I wanted to show him to be innocent.  Misguided physicians allegiance or hindsight that  what he did would not have worked?

Luke Blackburn was born in 1816, in Woodford County, Kentucky.  He was one of 13 children, born into a Presbyterian family strongly involved in politics. Apprenticed at 15 to his physician uncle, Churchill Jones Blackburn, he gained his degree in medicine at the age of 19 in 1835, which seems young by todays standards but was probably not that unusual at the time. Maybe he was primed to develop an interest in what would today be the field of Infectious Diseases – he witnessed cholera and yellow fever as it swept across the southern states.  His finals dissertation was on cholera:

Dr Luke Blackburn’s Dissertation

He married shortly after becoming a doctor, and had a child within a year (a son who later went into medicine) and for a while he cultivated his political interests.  His CV would have either been impressive with its variety of roles in working life or showed lack of sticking power to any one thing.  It was enough to impress the mayor of New York in 1854 who called upon Dr Blackburn to treat yellow fever patients – this seemed to be in exchange for a New York medical apprenticeship for his son so maybe not completely altruistic.

Kentucky was one of the border states during the civil war, while trading heavily in slaves for the southern states and being officially represented by the central star on the Confederate flag, they diplomatically tried to remain neutral. But Luke Blackburn was open for his support of the Confederates.

How he turned up in Bermuda is not exactly clear – some sources have the Canadian authorities sending him as a Confederal Agent, others claim he volunteered and had already devised his wicked scheme.  They report that he refused payment for his medical services, but far from intending to boost his credentials in generosity it is written as if to underline his evil intent.

Perhaps my favourite source is “The Biography of a Colonial Town” by Sister Jean de Chantal Kennedy, 1961. Not for its unbiased writing, but for the element of storytelling she manages to incorporate.  Luke is described as having “subdued an outbreak of yellow fever” and ‘stemming the onslaught” of cholera.

So, on arrival he took quarters in The Hamilton Hotel where the local medical men asked him to address their meeting.  One took offence at the suggestion that he used the “application of onion with tobacco to the stomach” as a remedy for yellow fever.  Luke Blackburn impressed upon them the need for strict quarantine procedures, a reasonable idea even if it would not have reduced the mosquito carriers of the disease. He began treating the fevered patients and again is noted for not charging a fee.

A girl suffering from yellow fever. Watercolour. From Wellcome Institute.

 

 

 

Fever!

 

 

 

 

 

 

What happened next may or may not be true.

Dr Blackburn reportedly (the nurse and the barman were witnesses) took the bedding and clothes from those who had just died of yellow fever and packed them into his trunks. In one instance he is supposed to have sent the relatives out to arrange burial while he himself laid out the deceased in an unknown nightgown, the patients own clothes “mysteriously” disappeared.  According to other sources he was in league with an Edward Swan whose role in this was to ship the trunks of (possibly) infected clothing to the northern states, to New York and Unionist ports.     It is even suggested that Blackburn himself selected particular fine shirts from amongst the dead persons’ clothing which he addressed to the President.

Note I have moved from referring to him as Luke, through Dr Blackburn and now Blackburn – and so they did on Bermuda as he fell from grace.  A man who might have been a federal agent or a double agent or a Unionist spy, Mr Fred Buckstaff, tracked the trunks and on finding them awaiting shipment challenged Edward Swan, who soon squealed.  Then another came forward , Godfrey Hyams, claiming he had been involved and had received shipments of infected clothing in Boston, Philadelphia and other ports, that the intent was a “cunning plan” to spread the contaminated clothes amongst the Unionists and so bring the Northern war effort to its knees.

The doctor’s supporters dwindled as the evidence seemed to mount against him.  It didn’t help that this was shortly followed by President Lincoln’s assassination so talk of conspiracy plots dominated the headlines.

No one seems to know quite how, but Dr Luke Blackburn left Bermuda and found himself in Canada. Here he was actually charged, but not with germ warfare or the equivalent of the time, but with damaging Canada’s neutrality.  His defence was reputed to be:  “it is too preposterous for intelligent gentleman to conceive”  The charges were dropped.

One might expect a guilty man to lay low, so perhaps it speaks well of him that he soon after travelled to the southern states when yellow fever took a hold in New Orleans.

I found one source that explains some of the research that was undertaken with respect to epidemics of fever – it appears that throwing cats from a height was involved …

So for the next ten years or so Dr Luke Blackburn seemed to have been an itinerant medic treating fevers of all descriptions with no little success – Memphis outbreak in 1873 and Florida in 1877.  Until he found himself back in Kentucky in 1879 and running in the election for Governor.   Some of his opponents tried to blacken his name with tales of “Dr Blackvomit” and reporting controversial statements of apparent evidence on a daily basis in the papers, but it seems his good deeds overshadowed any hint of malicious activity and he was selected as the Democrat candidate with a resounding majority of 935 votes to 22 and later on that year he was elected Governor of Kentucky with 56% of the votes.

He remained a controversial figure in this new role, granting pardons to criminals to avoid overcrowding in the prison, capping payments to state officials, reducing the number of jurors. After a tempestuous four years in post he withdrew from public life, set up a sanitarium where he worked until his death from an unknown illness in 1887.

The state of Kentucky erected a granite monument over his grave in Frankfurt (Kentucky town not German) which depicts the Parable of the Good Samaritan.

So what do you think? There is both information and misinformation on websites and it is probably impossible to get to the truth of the matter.  What I conclude is that no trunks were actually shipped from Bermuda with infected clothing; that it would have been a reasonable assumption that yellow fever was infectious and spread by contaminated bedding and clothes so it is logical to remove those items to prevent spread of disease;  that from all accounts it was a busy, scary period of time and fanciful stories tend to spread rapidly when tinged with the element of fear.

The link between mosquitoes and yellow fever was not far away – first proposed in 1881 but not confirmed until 1900.  The virus was isolated in 1927 and a vaccine developed by 1937, for which the South African Max Theiler won the Nobel Prize (1951). The same vaccine is used today and in 2013 WHO announced that one injection will confer lifelong immunity.  You don’t need one to come to Bermuda though 🙂

Postcard from DPLA
(US archives)

Pregnant in Bermuda

I am not, but the wife of one of my husband’s colleagues has just had a baby, which led me to thinking about how antenatal care and childbirth is managed here on the island.

 

The Queen visited in 1953 and was introduced to  Bermuda triplets. The paper reported that they were the first in over 200 years but the Outerbridge family had triplet boys born at a home on the North Shore Road in 1927. I tried to look up how common triplet births might be here but the search term triplet births in Bermuda led me to a page on raising goats!
( http://www.weedemandreap.com/2013/01/a-simple-guide-to-raising-milking-goats.html )

Although Bermuda is a British Protectorate the medical system is more akin to that in the States. So the bulk of maternity services are private and financed through insurance which is compulsory (the company has to organise health cover for employees).
The Bermuda Hospitals Board lists 9 Obstetricians on the island, (http://www.bermudahospitals.bm/bhb/find-physician/index.asp )
though the September 2013 Healthcare Directory states there are 7 (issuu.com/bermudasun/docs/health_care_part_3_-_july_2013 )
and there are around 600 births per year. In 2009 there were around 840 births annually, the drop probably reflects the reduction in population and loss of expat-workers during the last 5 years.

Unlike in UK where midwives are the primary carers during most normal pregnancies, here the obstetrician model of care persists. It is common to be delivered by your obstetrician and, perhaps not unrelated, the instrumental deliveries are higher than one might expect.
It seems to have taken a great deal of pressure and effort by concerned groups of midwives to enable them to practice as independent professionals and to offer the option of home births.

Antenatal medical checks are apparently more frequent than in UK and the tests include things such as cervical smear in early pregnancy, which in current UK practice is usually not done. (on the basis that the hormonal changes will affect the cervical cells so diagnosing pre-malignant change is inaccurate during pregnancy). It is difficult not to think that this is driven by the way healthcare is funded, but thats another issue and one it seems that even caused trouble for President Obama so I will avoid it! However you will have all the usual screening: Quadruple test for assessing Downs risk, ultrasound, Foetal heart rate monitoring, usual blood tests, glucose test, and if you should need it they have facilities for chorionic villous sampling in early pregnancy or amniocentesis in mid pregnancy to detect genetic abnormalities. If anything you will be seen more often and tested more often than if experiencing UK antenatal care and you will have access to a midwife and an obstetrician for all of this care – GPs do not tend to take on anything but the most routine antenatal checks.

Back in July of this year two Bermudian doctors (Dr Alton Trott and Dr Yusef Wade) set up a new and modern OB-GYN service at offices close to the hospital. They are both American trained but decided to return to Bermuda once they started their own families. Both can trace their families back hundreds of years on the island. The reporter who interviewed them was impressed by the comfortable clinic room “lined with bookshelves and with a fire place”. They have a website: http://contemporaryobgynbermuda.com

Prenatal classes are offered at the hospital, on Tuesday evenings, a four-week programme. You are permitted one birth coach (they were called husbands when I did this).

Baby Showers are customary

Gibbons stock absolutely everything you might need and many baby gadgets you don’t. There is no Mothercare or Early Learning Centre and the M&S only stocks a small selection of baby clothes. An overseas trip might be recommended for variety and to avoid turning up at a coffee morning with babies in identical outfits!

What are your options for delivery?
There have been 42 home births, some of them water births – but this is in the last 9 years, so clearly not widely available yet. If you are contemplating this you should speak with Sophia Cannonier, who was Bermuda’s first doula, or look up http://www.consciousbirthbermuda.com/ConsciousBirth/Welcome.html

The maternity unit has four delivery suites, each painted attractively, but the process is likely to be quite traditional. I don’t think they do six-hour discharges over here. Visiting times are strict and siblings can only come between 4pm and 6pm. The wards are locked and have a security guard – it sounds severe to write that but I suspect this is in fact reassuring.

There is a neonatal unit, but I cannot find out how many incubators or cots it has. They do send babies with more complex needs across to Halifax, Nova Scotia
http://www.iwk.nshealth.ca
No direct flights that I can find, a cost of around $300 each way and a journey time of at least 6 hours. My daughter, currently working in neonates in UK, told me of a poor mother in labour recently who had to be taken to another hospital to deliver because all of their neonatal beds were in use – I don’t think that would be a wise move from Bermuda. That does mean that if you have any difficulties with your pregnancy or the baby needs extra monitoring then you might need to consider being abroad for periods of time.

What about working in Bermuda as a doctor? Both UK and US have accredited training posts here for their programmes in most areas of medicine, including O&G. The issue of malpractice insurance needs to be looked at closely. Obstetricians tend to expect to pay more for this cover than some other specialties, in part because the child has until they are 21 to sue for problems that may have occurred during the pregnancy or delivery. So the premium on Bermuda for an obstetrician has risen in the last few years – around $200,000. The birth rate on the island is too low to compensate for this. The solution reached just last year was for the obstetricians to become employees of the hospital (King Edward VII Memorial Hospital) and receive cover under the umbrella of the local insurer. This allowed maintaining a threatened obstetric service on the island.

Once you have had the baby – it is a wonderful place to bring up children!:)

Sunburn

Sun burns!

Recent UK summers – that is, lack of sun – meant I had forgotten how uncomfortable sunburn can be, but with average daily sunshine of 9 hours for a Bermuda July I am ashamed to say I learnt the lesson once again.
😦

With apologies to the non-medical readers, this post has a distinctly medical theme, but I have tried to keep it jargon-free. I shall attempt to answer the following questions:

What happens to the skin in sunburn?
Why is it dangerous?
What are the best treatments?

Under the following headings:

Ouch it hurts – presentation
Serves you right – risk factors
How bad can it be? – assessment
I told you so, try vinegar – treatments
Never again – prevention

Ouch, it hurts!

I knew I was burnt because my skin was red, tender and warm – oh, and I had just been snorkeling for two hours just before lunch with a pea-sized amount of sun cream liberally rubbed onto my whole body (we will get to how much and how often later, but you will all be thinking, quite with reason, how inadequate my preparation was)

A few facts:
Sunlight is composed of UVA, UVB and UVC. In fact to call it “light” encourages a relaxed attitude, I should use the term “radiation”. We don’t need to worry about UVC, it is reflected off the upper layers of atmosphere back into space. Most of the sun’s radiation is UVA (95%) but during the midday hours (10-4) UVB is twice as high as in the rest of the day and it is UVB that burns. UVA is by no means innocent, it is associated with aging, though the precise physiology is unknown.

Now I tend to brown nicely and rarely burn (Fitzpatrick Skin Type III – if you are a medic, then go look it up, but briefly it is a descriptive scale devised in 1975, used for research and has no real predictive value, though Fitzpatrick himself, a Harvard dermatologist, might plead otherwise).

Nonetheless, two hours after lunch and I was beginning to blister, a sure sign of deeper skin damage. The redness, by the way, is caused by skin blood vessels dilating and is the start of an acute inflammatory reaction. It is supposed to occur some 3-4 hours after exposure, peak at 24 hours and resolve over 7-10 days. That I was red so soon after exposure suggested I was over-cooked.

Cooking is probably an apt description, though the tanning is not merely desiccation and carbonization of the upper layers, it has more to do with melanin. Melanin is there to protect the skin, it will reflect some of the UVB rays. In “normal tanning” first the melanin that is already in the skin darkens by oxidation and is redistributed. Then the skin increases the synthesis of new melanin over the next 1-2 days.
But where I had overdone things, mast cells in my skin (they are really fascinating if you want to look them up) were releasing histamine, serotonin and the alarming-sounding tissue necrosis factor (TNF). This led to prostaglandin and leukotrienes which in turn attracted neutrophils and so on …. (You can tell I could get quite excited about the chemical processes in the inflammatory response)

But it is not so simple as just the surface layers of skin dying and sloughing off, the damage is deeper, the actual DNA is affected, and it is this that leads to the increased risk of skin cancer.

In the image the cells that can become cancerous are squamous cells, basal cells and melanocytes. The epidermis, top layer, is usually separated from the lower layers by the basement membrane, but in advanced skin cancer it will grow through this and invade the deeper layers.

While we are talking about damage, sun damage can also lead to cataracts, particularly in India and Pakistan. Like sun-induced skin cancer the risk relates to exposure in children and young people, groups least likely to take precautions like wearing sunglasses and hats.

Serves You Right

For some reason this phrase carries echoes from my childhood. And it is appropriate since I did know better. Risk factors for sunburn include fair skin, infants and children, high altitudes, low latitudes, and the biggest – exposure between the hours of 10 and 4.

WHO developed a UV Index as far back as 2002, but inconsistency in its use has led to it being of less use than it might be. For grades 1-2 it is safe to be out without sun protection, for 3-7 it is recommended to stay in the shade during midday hours, for 8+ best to avoid exposure and always use protection. Today, in Bermuda, the maximum UV Index is 9. (http://accuweather.com )

90% of malignant melanomas occur in skin types I and II. Dark skinned people may be protected to a degree from skin cancer but are still susceptible to eye and immune system damage. A dark tan on a white skin will offer only limited protection, perhaps equivalent to using an SPF 4 lotion.

But I did use sun screen! Hmm – an adult should use 34g applied 20 minutes before exposure AND every 40-60 minutes.

Don’t waterproof ones last longer? Actually not, they are merely resistant to being washed off quickly but they still can only maintain the SPF for 40-60 minutes. I feel somewhat misled by the advertising!

How bad can it be?

Google “severe sunburn” and there are thousands of images, some horrifying. In quite a few the bearer is wearing a stupid grin. I don’t have pictures of my sunburn, I am too embarrassed.

If you are medical and presented with sunburn then assessment is along the lines for any burn – remember dehydration and pain levels. “Sunstroke” presents with fever, chills and nausea so if your patient is shivering and looking ill they may need admitting – you will have to present your case well to the on-call medical team as nobody is keen to use an acute bed for sunburn. In UK, 2011-12, there were 287 acute admissions for sunburn. (Hospital Episode Statistics- http://hscic.gov.uk )

I told you so – try vinegar

What sort of vinegar? It is a grandmother’s remedy, and online you will find lots of conflicting advice on what sort and how to apply it – there is no difference between white, apple-cider or malt, apart from the smell. I have no idea how it works, nor do dermatologists. Baking soda, cornstarch paste, calendula oil …. The list is endless.

 

Turmeric! Yes I am not kidding, applying a thin paste once daily apparently provides relief from sunburn – that one I must try!

With a doctor hat on I would suggest after-sun gel, one with lidocaine in if available, ibuprofen orally and plenty of water to drink. Aloe Vera has been researched but not shown to improve recovery time. Systemic steroids have advocates but again there is little evidence they help and plenty of risks, they are of no benefit topically either.

Never again!

There have been some recent surveys of Australian youth which suggest that the messages to cover up and use cream are wearing thin and along with fewer using protection are increased numbers suffering sunburn.

Meanwhile an SPF 8 cream is no longer considered sufficient but SPF 50 creams now cost well over $20 (£15) for quite small tubes. What is in these potions that makes them so expensive? One Aloe Vera sun lotion has a list of 43 ingredients.
There is a lot of hype about antioxidants and their protective effects against cancers but I was sceptical about their effect topically. My reading suggests, however, that some (selenium, CoQ10, alpha lipoic acid) have supporting evidence for topical use at least with regard to the aging effects of sun. Others, such as Vitamin E, pomegranate, ginger and grape seed extract, are currently being researched. The main problem with antioxidants is that they tend not to be absorbed well through the skin, so another topic of research is novel methods of application.

One thing I did learn was that sunscreen suitable for adults is probably not advisable for babies and infants – I guess it makes sense, given that baby skin is so much more susceptible to damage. Children need oil-based emollients with inorganic filters and should not be using the organic filters that are used to create higher SPF creams, specifically not oxybenzone.

And one last comment on fake tans – these are merely chemical dyes that color the dead skin layer various shades of brown, they neither increase melanin nor even moisturizer the skin. They use dihydroxyacetate (DHA) which has been used in cosmetics since 1920s, and while they may be mixed with moisturizers or SPF creams, none currently available provide sufficient protection for use instead of a proper SPF50 lotion.

You have been very patient while I have learned my lesson, my husband has been sympathetic – last weekend he bought me an SPF50 shirt to cover me up when swimming next time. It is bright yellow, so not sure how good it will be for snorkelling, do fish get frightened by giant yellow things?

 

 

Formica

I woke to freshly brewed “proper” coffee and the question “Where’s the baby powder?”
Post-dream disorientation took me back 25+ years: babies, nappies, feeding, changing… let me go back to sleep, please. But now we keep baby powder for the ants.

The ants have found their way into the kitchen.

This isn’t actually my kitchen, the kitchen ants are not photogenic, these ones are to be found on the path outside, every day running back an forth along an invisible scented line.

They are quite small, well of course ants are, but to me they appear smaller then the UK ants. Pheidole megacephala – big-headed brown house ant. Like the English ants it is a member of the Formica family (nothing to do with laminate worktops) but the Bermudan ants seem to have two-segment waists while UK ones have single segment middles (petioles).

Until today I had no idea there are so many different ants:

http://en.wikipedia.org/wiki/List_of_ants_of_Great_Britain

The “bigheads” were first found in Mauritius and its a long way to Bermuda so I guess they travel well; in fact it is listed in the top 100 most invasive species. There are two types of worker ants in this species: Soldier ants with the biggest heads, about 4mm long, and Minor worker ants that are half the size and whose heads are relatively smaller. I think the ones in my photo above must be minor workers as none of them seem to have large heads. They feed on dead insects – I have been advised that they will congregate around dead cockroaches but that I should first trace the line of ants back to their nest before moving the cockroach and then spray the nest.

Wellcome Images

I am told you can still buy DDT in Bermuda; banned in US in 1970s and UK in 1984, but still manufactured in India and still used to fumigate homes in some places in the world.
For the medical audience, it works by opening sodium channels in neurons, which for the ants means spasms and death. The toxic effects on humans include endocrine effects, it is an anti-androgen, and direct effects on the genes, hence is a carcinogen. The DDT story is as much political as it is science and the ban is as controversial as its continued use in some countries. Paul Mueller, a Swiss biochemist, received a Nobel prize in 1948 for his work on DDT and it did prevent millions of deaths from Malaria.

The following have all been recommended to me to get rid of ants:

Mint leaves…. apparently they dont like the smell
Cayenne pepper….the capsaicin in cayenne pepper is an irritant to ants
Baby powder….the cornstarch in baby powder is irritant
Cornmeal …makes ants explode: they take the grains home, eat them and then presumably drink some water so grains expand inside the ant, and then they go pop – but might take an awful lot of cornstarch to feed a whole colony
Cinnamon ….but some people dont like the smell any more than the ants
Bay leaves … not very tidy
Vodka. …. 3:1 ratio of vodka to water, sprayed liberally, but might give visitors the wrong impression
Washing-up liquid and water mix ….works for a while but then they come back when it has dried

We have settled on baby powder, as you have surmised from my wake-up call. I have no idea where the houseproud urges came from as I never had them in UK, but I am resisting the inclination to hoover it all up as soon as the ants take a break. The smell brings back some of the nicer memories of having children, it is relatively cheap and so far I haven’t heard any suggestion that it is carcinogenic….

Update on that: baby powder does contain talc which a recent meta-analysis suggests is linked to ovarian cancer

http://www.dailymail.co.uk/health/article-2343974/Women-regularly-use-talcum-powder-increase-risk-ovarian-cancer-24.html#

(Daily Mail version)

http://cancerpreventionresearch.aacrjournals.org/content/early/2013/06/12/1940-6207.CAPR-13-0037.abstract

(Academic link)

OK so keep it well away from “intimate personal hygiene”, probably still safe for ant prevention.

I mentioned cockroaches earlier, the Periplaneta americana.

 

After fruitless search for one to photograph I have resorted to that well-known w…pedia for a picture. They eat anything that is not alive and are common in basements – guess who isn’t going to unpack the cardboard boxes when it is time to return to UK! I havent actually seen a living one out here yet, I am assured it is only a matter of time, and I rather wish it would happen so I can get over it as the apprehension at meeting one in the bathroom at night grows with every night I escape unscathed. I like the friendly name given to them here: Palmetto bugs.

On my search just now I did find this:

It think it is a June Bug (Lygyrus cuniculus ) which apparently fly drunkenly at night in June (obviously), but it doesnt look exactly like the one in my field guide book so I might be wrong. Any suggestions?

There are many prettier and less annoying insects and bugs, butterflies, millipedes and snails, but none of these are threatening my kitchen so not priority no1.

Absolutely no oxygen

Yesterday in a shop I overheard a woman saying to her friend “My doctor sent me for lung function tests which showed that I had absolutely no oxygen in my lungs whatsoever, so no wonder I couldn’t breathe.”

Aside from the impossibility of this statement, which had me laughing behind the brightly-colored-ultra-fluffy-highly-expensive towels, the incidence of asthma in Bermuda is of interest.

A seminal study in Bermuda in1986 documented the effects of weather changes on acute asthma.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1341634/

The conclusions were that a NE wind with its colder air and lower humidity will precipitate acute asthmatic attacks while a SW wind, high humidity and higher temperatures seemed beneficial.

It was known as far back as 1776 that cold dry air triggered asthma ( Philosophical Transactions of the Royal Society of London, 1776) . Dramatic increases in incidence have occurred with the passing of cold fronts and thunderstorms in New Orleans, Birmingham UK, and Melbourne (Brown and Jackson 1983 Lancet ii, 260.) But Bermuda has a sub-tropical climate with temperatures not below 16C and generally high humidity all year round so extrapolating from the 1986 study, one might expect a low incidence of asthma.

So why did I read in May this year that the prevalence of asthma in Bermuda is as high as 1:5 children and 1:10 adults, one of the highest in the world?

The Bermuda Health Council last surveyed adult health in 2011. They reported:

Overall, 15.2% of respondents had asthma at some time and 9.8% said they currently had asthma. Women (11.1%) were slightly more likely to have asthma than men (8.2%). Asian and other races (14.6%), single parent households (16.4%), and those with a household income less than $60,000 (14.8%) were more likely to currently have asthma. Those aged 65 and over were slightly less likely to have asthma than other age groups (8.5%).

Last year (2012) around 2000 people were treated for asthma at the Emergency Department of the local hospital – that excludes visitors to the island. This compares with UK figures of 1:11 children and 1:12 adults (http://asthma.org.uk ). Why?

I have just spend half a day reading research papers on asthma in sub-tropical climates, only to conclude “it’s complicated”. Clearly Bermuda does not have high levels of atmospheric pollution, at least not outdoors, but it does have high humidity and this is linked with increase in moulds and dust mites (http://www.lung.org/healthy-air/home/resources/dust-mites-and-dust.html )

It is recommended to minimize dust mites one should keep internal humidity to 50% or less. Bermuda humidity is never below 70% and often above 80% – hence the demand for air conditioners and dehumidifiers is high.

So humidity, mold and dust mites account for much of the high prevalence. But we must not forget the cockroach! Calling them “Palmetto Bugs”, as the Bermudians do, makes them seem more like friendly beetles, but their droppings contain allergens and they love warm places, especially if they can find some food crumbs. If that doesn’t trigger your obsessive cleaning then nothing will.

World Asthma day this year was May 7th and Open Airways, the asthma charity in bermuda, were giving away pillows, spacers and microfibre cleaning cloths to encourage chemical-free cleaning. Next World Asthma Day is May 8th 2014.

So, back to asthma: is there a bottom line?
Should people with asthma come to Bermuda?

Well, the prevalence has apparently “tumbled by a record 76%”
(http://www.royalgazette.com/article/20130507/NEWS06/705079966 ) – Don’t you love journalism – no reference, no figures, no timescale, just believe it!

But some people would have you warned away: http://www.bermudasucks.com/forum/general-discussion/asthma-and-bermuda-what-you-need-to-know-before-moving/
(“Bermuda-sucks” is an interesting site for an alternative view, maybe I’ll return to it in a later blog)

For short term, it would seem sensible to bring spare medication, have full travel insurance and be aware of your environment.
For those coming to reside then I would suggest a visit first, discussion with your specialist and lots of online reading in order to get a balanced view.
(disclaimer: I am not giving medical advice here, this article merely relates a few facts and my own meanderings)

 

A strange experience

I turned into the road which wound steeply up the hill and as the engine struggled (it’s only a little Kia) I was confronted by a woman standing in the middle of the road waving both hands at me. Was I going the wrong way on a one-way street (easy to do as they don’t seem to have many road signs telling you things like that) or had there been an accident up ahead? Neither, she wanted a lift up to the hospital at the top of the road!

The Mid Atlantic Wellness Institute (MAWI) is a psychiatric hospital, established as St Brendan’s Hospital in 1846. The building is an encouraging bright turquoise color. It is a far cry from the Victorian edifices that house many of UK psychiatric units. In 1848 there were just 8 patients, now it has 89 inpatient beds and provides over 10,000 outpatient appointments.

There are currently 4 Psychiatric Consultants and 4 training posts. In 2011 a new mental health plan was implemented, but even so one of the psychiatrists has openly stated that Bermuda is 40 years behind the developed world when it comes to psychiatry. The focus is only gradually changing to community management of mental illness but they struggle to cope with the many “revolving door” patients due to the lack of services outside. Stigma flourishes in the dark, as I realised during a conversation which was muted to a whisper for the phrase “she suffers from bipolar disorder you know, lots of issues”
It wasn’t referring to me, but for the fight against stigma I should say it could have been me.

So what should I do about this lady standing in the road? I felt apprehensive but for no good reason – she had no bag, no weapons, and when she spoke I could see she had few teeth. Her mouth betrayed the prolonged use of antipsychotic drugs – she had tardive dyskinesia and slurred speech. In the event I had little choice as she was by then climbing into my passenger seat. I felt guilty for immediately sitting on my purse and mobile phone, there was really no basis for my anxiety.

In our first week here we were warned about gun crimes and from the number of people mentioning it I presumed it was a big problem. The figures for 2012 showed that 5 people were shot dead and another 7 injured by guns. Equivalent figures for London are 89 deaths and for US over 30,000 gun or knife deaths. Ok so these are not fair comparisons, but overall crimes against the person in Bermuda are uncommon and are decreasing.

“It’s a hot day” I made polite conversation.
“This your car?”
A vague affirmation and “in Devonshire” as to where I lived.
Then, blow me down, just round the corner a man is waving me down, does he too want a lift to the hospital? It is within view, just 200 yards, so I decide he is just being friendly. Bermudians are very friendly. I have been instructed that Good Morning or Good Afternoon should precede any attempt at conversation and the correct response to this greeting is to make eye contact, smile and repeat. There have been times in my life when I avoid eye contact, not through any sense of guilt, rather because I prefer my own company or am feeling somewhat depressed, so I am deliberately looking up and smiling in case I am perceived as rude. Not sure if it is the weather or the friendliness, but my mood is certainly comfortably happy. My passenger too seems pleased with life and starts humming.

I don’t get to hear the whole hymn she is singing as we have arrived at the brightly optimistic turquoise building. I am sad in a way that I don’t get the chance to ask her about herself, about her medication, her life and her battle with mental health issues – yes, once a doctor, always a doctor, or maybe I am just plain nosy.

I drive on and find The Barn -effectively an enormous charity shop on behalf of the Bermuda Hospitals. I buy two books, one on brain surgery and the other on Bermuda wildlife.