Army’s Aggressive Surgeon Is Too Aggressive for Some

Army’s Aggressive Surgeon Is Too Aggressive for Some 

 

CRITICAL CARE Col. John Holcomb, a top trauma surgeon in the Army. 

Since the war in Iraq began, Col. John Holcomb has been working to change the way the military takes care of its wounded.

TOLL With 29,000 American injuries from hostile fire in Iraq and Afghanistan, said Col. John Holcomb, doctors must run clinical trials to ensure that patients are receiving the best treatments.

Along the way he has suffered a few dings himself.

A tall medical doctor with a Southern lilt and close-cropped gray hair, Colonel Holcomb, 48, has spent his entire 27-year career in the Army, earning a reputation as one of the military’s top trauma surgeons. Since 2001, he has headed the Army’s Institute of Surgical Research, based on the campus of the Brooke Army Medical Center here.

Under his watch, Army surgeons have become aggressive users of a controversial drug called Factor VII, which promotes clotting in cases of severe bleeding. He has also guided a redesign of the transport system for wounded soldiers, encouraging helicopter pilots to take the severely injured to the hospitals best able to treat them, even if they are not the closest.

Colonel Holcomb also strongly advocates conducting clinical trials to improve trauma care. It is an ethically tricky area, because trauma research can involve trying novel treatments on severely injured patients who cannot give informed consent. But he argues that any ethical problems pale in comparison to the toll that traumatic injuries take on civilians and soldiers every day.

He is fond of quoting a surprising statistic: trauma is the third-leading cause of death in the United States, taking 160,000 lives in 2004, more than any other cause except heart disease and cancer. Because it primarily affects the young, trauma leads all diseases in terms of life-years lost.

And besides the 4,000 American deaths in Iraq and Afghanistan, there have been 29,000 injuries from hostile fire, including 9,000 severe enough to require transport to hospitals outside the war zones.

In the face of that toll, Colonel Holcomb said, doctors must run clinical trials to ensure that patients are receiving the best treatments. Without those trials, even basic questions — which patients should be put on breathing tubes, for example — remain unanswered.

In an interview in his office at Brooke, Colonel Holcomb said he was determined to generate data that would help military and civilian surgeons answer those questions.

“We run a research institute,” he said. “Everything we do, we try to drive on data.”

Colonel Holcomb’s backers, who include surgeons both in and out of the military, say he is an exceptionally hard-working physician whose single-minded focus on wounded soldiers has led to improvements in the way the military treats its injured.

“John Holcomb is making a huge contribution to the advancement of trauma care in this country,” said Dr. Brent Eastman, the chairman of trauma for Scripps Health in San Diego and a regent of the American College of Surgeons.

But Colonel Holcomb is not without critics, who say his efforts, however well intended, may be doing more harm than good.

Dr. Andrew F. Schorr, a former military physician who is associate director of critical care medicine at Washington Hospital Center in Washington, said he believed that Colonel Holcomb had pushed military surgeons to use Factor VII despite a lack of data on its benefits — and some evidence that it can increase the risk of blood clots that cause strokes. Factor VII is a naturally occurring protein that helps the blood clot; an artificial version is produced by the Danish company Novo Nordisk under the name NovoSeven.

“I certainly disagree with his approach to Factor VII,” Dr. Schorr said.

Colonel Holcomb has also been criticized for his advocacy of an experimental blood substitute called PolyHeme, which recently failed a clinical trial in trauma patients. The trial, which ran from late 2003 until last year, was conducted on people who were severely injured and could not give consent to the experiment.

The trial followed an earlier failed test of PolyHeme in patients undergoing surgery for aneurysms. In the earlier trial, 54 percent of people who took it went on to suffer serious adverse events, compared with 28 percent who did not.

But the Brooke Army Medical Center and Colonel Holcomb did not disclose the results of the earlier trial to the public when they agreed to participate in the new trial. “Up to now, PolyHeme has not caused any clinically bad problems,” researchers for Brooke wrote in materials prepared for a public meeting, according to a 2006 article in The Wall Street Journal.

“He knew about this data, and he should never have approved the trial for his center and allowed the Army to participate in it,” said Keith Berman, a medical products consultant who specializes in research on blood substitutes. “Many, many centers declined to participate in this trial.”

 

SimCity Societies: A Greener Version of the Urban Jungle

SimCity Societies: A Greener Version of the Urban Jungle

The much-anticipated game update will address how cities are built with the environment in mind

	VIRTUAL CITY BY THE SEA:  SimCity Societies encourages its virtual architects to design cities that maximize any one of a number of different values, including authority, creativity, knowledge, productivity, prosperity and spirituality.

Since its debut nearly two decades ago, Electronic Arts's (EA) SimCity has allowed its players to become the masters of their own mini-domains. But there was always a nagging feeling that the game judged their moves based on some preset moral compass. No more: in the new version of the game SimCity Societies, set to hit stores on November 15, zoning and infrastructure planning requirements designed to keep city planners on the right track have been replaced with a much broader definition of success.

SimCity Societies encourages its virtual architects to design cities that maximize any one of a number of different values, including authority, creativity, knowledge, productivity, prosperity and spirituality. Players determine whether their cities turn out to be capitalist meccas or artistic hippie societies based on criteria such as the power source, types of buildings and the proximity of those buildings to one another.

SimCity has always allowed its players to decide whether to power their metropolises by coal, nuclear, solar or wind energy. But the new version takes a different tack. "We wanted the next SimCity to reflect how societies evolve," says Rod Humble, studio head at EA's Sims label, based in Redwood City, Calif.

The goal is to produce a high level of "societal energy," by developing a city with one or more of the game's six values. Societal energy is a fairly intangible force, but players know they have it when their cities grow and their citizens are happy and productive. "If you put the city together right, it has the right energy," says Rachel Bernstein, producer of SimCity Societies. Players place buildings within their cities in order to maximize the values most important to them, whether they are productivity and prosperity or creativity and spirituality.

A courthouse, for example, creates a city's societal energy by increasing the output of simoleons—the game's currency—in the surrounding workplaces. In that same city, a building containing a focus test lab makes corporate buildings throughout the city produce a higher simoleon output per worker. So, the focus test lab not only increases the city's revenue, it also makes corporate buildings produce greater societal energy, a feature that helps raise the city's prosperity value, Bernstein says.

KEEPING THE LIGHTS ON:  SimCity has always allowed its players to decide whether to power their metropolis by coal, nuclear, solar or wind energy.

In the updated game, decisions about energy sources are more important than ever and better reflect the decisions that today's real-world city planners face. Players choose their energy sources based primarily on cost, power output and pollution. Whereas solar or wind farms have few negative environmental side effects, they require more space and produce less energy than environmentally unfriendly coal plants.

To make these decisions as realistic as possible, EA took the unusual step of designing the game with the help of London-based energy giant BP (formerly British Petroleum). "BP came to us more than a year ago wanting to make a game about alternative energy," Bernstein says. "It made sense to show them where we were [with SimCity] and see what they were looking to accomplish."

BP saw its role as helping EA—and by extension SimCity players—understand the role of electricity in climate change. "Globally, twice as many emissions come from generating electricity than from all forms of transportation—planes, trains, cars and others," says Carol Battershell, vice president for strategy and policy at the company's subsidiary, BP Alternative Energy.

"We wanted there to be a range of power sources and an understanding of the impact of each, including local pollution, greenhouse gas emissions and the willingness of people to live next to energy-producing facilities," she adds. "SimCity is a strategy game, and these have been shown to be a good for helping people understand complex issues."

The collaboration with EA follows BP's promise two years ago to double its investment in alternative and renewable energies, creating a new low-carbon power business with the growth potential to deliver the company $6 billion in annual revenue within the next decade. Building on its BP Solar business—which BP expects to hit revenues of $1 billion in 2008—BP Alternative Energy manages an investment program in solar, wind, hydrogen and combined cycle gas turbine power generation, which the company predicts could amount to $8 billion over the next 10 years.

Although the BP Alternative Energy logo appears on several buildings available to players, Bernstein dismissed the idea that BP's visibility in the game amounts to product placement. "As we moved toward SimCity Societies, we were thinking we wanted to have a broader, more nuanced look in our energy resources," she says, "and BP helped us flesh it out. We saw BP as expert consultants."

The logo "should be seen as a small part of the SimCity game," BP's Battershell says. "If you get a million people an hour of education on power plants, I would feel this is wildly successful." She notes that BP is huddling with EA and other video game makers with an eye toward future collaborations.

Both companies say that they hope the costs and consequences of energy decisions made in the game will translate to the real world. "One thing that we can do with video games that other mediums can't," Humble says, "is provide an interactive simulation where you can figure things out and find solutions."

Scientists Decode Most of Mo. Cat's DNA

Scientists Decode Most of Mo. Cat's DNA

An Abyssinian cat from Missouri, named Cinnamon, has just made scientific history. Researchers have largely decoded her DNA, a step that may aid the search for treatments for both feline and human diseases.

The report adds cats to the roughly two dozen mammals whose DNA has been unraveled, a list that includes dogs, chimps, rats, mice, cows and of course, people.

Why add cats? They get more than 200 diseases that resemble human illnesses, and knowing the details of their genetic makeup should help in the search for vaccines and treatments, researchers say. The list includes a cat version of AIDS, SARS, diabetes, retinal disease and spina bifida, said Stephen J. O'Brien of the National Cancer Institute.

The new work is reported in the November issue of the journal Genome Research by a team including O'Brien and colleague Joan Pontius. It covers about two-thirds of the DNA of Cinnamon, a research cat that lives at the University of Missouri in Columbia; more complete results are expected next year, O'Brien said.

Richard Gibbs of the Baylor College of Medicine in Houston, who led a team that decoded the DNA of a monkey called the rhesus macaque, called the new work "a good outline" of cat DNA. Scientists are looking forward to the complete version, which will be useful for making detailed comparisons to the DNA of other animals, he said.

The full complement of an organism's DNA is called its genome. In cats, as in people, it's made up of nearly 3 billion building blocks. The sequence of those blocks spells out the hereditary information, just as strings of letters spell out sentences. Decoding a genome, which is called sequencing, means identifying the order of the building blocks.

The new work identified 20,285 genes in the cat, probably about 95 percent of the animal's full complement, O'Brien said. That's similar to the 20,000-25,000 genes estimated for humans.

 

This undated photo released by University of Missouri shows a cat, a 4-year-old female Abyssinian... 

Water: A Precious, and Wasted, Resource

Water: A Precious, and Wasted, Resource

NEW YORK -- On an illuminated wall in the American Museum of Natural History, three clear plastic tubes about 5-feet long and a couple inches in diameter automatically fill with water. In the first tube, a small amount shoots up, barely visible at the tube's bottom, representing the meager 3 gallons of water that the average Ethiopian subsists on daily. The middle tube fills about one quarter full, showing the more bountiful 30 gallons of water the average Briton uses in a day.

Both amounts pale in comparison when water fills to the top of the third tube and shows the astounding 150 gallons of water that the average American uses in a day.

This waste of one of Earth's most precious resources is a central theme of the AMNH's new exhibition, Water: H2O=Life. In the exhibition, visitors can explore the many facets of water: its astounding physical properties, its ability to shape ecosystems, landscapes and societies, the importance of conserving water and ultimately the fact that water is essential to life.

Water and life

Throughout the exhibition are examples of the different ways that life has evolved around the amount of water available to them. Tiny fish, adapted to live in an entirely aquatic environment, swim in tanks, while at the other end of the spectrum the Texas horned lizard, which lives in a very arid climate, has tiny channels between its scales (pictured in a display) that guide rainwater to its mouth.

In another tank, visitors can see mudskippers, an unusual amphibious type of fish, swimming through the water, then taking brief rests on rocks where they can breathe in the air.

Water is essential to life, because "every living cell is composed primarily of water," said AMNH president Ellen Futter during a press preview of the event.

We humans are two-thirds water ourselves. Visitors to the exhibition can stand on a scale that will tell them just how much water they contain (this reporter had 3. 2 gallons, or 12 liters, in her).

Water and society

Like other animals, humans have also learned to survive in lands with wildly varying amounts of water—a fact reflected in the entrance to the exhibition, which features a curtain of mist on which the words for water in many different languages are emblazoned in light: Eau. Nepo. Siram. Su. Maji, Agua. Water.

Often, the places with the most people have the least water. In some African and Asian countries, women must carry water in jugs over long distances to have enough for their families. Visitors can try to lift one of these jugs themselves, but good luck, because it holds 11 liters (weighing 25 pounds) of water.

Humans have manipulated water's sources to irrigate our crops, bolster our drinking supplies and provide us with power. We appropriate more than 50 percent of the world's surface freshwater for our needs, the exhibition notes.

Freshwater comprises only 3 percent of the water on Earth, and two-thirds of that is locked up in glaciers and polar ice caps. A projector throws images onto a giant globe (about 6 feet in diameter) suspended from the ceiling mid-way through the exhibition to demonstrate how little freshwater there is. Earth's water is broken up into grids— while ocean water takes up almost the entire globe, the proportion that is available to us looks like a blue rubber band stretched around the equator. And that amount is unlikely to get much bigger.

"Water on Earth is finite. We will never get more than we have now," said exhibition curator Eleanor Sterling, director of the Museum's Center for Biodiversity and Conservation.

To bring large quantities of this freshwater where it is needed, humans have built dams—more than 60 percent of the world's rivers have been dammed or diverted, with 47,000 large dams built in just the last 50 years. While these dams bring water to cities and crops or provide electricity, they also block migration routes for fish, flood nearby lands and create erosion downstream because they block sediments behind them.

Visitors can see the effects of dams first-hand with a model stream in a clear plastic rectangular box that has a lever that can be pulled up or down to dam and un-dam the "stream" to see how it causes a pile-up of sediment behind it.

These dams and diversions can leave some areas dried up—Soviet diversions have shrunk the Aral Sea to a fraction of its former size. With water already scarce in some areas and becoming scarcer in others due to dams or the effects of global warming, water looks to become an even more precious commodity in the future.

"Water in the future will have wars fought over it," Futter said.

This impending scarcity underscores the need to implement better water practices and conservation, Sterling says.

Water conservation

The exhibition is full of helpful tips on how to conserve water.

Touch-screen monitors let visitors take a quiz on water conservation, including questions on what do if your sink is leaking (call a plumber!), whether an 8-minute shower with a low-flow head is better than a 5-minute shower with a standard head (it is), or whether an aerator really reduces the amount of water you use (it does).

To set an example in water conservation, the exhibition uses re-circulated water in all its displays.

Because the American lifestyle relies on copious water, another interactive monitor lets visitors compete in a three-player "quiz show," with questions centering on the concept called virtual water. Water use doesn't just include what you drink from the bottle or what you use to wash your clothes. It also includes the water used to grow the things we eat and wear. If you take the quiz, remember that the average fast food meal takes nearly 3,000 liters of water to make (because of the water used to grow the corn that feeds cattle).

A movie playing constantly in one corner of the exhibition touches on the ways that agriculture (which comprises most of our use of freshwater) can institute better water practices. These include using drip irrigation instead of standard methods and growing crops in areas that having the appropriate amounts of water needed (so cotton, a very thirsty crop, should not be grown in drier areas).

To show that individuals can make a difference in water conservation, pictures at the end of the exhibition show the ways that ordinary people are reducing their own water consumption.

Images of the word "water" in different languages projected on a fog screen greet visitors as they enter the exhibition.

Is a Green Revolution Finally Blooming in Africa?

Is a Green Revolution Finally Blooming in Africa?

Three years ago, experts and officials called for a green revolution in African agriculture.They are beginning to get their wish.

	GREEN REVOLUTION:  Simply subsidizing fertilizer and the seeds of improved corn strains has allowed countries like Malawi to improve their agricultural productivity.

For the first time since record keeping began in the 1960s, per capita food production in sub-Saharan Africa is beginning to rise.

According to the World Bank's World Development Report 2007, "agricultural growth in sub-Saharan Africa has accelerated from 2.3 percent per year in the 1980s to 3.3 percent in the 1990s and to 3.8 percent per year between 2000 and 2005." As a result, the report stated, "rural poverty has also started to decline in 10 of 13 countries analyzed."

This is thanks largely to an African "green revolution"—a combination of better crop varieties and increased use of fertilizers—says soil scientist Pedro Sanchez, director of tropical agriculture at The Earth Institute at Columbia University in New York City and co-leader of the Millennium Villages Project, an effort to transform selected African villages with targeted aid and technology interventions.  

"The green revolution called for by [former U.N. Secretary General] Kofi Annan in 2004 is really beginning to happen," Sanchez says. "Countries, like Malawi, have gone from net food importers to net food exporters."

"In past years, food production had not been keeping up with population growth," adds a spokesperson for the U.N. Food and Agriculture Organization (FAO). "In recent years, food production has been increasing more than population growth."

Countries, such as Malawi, have transformed their food production using relatively simple means: With the help of government subsidies, farmers can now obtain two bags of fertilizer and five kilograms of hybrid maize seed at just 25 percent of the actual price. And, whereas the World Bank and other donors have refrained from such agricultural subsidies over the past few decades due to concerns about corruption, they are now supporting them and refocusing on agriculture as a priority. "It's a 180-degree turn for the better," Sanchez says. "You can avoid corruption by keeping it on a small scale."

And thanks to high prices for crops such as corn, which can also be used to make fuel, farmers have been able to absorb the rise in fertilizer prices, which have spiked in response to buoyant oil prices (that are also driving demand for biofuels). "[Fertilizer] is expensive as hell," Sanchez admits. But "if you are able to use it, it pays."

A host of problems still face sub-Saharan Africa—from lack of access to agricultural markets in the developed world to a continued failure to produce enough food for the people living there. "Ethiopia is about to quadruple its food production from 1997 levels," Sanchez says. "It's still not enough for self-sufficiency."

And growing economic pressure globally to produce biofuels rather than food may mean that hunger will not be erased anytime soon. Augustine Mahiga, ambassador to the United Nations from Tanzania, notes that his office has been approached to partner with investors in massive plantations—as large as 600,000 acres (242,800 hectares)—to produce biofuels from palm oil, jatropha or sugarcane. "Diverting food production to the production of biofuels…," Mahiga says, "is particularly dangerous to Africa at this point in time."

As the FAO notes in its June Food Outlook, biofuel production from grains and vegetable oils is driving up food prices globally; food imports in the least developed countries of the world, including those in sub-Saharan Africa, cost 90 percent more in 2007 than in 2000. There is a silver lining, according to Sanchez. "It's a fantastic opportunity to increase production when things are at a higher price."

"This biofuels question is really going to bedevil us," adds Jeffrey Sachs, director of The Earth Institute." [Such] vast acreage is going to come out of the forest margins against a backdrop of quite massive deforestation. And about 23 percent of carbon emissions are directly from deforestation."

It remains to be seen if improved agricultural techniques, wider use of fertilizer and government subisidies help promote development and curb hunger in sub-Saharan Africa—a true "green revolution" like the one that took place in Asia in the 1960s and 1970s. "If food levels are going up, they are not going up in sufficient numbers," says Zachary Muburi-Muita, U.N. ambassador from Kenya. "The condition on the continent that leads to ecological stress is really low incomes."  

But improving farming may yet prove the key to solving that dilemma, as it remains the key form of economic activity in sub-Saharan Africa, the World Bank report notes. And Sanchez is in full agreement: "Agriculture is the engine of growth."