One Health strives to unite human, animal medical care

One Health strives to unite human, animal medical care

One Health strives to unite human, animal medical care

This past December, a team of professionals from different scientific fields, led by coauthors from NC State, won a competition to have their new case study published in the Association of American Veterinary Medical College journal last Friday. 

The competition, as a part of the AAVMC One Health initiative, brings attention to connections between the health of humans, animals, and the environment.

“The One Health initiative is a program that understands the connections between animal, human and environmental health. So it seeks to promote collaborations between those disciplines,” said Erika Rost, a co-lead author of the case study. 

Rost, along with co-lead author Erin Brewer, are members of the NC State Clinical Veterinary Pharmacy Residency. Other members of the team come from NC State, UNC-Chapel Hill, the UNC Eshelman School of Pharmacy and the Banfield Pet Hospital in Augusta, Georgia. 

“When you think about it, human medicine typically starts with animals,” Brewer said. “When we do drug trials, they all start with animals — looking for safety, toxicity, finding appropriate doses, whether it’s absorbed. So it’s definitely all related. There’s no reason why you can’t benefit from all of that information for all species.”  

The case study, titled “A Veteran and His Dog,” highlights issues that can cause common symptoms in both humans and animals. 

“The case is about a man named Robert, and he is a veteran and has PTSD,” Rost said. “So he has a service dog, Siri, for PTSD.”

The case study is directed toward professional students who receive medical records for both Robert and Siri. They watch videos of Robert speaking with a doctor and a veterinarian about his and Siri’s health respectively. 

When similar symptoms arise, students must come up with a diagnosis and a plan to treat the two companions. In addition, the complexities of their health are interloped with various financial and social issues that could also be playing a role. 

“The reason this is important for students is, back in the 80s, the World Health Organization found that students who participated in inter-professional studies such as this one were more likely to collaborate later when they were out in practice,” Rost said.  

Brewer agreed, saying, “Everybody has their own specialty. We spend four years learning specifically about drugs, so we might have something to offer another profession who only gets a couple of hours of that kind of instruction. And the same with anybody’s specialty, you have something to bring to the table that everyone can benefit from.” 

Brewer encouraged others to participate in the competition in the future. 

“If anyone’s interested in it, it’s a great opportunity, a great experience, to learn from other professions and to come up with something really unique,” Brewer said.

This post originally appeared on the Technician website on 9th February, 2016 authored by Adam Davis. Available at: http://www.technicianonline.com/news/article_535faa4a-ceed-11e5-b92a-b342f6fbef10.html

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The Philippines Rabies vaccination campaign: a One Health success story

The Philippines Rabies vaccination campaign: a One Health success story

The Philippines Rabies vaccination campaign: a One Health success story

Philipines Rabies vaccinationRabies still causes the death of tens of thousands of people every year. Knowing that dog bites are responsible for more than 95% of all human rabies cases, the eradication of canine rabies is the only way to end the disease’s animal-human transmission cycle. It is estimated that vaccinating 70% of dogs in zones where rabies is present can dramatically reduce human cases.

The World Organisation for Animal Health Director-General, Dr Monique Eloit, explains the work of the OIE carried out regarding the One Health concept, with a particular focus on the success story of the Philippines Rabies vaccination campaign, where 1,701,150 doses of rabies vaccines have been delivered between January and February 2016. These recent deliveries raise the number of doses purchased by a beneficiary country in collaboration with WHO through the OIE rabies vaccine bank to almost 8 million.

The OIE thanks the WHO Pandemics and Epidemics Diseases Department for authorizing the use of the interview’s footage recorded in December 2015.

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One Health Case Studies Now Online

One Health Case Studies Now Online

One Health Case Studies Now Online

Veterinary, medical, nursing and public health students can learn from an AAVMC-led initiative.

The concept of One Health is taught at institutions such as Midwestern University, which operates a veterinary college in Glendale, Ariz.

The concept of One Health is taught at institutions such as Midwestern University, which operates a veterinary college in Glendale, Ariz. Tom Boggan/Midwestern University

he Association of American Veterinary Medical Colleges has teamed up with another organization to publish 15 case studies on One Health topics.

The material, produced by researchers and available here, may be used by instructors in fields such as veterinary medicine, human medicine and public health.

One Health is a concept that closely links the health of animals, people and the environment.

“This is one of our most promising initiatives in the area of One Health,” said AAVMC’s executive director, Andrew T. Maccabe, DVM, MPH, JD. “What’s unique about this program is it unites different health professions on a common platform to begin educating new generations of health professionals about the One Health approach.”

The case studies range from “A Veteran and His Dog,” which focuses on carbon monoxide poisoning, to “Pet Ownership,” which addresses the health benefits of human-animal interaction.

Each online report, selected from among 34 proposals, targets a potential audience and offers student and facilitator materials. “Pet Ownership,” for example, is recommended for veterinary, veterinary technician, medical, nursing and public health students.

Managing the project with AAVMC were the Association for Prevention, Teaching and Research and the Washington, D.C., organization’s Healthy People Curriculum Task Force.

The case studies will be presented in early March at AAVMC’s annual conference. Each lead author will be named a One Health Scholar.

Besides “A Veteran and His Dog” and “Pet Ownership,” the other case studies are:

  • “Bordetella Infections in Cystic Fibrosis Patients”
  • “Staphylococcus pseudintermedius: Look What the Dog Dragged In?”
  • “Care of Immunocompromised Individuals: The Role of Companion Animals in Mental Health”
  • “Lead Poisoning”
  • “Q Fever in the Suburbs: Zoonotic Disease Outbreak Tabletop Training Exercise”
    “Brucella suis: A Re-emerging Pathogen at the Human, Livestock, and Wildlife Interface”
  • “Of Dogs and Men: Methicillin-resistant Staphylococcus aureus”
  • “Human-Animal Interaction”
  • “Chagas Disease: Connections Between Humans, Animals and the Ecosystem”
  • “More Than Just Companions: The Role of Animal Assisted Therapy in Prevention, Health and Wellness”
  • “Animals, Humans and the Environment in the Epidemiology of Chikungunyavirus”
  • “When Nature Strikes! An Unusual Infection in a Child from New Orleans”
  • “The Pathomechanics of Degenerative Joint Disease: A One Health Comparative Case Study Approach”

This post originally appeared on the Veterinary Practice website on 23rd February, 2016, authored by Veterinary Practice News editors. Available at: http://www.veterinarypracticenews.com/one-health-case-studies-now-online/

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Researchers offer new insights into animal-to-human disease transmission

Researchers offer new insights into animal-to-human disease transmission

Researchers offer new insights into animal-to-human disease transmission

Key findings on who gets sick and why from the Dynamic Drivers of Disease in Africa Consortium are being shared at One Health for the Real World: zoonoses, ecosystems and wellbeing, a high-level international symposium taking place at the Zoological Society of London this week.

Jeremy Farrar, Director, Wellcome Trust

Jeremy Farrar, Director, Wellcome Trust

Resilient global health systems, strong civil society and leadership for those health systems and broad research agendas from disparate fields are the three essentials to face the challenges of 21st century equity and health, according to Professor Jeremy Farrar, Director of the Wellcome Trust.

Speaking at  the One Health for the Real World: zoonoses, ecosystems and wellbeing symposium, co-organised by the STEPS-led Dynamic Drivers of Disease in Africa Consortium and the Zoological Society of London, with support from the Royal Society, Professor Farrar stressed that people were not passive observers in history and could bring about these changes.

However he said a move to individualised medicine would act against public access, equity and a holisitic approach to health.

Key findings from the Drivers of Disease consortium are being shared with high-level policymakers, practitioners and academics at the two-day symposium, which is taking place at the Zoological Society of London. They include representatives of the World Health Organization, the UK Department for International Development, the UN Food and Agricultural Organization and EcoHealth Alliance.

The Consortium has been researching the relationships between diseases transmitted from animals to people (zoonoses), ecosystems and wellbeing for the past four years. In particular it has explored henipavirus infection in Ghana, Rift Valley fever in Kenya, Lassa fever in Sierra Leone, and trypanosomiasis (sleeping sickness) in Zambia and Zimbabwe.

One Health

Importantly, it took a One Health approach to its research. One Health recognises the interconnectedness of human and animal health with environmental health. It seeks to promote the collaborative effort of multiple disciplines, working locally, nationally and globally to attain optimal health for people, animals and the environment.

The Drivers of Disease Consortium involved 20 partners in Africa, Europe and America. It saw social scientists from STEPS (IDS/University of Sussex) working together with ecologists, epidemiologists, virologists and other natural scientists – with the integration of multiple disciplines and research approaches proving essential to learn how diseases transmit from animals to people.

Local and participatory

The research has underlined the value of taking a ‘local’ approach. First, understanding the local circumstances in which diseases pass from animals to people was shown to be essential for disease preparedness and prevention.

Second, participatory research undertaken by the Consortium showed the importance of considering local people’s various perspectives to open up new lines of inquiry and reveal links otherwise missed.

Policy and practice

Professor Melissa Leach, Director of the Institute of Development Studies (IDS) and lead researcher for the Consortium, said: “This work has many implications for policy and practice. It suggests opportunities for new integrated interventions involving collaboration between vets, medics, environmental planners, agricultural technicians, social development practitioners and more.

“Such interventions need to be adapted to diverse local settings and contexts yet also have the potential to scale up and out. Identifying and taking these opportunities forward is what doing ‘One Health for the real world’ means.”

Silos and hierarchies

She added that the work was just beginning: “Unfortunately, there are forces that make the One Health approach difficult. These include the tendency for sectoral and disciplinary silos and the dominance of old hierarchies, interests and perspectives. Findings ways to overcome these forces is the key challenge now.”

The research has been funded by the Ecosystem Services for Poverty Alleviation (ESPA) programme. ESPA spokesperson Rob Bruce said: “We are a proud partner in this project. The work of the team has been phenomenal, delivering real game-changing science that could genuinely save and improve lives. This is what ESPA is all about: helping nature to help people in an effort to make the world a better place for both.”

This originally appeared on the Institute for Development Studies website on 17th March, 2016 authored by Naomi Marks. Available at: http://www.ids.ac.uk/news/researchers-offer-new-insights-into-animal-to-human-disease-transmission

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It is time to rethink the way we handle pets and wildlife

It is time to rethink the way we handle pets and wildlife

It is time to rethink the way we handle pets and wildlife

In Summary

  • During the Kenya Medical Research Institute’s fifth scientific conference, which also took place in February, scientists raised the alarm over the transmission of diseases from animal to humans.
  • The World Health Organisation says that 60 per cent of the pathogens that cause infectious diseases in human beings come from animals.
  • According to the US’s Centre for Disease Control and prevention, zoonoses include a wide range of diseases, ranging from mass killers such as anthrax, Ebola, swine flu, West Nile Virus, bird flu, Crimean-Congo haemorrhagic fever and the Hendra Virus to subtle and slow killers like rabies, Rift Valley Fever and Brucellosis

During the funeral of a 39-year old woman who died of Aids in Homa Bay in February this year, a clinical officer who had attended to her engaged DN2 in a discussion about the Zika Virus in South America, and how it had triggered yet another debate on how man’s unguided relationship with nature is hurting him.

Sadly, neither the potential victims, nor the government, are adequately conversant of this to take the necessary precautions.

It is worth noting that at the time the Homa Bay funeral was taking place, across the Atlantic Ocean in Boston, US, the annual Conference on Retroviruses and Opportunistic Infections (CROI) was also taking place. The discussion focused on yet another deadly infection that came to human beings from animals: Ebola.

In Kenya, the Ministry of Health allayed fears of possible disease outbreaks from the Ebola and Zika viruses.

Only a few scientists, like Lancet Laboratory’s executive officer, Dr Ahmed Kalebi, took note of the public health issues raised at CROI.

Meanwhile, during the Kenya Medical Research Institute’s (KEMRI) fifth scientific conference, which also took place in February, scientists raised the alarm over the transmission of diseases from animal to humans. They expressed concern about humans’ continued intrusion into wildlife territory.

Whether it is the burgeoning population or the desire to live in quiet, exclusive environments, human intrusion into animal habitats has grown considerably in the country in recent times.

The area around the Lewa Conservancy which straddles Meru and Laikipia counties, is a case in point. Apart from the herds of elephants and buffalos that roam the plains, one can also spot residential houses tucked away in between the trees.

A great deal has been documented about the booming real estate business in Laikipia County, which for decades was dominated by large territorial mammals such as rhinos, elephants and buffaloes.

Not surprisingly, this intrusion has seen elephants destroy crops in the areas neighbouring their habitat.

Now, experts are warning of a threat greater than the destruction of crops of trampling to death of humans: zoonoses.
Zoonoses are diseases transmitted from animals to humans.

The World Health Organisation, (WHO) says that 60 per cent of the pathogens that cause infectious diseases in human beings come from animals.

And researchers warn that the close interaction between humans and animals, whether wild or domesticated, is increasingly making Kenyans ill.

According to the US’s Centre for Disease Control and prevention, zoonoses include a wide range of diseases, ranging from mass killers such as anthrax, Ebola, swine flu, West Nile Virus, bird flu, Crimean-Congo haemorrhagic fever and the Hendra Virus to subtle and slow killers like rabies, Rift Valley Fever and Brucellosis.

Although these diseases are a global health problem, their impact is felt more in Africa than in other parts of the world because they tend to be neglected. African governments dedicate few or no resources to detect and respond to them at the local or national levels. Only 0.7 per cent of these diseases affect people in developed countries as poor nations bear the brunt.

It was only after the Ebola outbreak in West Africa in 2013, which wreaked havoc in West Africa, that people started paying attention to the usually muted voice of researchers on the link between diseases, animals and the environment.

PUTTING UP SKYCRAPPERS

Given the rate at which construction is going on in the country, it is time we sat up and took notice.

Not too long ago, the ambience in Nairobi’s upmarket Kilimani allowed residents and colobus monkeys to live in harmony. Today, the gibbering of monkeys has been replaced by the roar of construction machines putting up skyscrapers.

The same trend can be observed in other parts of the country such as Lower and Upper Kabete, Gathiga, slightly past Kitisuru in Nairobi, Mang’u (Kiambu County), Kabarak and Sobea (Nakuru County) Nyahera (Kisumu County and Kapchorua in Nandi Hills (Nandi County).

Unknown to many, as this trend continues, disease-causing pathogens are mutating, becoming more lethal and embedding themselves in the complex yet delicate human food chain and way of life.

A study in 2012 titled “Zoonoses: A potential Obstacle to the Growing Wildlife Industry of Namibia published in the journal, Infection Ecology and Epidemiology, drew a chilling pattern in Kenya, similar to Namibia’s cases of zoonoses: the serum of buffaloes in Ijara, Nakuru, Laikipia, Nairobi and parts of the North Rift tested positive for antibodies of Rift Valley Fever.

Dr Eric Osoro, a medical epidemiologist at the Zoonotic Diseases Unit (ZDU) in the Ministry of Health, says that at least 2,000 Kenyans die of rabies every year, which is unfortunate, given that it costs less than Sh100 to vaccinate a dog, compared with the thousands of shillings required to treat the viral disease.

“The number of rabies deaths reported is a gross underestimation of the actual number of deaths that occur in Kenya annually from this terrifying fatal disease,” he says.

Many more Kenyans could be dying of rabies, which can be caused even by a scratch by an unvaccinated dog, because the incubation period for the virus is estimated to be about two months.

“Sometimes the wound might have even healed, so none one would suspect it is rabies,” Dr Osoro says.

While rabies can be prevented by vaccinating dogs, WHO says it is 100 per cent fatal once the clinical signs appear.

Apart from rabies, Dr Osoro also cautioned about Brucellosis — a disease one gets from taking milk that has not been boiled properly — and anthrax.

“Anthrax kills cattle in less than 12 hours, but many will consume the flesh because the animal looked healthy,” he says.

Prof Thumbi Mwangi, a clinical assistant professor at Washington State University in the US and a researcher on zoonoses at the Kenya Medical Research Institute (KEMRI), told DN2 that while the interaction between humans and animals is not necessarily a bad thing, failure to keep healthy animals increases the chances of ill health for humans.

PATHOGENS FIND NEW HOSTS

In March last year, Prof Mwangi carried out a study in which he tracked 1,500 households and their livestock in 10 villages in Western Kenya. He and his team obtained data on 6,400 adults and children, 8,000 cattle, 2,400 goats, 1,300 sheep and 18,000 chicken.

The results, published in the open journal, Plos One, revealed that for every 10 cases of animal illnesses or deaths that occurred, the probability of human sickness in the same household increased by about 31 per cent.

Prof Eric Fèvre, a professor of veterinary infectious diseases at the Institute of Infection and Global Health at the University of Liverpool and the International Livestock Research Institute (ILRI), wrote a blog post, “Zoonoses in Africa” on the websitemicrobiologysociety.org, in which he said that urbanisation is presenting opportunities for pathogens to find new hosts to survive.

The post, published on November 11, 2015 read: “The intensification of farming, for example, leads to closer relationships between individuals and animals, generating opportunities for more rapid mutations as organisms move from host to host, while also providing a structured way for those pathogens to enter highly ordered food chains that branch out and reach very large numbers of people”.

Other studies paint an increasingly disturbing pattern of diseases either emerging, or the incidence of existing ones increasing.

A study in Dagoretti, Nairobi, by the International Livestock Research Institute (ILRI), found that women were more exposed to cryptosporidiosis, a diarrhoeal disease transmitted from cattle to humans, because of their involvement in milking, feeding and watering the animals.

And a study by the Kenya Medical and Research Foundation (KEMRI) Kisumu and the US’ CDC linked a strain of tuberculosis to an area in Western Kenya where homes had a higher cattle:human ratio.

In wildlife settings, the situation is more complex. A 2014 study found cases of suspected rabies in Laikipia County where humans had encroached on animal habitat.

When landscapes and bio diversities are altered by activities relating to construction such as roads and farms, diseases are “created”: as trees are felled, the species that protect humans from the ones that act as disease-reservoirs are destroyed.

The harmful pathogens are usually multi-host, meaning they can live in many different animals, which gives them a competitive edge to survive as the protective trees are wiped out by human activity.

In 2012, ILRI reported that 2 million people are killed by zoonoses every year, thanks to the disruption of the ecosystem.

Malaria is a good example: as people in tropical countries like Kenya encroached on the habitat, the incidence of the disease quadrupled.

ECOLOGICAL BALANCE

When DN2 asked nine developers from Nakuru, Nairobi and Kisumu whether they consider the ecological balance of a location important when they are building, six responded with the question, “What is that?” After it was explained to them, all except one said they were “satisfied with the National Environmental Management Authority (NEMA) clearance”.

It is notable that NEMA officials and environmental inspectors have said at scientific forua that many of the constructions approved by the counties do not heed their counsel.

Only 1 per cent solution to wildlife viruses are known, according to WHO, and the ecology of diseases and wildlife immunology is in its infancy in Kenya.

Meanwhile, Kenya’s Zoonotic Disease Unit, has been lauded at various fora for its holistic approach, with its national rabies control strategy highly regarded.

It has conducted a large-scale study on the epidemiology of brucellosis, responded to many zoonotic disease outbreaks, and developed preparedness strategies for epidemic zoonoses such as Rift Valley fever.

But for now, one can only hope that ecological safety will be factored in amid the real estate industry boom.

SOURCE

This article originally appeared in the Kenya Daily Nation website on 9th March, 2016 authored by Verah Okeyo, available athttp://www.nation.co.ke/lifestyle/DN2/Take-care-how-you-interact-with-animals/-/957860/3108294/-/15fadaoz/-/index.html

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If we want medicine to be evidence-based, what should we think when the evidence doesn’t agree?

If we want medicine to be evidence-based, what should we think when the evidence doesn’t agree?

If we want medicine to be evidence-based, what should we think when the evidence doesn’t agree?

To understand if a new treatment for an illness is really better than older treatments, doctors and researchers look to the best available evidence. Health professionals want a “last word” in evidence to settle questions about what the best modes of treatment are.

But not all medical evidence is created equal. And there is a clear hierarchy of evidence: expert opinion and case reports about individual events are at the lowest tier, and well-conducted randomized controlled trials are near the top. At the very top of this hierarchy are meta-analyses – studies that combine the results from multiple studies that asked the same question. And the very, very top of this hierarchy are meta-analyses performed by a group called the Cochrane Collaboration.

To be a member of the Cochrane Collaboration, individual researchers or research groups are required to adhere to very strict guidelines about how meta-analyses are to be reported and conducted. That’s why Cochrane reviews are generally considered to be the best meta-analyses.

However, no one has ever asked if the results in meta-analyses performed by the Cochrane Collaboration are different from meta-analyses from other sources. In theory, if you compared a Cochrane and non-Cochrane meta-analysis, both published within a similar time frame, you’d tend to expect that they’d have chosen the same studies to analyze, and that their results and interpretation would more or less match up.

Our team at Boston University’s School of Public Health decided to find out. And surprisingly, that’s not what we found.

What is a meta-analysis, anyway?

Imagine you have five small clinical trials that all found a generally positive benefit for, let’s say, taking aspirin to prevent heart attacks. But because each of the studies only had a small number of study subjects, none could confidently state that the beneficial effects weren’t simply due to chance. In statistical-speak, such studies would be deemed “underpowered.”

There is a good way to increase the statistical power of those studies: combine those five smaller studies into one. That’s what a meta-anaysis does. Combining several smaller studies into one analysis and taking the average of those studies can sometimes tip the scales, and let the medical community know with confidence whether a given intervention works, or not.

Taking the average. Magazine image via www.shutterstock.com.

Meta-analyses are efficient and cheap because they don’t require running new trials. Rather, it’s a matter of finding all of the relevant studies that have already been published, and this can be surprisingly difficult. Researchers have to be persistent and methodical in their search. Finding studies and deciding whether they are good enough to trust is where the art – and error – of this science becomes a critical issue.

That’s actually a major reason why the Cochrane Collaboration was founded. Archie Cochrane, a health services researcher, recognized the power of meta-analyses, but also the tremendous importance of doing them right. The Cochrane Collaboration meta-analyses must adhere to very high standards of transparency and methodological rigor and reproducibility.

Unfortunately, few can commit the time and effort to join the Cochrane Collaboration, and that means that the vast majority of meta-analyses are not conducted by the Collaboration, and are not bound to adhere to their standards. But does this actually matter?

Not quite the same. Apple and orange via www.shutterstock.com

How different can two meta-analyses be?

To find out, we started by identifying 40 pairs of meta-analyses, one from Cochrane and one not, that covered the same intervention (e.g., aspirin) and outcome (e.g., heart attacks), and then compared and contrasted them.

First, we found that almost 40 percent of the Cochrane and non-Cochrane meta-analyses disagreed in their bottom-line statistical answers. That means that typical readers, doctors or health policymakers, for instance, would come up with a fundamentally different interpretation of whether the intervention was effective or not, depending on which meta-anlyses they happened to read.

Second, these differences appeared to be systematic. The non-Cochrane reviews, on average, tended to suggest that the interventions they were testing were more potent, more likely to cure the condition or avert some medical complication than the Cochrane reviews suggested. At the same time, the non-Cochrane reviews were less precise in their accuracy, meaning that there was a higher chance that the findings were merely due to chance.

A meta-analysis is nothing more than just a fancy weighted average of its component studies. We were surprised to find that approximately 63 percent of the included studies were unique to one or the other set of meta-analyses. In other words, despite the fact that the two sets of meta-analyses would presumably look for the same papers, using similar search criteria, over a similar period of time and from similar databases, only about a third of the papers the two sets had included were the same.

It seems likely that most or all of these differences come down to the fact that Cochrane insists on tougher criteria. A meta-analysis is only as good as the studies it includes, and taking the average of poor research can lead to a poor result. As the saying goes, “garbage in, garbage out.”

Interestingly, the analyses that reported much higher effect sizes tended to get cited again in other papers at a much higher rate than the analyses reporting the lower effect size. This is a statistical embodiment of the old journalistic saying “If it bleeds, it leads.” Big and bold effects get more attention than results showing marginal or equivocal outcomes. The medical community is, after all, just human.

Why does this matter?

At its most basic level, this shows that Archie Cochrane was absolutely correct. Methodological consistency and rigor and transparency are essential. Without that, there’s a risk of concluding that something works when it doesn’t, or even just overhyping benefits.

But at a higher level this shows us, yet again, how very difficult it is to generate a unified interpretation of the medical literature. Meta-analyses are often used as the final word on a given subject, as the arbiters of ambiguity.

Clearly that role is challenged by the fact that two meta-analyses, ostensibly on the same topic, can reach different conclusions. If we view the meta-analysis as the “gold standard” in our current era of “evidence-based medicine,” how is the average doctor or policymaker or even patient to react when two gold standards contradict each other? Caveat emptor.

Article originally appeared on the Conversation Africa website, authored by Prof.  Available at: https://theconversation.com/if-we-want-medicine-to-be-evidence-based-what-should-we-think-when-the-evidence-doesnt-agree-53152

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