My doctor is an algorithm: ‘Medicine has always welcomed new technology’
With the advance of artificial intelligence, medical practises are being overtaken. Could the GP become a relic of a bygone age
April 13 2017 2:30 AM
‘Good afternoon, the AI will see you now.” This could be the future of family practice medicine as machines become better equipped to do many of the things that traditionally made up the GP’s job description.
Machines have always threatened human jobs, but up to the 21st century they were only a serious threat to repetitive, low-skilled jobs. Times have changed and the higher skilled jobs today are threatened by the advance of artificial intelligence (AI). In the past few years, intelligent machines have begun to perform complex tasks far better and quicker than intelligent, skilled humans.
The ‘good GP’ we know will always know his patients well; their medical history, their personality, details about their family and their foibles, and will retain this background information and call on it when assessing patients. The good GP would know, for example, that Mr Murphy is probably upset, rather than clinically depressed, because his father died last week and he has no depression history.
However, unlike the good GP, who may be overworked, and stressed by the demands of a busy clinic, computers with built-in AI have an almost unlimited capacity to store information in medical records, and to recognise patterns that may have been missed by the GP. They are also excellent at measuring things, such as blood pressure, and analysing results, such as a routine blood test.
In recent years, scientists working in AI made a breakthrough when they developed software based on the working of the human brain, rather than, as was the case before, sticking to a rigid rule book. This software could learn from the environment, making mistakes, and correcting them, like a child learns. The world saw its first artificial ‘self-learning systems’.
There were implications from this for the GP, and other professionals, as suddenly it wasn’t just the old story of machines replacing low-skilled workers; their jobs were on the line too. GPs faced the prospect of being confined to a decreasing number of areas where they are still superior to artificial rivals, or worse still, to become redundant; a charming medical relic of a bygone age.
The role of specialist medical consultants – not just GPs – is also coming under threat too from sophisticated ‘deep learning systems’ which are already outperforming doctors in specialised areas of medicine, says Professor Barry O’Sullivan, director of the Insight Centre for Data Analytics at the Department of Computer Science, in University College Cork, and a leading AI researcher.
“Dermatology is one such field,” he says. “A very recent paper that appeared in (research journal) Nature showed that a deep learning system could outperform human dermatologists at identifying skin cancer by quite a margin.”
Another area where AI is already better than doctors is radiology, adds O’Sullivan. A radiologist can recognise patterns in scans, based on years of experience. However, no matter how experienced the radiologist, he can’t store the amount of scans that AI can, while comparing them to a particular scan in order to assess, for example, the likelihood of a stroke or epilepsy. Meanwhile, there are further reasons for GPs not to be cheerful about the future with plans in the UK, supported by the NHS, to use smartphones to bypass the GP clinic altogether. A pilot scheme, run by private firm Babylon Health is encouraging people to consult a ‘chatbot’, equipped with AI, rather than a human being when they contact the 111 non-emergency line.
Patients key in symptoms, and AI determines how urgent each case is, and whether the user should be told to go straight to A&E, the chemist or simply go home to bed. The AI system makes decisions based on 300 million pieces of information, and the company says trials have shown the system is faster and more accurate than doctors. Certainly, most experts agree the future of medicine is ‘personalised medicine’, with disease treatments being tailored to suit personal needs. This is an area that AI excels, as it is very good at looking at medical data and finding specific treatments for patients which can, in some cases, even save their lives.
“For example, organisations such as Cancer Commons have assisted cancer patients survive conditions that were regarded as fatal in their situations by combining AI with extremely rich and individual-level data,” says Prof O’Sullivan. “The founder of Cancer Commons, Marty Tenenbaum, is one such survivor.”
Brendan Kelly, professor of psychiatry at Trinity College Dublin, says: “Computers and electronic diagnostic aids are delivering more and more information every year in medicine. And it is likely that computers and other devices, with their essentially infinite data storage and pattern recognition abilities, will continue to add increasing value to medical care.
He adds: “AI is especially useful in diagnosis: recognising skin lesions, monitoring measurable indices of body function, and identifying known patterns of symptoms and signs.
“It is less useful for other dimensions of medical care: contextualising findings in the context of the patient’s life, moving from recognising a pattern to agreeing a narrative between doctor and patient, and providing reassurance.
“AI is also less useful for picking up on the unexpected elements in a patient’s presentation: noting, for example, that a patient presenting with a lesion on his ear also has swollen ankles. Or noticing that someone with chest pain smells strongly of alcohol at 11 in the morning and might have an alcohol problem (which might or might not be related to the chest pain). Or noticing that a woman who comes to have a prescription renewed brings along her child, whom the nurse remembers has missed a vaccination, and can receive it today.”
Kelly isn’t worried about his job just yet though.
“Medicine has always welcomed new technologies and benefited hugely from them: stethoscopes, x-ray machines, MRI. But these tools amplify the effectiveness of healthcare professionals, rather than replacing them.”
The doctor will still see you now
Dr Mark Murphy, GP, and chair of Communications with the Irish College of General Practitioners, responds:
“It is unlikely that AI will make a meaningful difference in the GP setting, given the significant human factors at play in a consultation.
“There is a requirement for the GP to conduct face-to-face consultation to develop a rapport, to physically examine a patient and read nonverbal cues.”
“AI systems cannot get rid of the complex uncertainty and greyness at the heart of the undifferentiated presentations to General Practice.
“However, AI and machine learning will help with the handling of information in the healthcare system, and may be able to assist with complicated ‘black and white’ diagnostic process, such as imaging or to make sense of the complex genomic factors with rare-disease treatment.”
The Immortal life of Henrietta Lacks based on the book written by Rebecca Skloot in 2010 will appear on our cinema screens this year, with Oprah Winfrey in the role of Henrietta.
But, who was Henrietta Lacks, what was her story, why is her life described as “immortal” and how has it influenced the lives of millions of people around the world since her death in 1951?
Henrietta Lacks, pictured, died from cervical cancer in 1951, aged 31. Cancer cells removed from her body without her knowledge or permission were used to produce the polio vaccine Credit (Henrietta Lacks Foundation).
Henrietta Lacks was a poor black woman from the tobacco fields of the state of Virginia, USA, part of the old South.
She has made a huge contribution to mankind, because of the cells she unwittingly gave to the world, so called ‘HeLa cells’ which were taken from the cancer that killed her in 1951 and grown in labs around the world to combat disease, and help scientists develop techniques like cloning and I.V.F.
The cells have been used to produce a vaccine for polio, leading to its eradication in the USA and most parts of the world, but they have also been used to produce commercial revenue. Henrietta didn’t provide ‘consent’ for her cells to be used in this way, but in 1951, consent was not a requirement for doctors to remove cells or tissues from patients for research purposes.
Henrietta was born with the name Loretta Pleasant on the 1st August 1920 in Roanoke, the biggest town, but still a small-ish city, in southwestern Virginia. At some stage, for reasons not clear, she became Henrietta, a name that was shortened to ‘Hennie’ after the death of her mother.
Henrietta’s mother died when Henrietta was 4 and ‘Hennie’ and her nine siblings were sent to live with various aunts and uncles and cousins in the little farming town of Clover, Virginia.
Hennie ended up with her grandfather, who was also trying to raise one of Hennie’s first cousins – David. They lived in a two-story cabin built of hand-carved logs, and held together by pegs that was once the slave quarters of their ancestors.
In 1924 rural Virginia, black people were no longer slaves, but their social, economic and living circumstances, even the actual buildings that that lived in, hadn’t changed much since the Emancipation Proclamation was issued by President Abraham Lincoln on 1st January 1863. This executive order changed the federal legal status of some 3 million black slaves trapped in the Confederate south from ‘slave’ to ‘free’.
The former slave quarters that Hennie found herself living in with her grandfather and cousin David looked over the family cemetery where Hennie’s ancestors, who were black, but some of whom were also white, including one of her great grandfathers, were buried.
All around the slave house, or ‘home house’ as its residents called it were hundreds of acres of tobacco fields. The area was, and is known as Lacks Town, as many of the people living in and around the tobacco fields were ‘kin’ to Henrietta.
Hennie had honey coloured skin, a round face, and an attractive, welcoming smile. After a time, according to cousins accounts, Hennie and David, who was called ‘Day’ became an item, even though they had been raised like a brother and sister.
Children followed. Lawrence was born in 1935, and Elsie, who was “deaf and dumb”, and ended up later in a home for the Negro Insane, was born in 1939.
In 1941, Hennie and Day got married, and made plans to get out of Clover, forget the tough life of tobacco farming, and join the many black people that were heading for Baltimore and Washington DC to get jobs in the booming wartime shipyards and steel mills.
Hennie, according to accounts, settled into her new life as housewife in a brick city apartment, but she missed the country and would often grab her kids, and pile them onto a bus for a trip back to Clover.
It seems Hennie loved being a mother, and more children came with Sonny born in 1947, and Deborah in 1949. Their fifth child, Joe, was born in 1950.
A few months after Joe was born Hennie shared a secret with her cousin Sadie, Sadie later recalled. She started bleeding, even though it was not her time of the month, and one morning when she was taking a bath she felt a lump.
Hennie decided to attend the outpatient centre at Johns Hopkins Hospital in Baltimore – a renowned centre for medical excellence in February 1951 and the gynaecologist on duty when Henrietta came in was Dr Howard Jones. Dr Jones examined Henrietta and found something remarkable: a glistening, smooth growth that resembled what he called “purple Jell-O” (jelly).
The growth was about the size of a US quarter, and positioned at the lower right of Henrietta’s cervix. The growth bled easily when it was touched.
Dr Jones thought it might be an infection and tested for syphilis, but the results came back negative. He ordered a biopsy and got the diagnosis: sadly for Hennie, it was cancer.
Henrietta came back for treatment 8 days later, and another doctor took another slice off her tumour. Henrietta wasn’t told about this, but, at the time, that was normal medical practice.
Capsules of radium were placed around her cervix to try and kill the cancer cells and she was released from hospital and went home. Henrietta didn’t tell anyone about her illness, and continued with home life as normal.
She came back regularly for treatment, but the cancer cells were growing faster than radium could kill them and it was difficult for her now to hide her pain.
She was admitted to hospital for the last time in August 1951, for what would be the last time. A few months later, on 4th October 1951 Henrietta died, aged 31, with an autopsy showing that she had cancerous lumps in her chest cavity, lungs, liver, kidney and right through her bladder. The cancer had been relentless, and grew and spread at a pace that proved uncontrollable.
Henrietta was buried in an unmarked grave her the ‘home house’ in Clover. Her children remember it as a day when the rain poured from the sky as though heaven were weeping for ‘Hennie’.
The death of Hennie was devastating to Henrietta’s family, her husband Day and their five children. This is apparent, as even all these years later they get upset talking about her death, it seems.
Her death was something of a taboo subject, and no-one was comfortable talking about it, as it affected them so deeply.
Day tried to keep the show on the road by working shifts at the shipyard, while minding his three youngest children. Elsie was now in a home for the Negro Insane and family visits were not as frequent was when Henrietta was alive, as she visited Elsie regularly. Lawrence, the eldest left to join the Army.
Two relatives moved in to live with Day and the three children, one of which was described as ‘evil’ and life became brutal and horrible, with the children being beaten for no reason and having little food to eat.
As the children grew older, they – understandably – wanted to get away as much as possible from the nightmare house in Baltimore and they regularly returned to Clover to work on tobacco, as their mum had done, keeping their abuse a secret.
Elsie died in 1955, aged just 16, and it appears that sadly she had been abused, and she may even have had holes drilled in her head for some kind of human experimentation.
When Henrietta’s children had their own children, it seems that – perhaps sensing something from their parents – they too avoided the subject of their grandmother, how she lived and how she died.
Henrietta’s family knew nothing until the early 1970s when family members received phone calls from researchers asked for them to donate blood samples. The researchers said that they wanted to find out more about their mother’s genetic make-up.
Naturally, the family members wanted to know why they were interested in this, now, many years after Henrietta’s death. They were then told – and this must have been utterly shocking to them – that part of their mother, some of her cells, were still alive and growing now, more than 20 years after her death.
The Lacks family finally learned that tissue from their mother’s second biopsy in 1951 had been given to Johns Hopkins researcher Dr George Gey, who was searching for a cure to cancer, and had, towards this end, but trying – unsuccessfully – to grow human cells outside the body, so that they could be closed studied in the lab.
Dr Gey’s lab technicians got Henrietta’s cells, but – by now programmed for failure – expected them to do what many previous cell samples had done – live for a short time, a few days tops, then die. Yet, what happened astonished them. Henrietta’s cells multiplied in petri dishes, uncontrollably spreading and piling up on one another.
On the very same day that Henrietta died, 4th October 1951, Gey was appearing on a TV show called ‘Cancer Can be Conquered.” On the show he held a bottle close to the camera, and in it he said was the first human cell line ever grown. This was Henrietta’s legacy.
The cells were called “HeLa cells” by Gey, to acknowledge the first two letters of Henrietta Lacks’ first and last names. He then gave samples out to other researchers around the USA. The idea was that HeLa cells would work enough like normal cells so that doctors could test, probe and unlock their secrets and weaknesses in the lab. This new knowledge, it was hoped, would lead to a cure for cancer.
The biggest impact, without doubt, that HeLa cells have, so far at least, made on the world is by helping Jonas Salk create a vaccine which has almost eradicated – worldwide – what was a crippling disease affecting children.
Salk infected HeLa cells with the poliovirus – something that could easily be achieved – and studied how they reacted. After a number of years of work, in 1955, he had created a working vaccine.
This received huge attention because polio mainly affects children under 5 years of age, so young children had been dying and the name polio was a terrifying one until Salk came along.
Polio is highly infectious. It kills when some infected children become paralysed and their breathing muscles immobilised. It is still a threat in certain parts of the world, according to the WHO, but the number of cases, worldwide have decreased from 350,000 cases in 1988 to just 74 reported cases in 2015.
It is estimated that the polio vaccine, and, thus, HeLa cells that helped created it, have saved the lives of one million people, many of them young children, around the world since 1955, who would otherwise have died of polio.
In 1952, just three years beforehand, there was a polio outbreak in the USA which killed 3,145 people, including 1,873 children. At that rate, some 192,000 Americans would have died if the polio vaccine had not been available there from 1955.
The HeLA cells were ideal for developing a polio vaccine because they could be easily infected by poliomyelitis, which caused infected cells to die. However, a large volume of HeLa cells were needed to test Salk’s vaccine, and this led to the mass production of HeLa cells from 1953 in a cell culture ‘factory’ at Tuskegee University.
Controversially, however, companies also used HeLa cells to test cosmetics, and to measure the effects of radiation on human cells. They were used to test how human cells responded to other viruses, and were used in a number of cancer trials.
HeLa were the first ‘cell lines’, they stored well, were robust and could be sent out to laboratories all over the world. They replicate very fast, which is useful, but can also cause problems for scientists in terms of contamination of the lab.
HeLa cells have been used to study all kinds of viruses, and helped in the creation of a vaccine to HPV, the human papillomavirus, as well as to act as a testbed for new medications for cancer and Parkinson’s disease. They have also been used to test how certain products, such as cosmetics, affect human cells.
Because some HeLa cells behave differently to others, it has been possible for scientists to isolate a specific cell type, multiple it, and start a new cell line. This method of isolating a cell and keeping it alive is the basic technique behind I.V.F. which is so much part of our world today.
One discovery from HeLa cells has big potential in the fight against cancer. It was found that HeLa cells used an enzyme to repair their DNA and keep functioning when other cells would have died. Anti cancer trials against this enzyme are currently ongoing.
There are some who would say that the importance of HeLa cells in saving lives has been overstated. For example, saving one million lives with the polio vaccine, is small potatoes compared to, say the Measles vaccination, which has saved about 17 million lives since 2000.
Henrietta’s family were angry when they finally heard the full story of the HeLa cells. They felt that Johns Hopkins Hospital had removed Henrietta’s cells without permission. The hospital had done that, they didn’t deny it, and neither did they deny that they hadn’t asked permission. Permission to do this wasn’t required back in 1951.
The Lacks family were also confused by all the scientific jargon that started to come their way. I think they their initial reaction was that their mother, and themselves had been exploited by researchers. For instance, they said that they gave blood to the researchers when asked, but the researchers did not bother to follow up with them when results came out or to explain results.
None of the children have developed their mother’s aggressive cancer, so Henrietta left no deadly legacy to her children.
There was a financial issue also, as far as the Lacks family were concerned because biomedical companies in the decades since their mother’s death had been mass producing HeLa cells, like a license to print money, and sending them out all over the world.
Fortunes were being made on the back of their mother’s cells, while they themselves, could even afford health insurance.
They were also apparently hurt that so many people, researchers, scientists and doctors, appeared to know so much about their mother, and that they, her children, knew very little.
Their father Day died in 2002 (41 years after his wife Henrietta) but the family only managed recently to pool together money for a headstone for his grave.
Johns Hopkins have honoured the contribution of Henrietta, and others like her, to their research, but they remain sensitive to criticism of their role in the Lacks’ story. They made the point that the hospital as it was in 1951 can’t be judged by today’s standards, and that patient consent, now a basic standard, wasn’t even considered in 1951.
The HeLa cells, Johns Hopkins state, were given away by their researcher Dr Gey, acting on his own and the hospital never patented the HeLa cells or sold them to make money. Dr Gey, they add was acting with good intent as he passed the cells on in the hope researchers could develop a module from which scientists could learn more about human cell function (and by corally, cancer cell function).
HeLa cells have today multiplied to the point where they weigh some 20 tonnes, all together, while, according to the US Patent and Trademark Office there are close to 11,000 patents that involve HeLa cells. The cells are so widely available that they can be ordered for delivery on the Internet.
The words on Henrietta’s gravestone, composed by her grandchildren reads:
“In loving memory of a phenomenal woman, wife and mother who touched the lives of many. Here lies Henrietta Lacks (HeLa). Her immortal cells will continue to help mankind forever.”
The Tesla Model S electric cars which are making inroads into the luxury class car market in the USA will be available for sale in Ireland in 2017 [Picture source: http://www.mashable.com]
In 2008, the then Coalition government of FF, PDs and the Green Party, announced a target of having 200,000 electric vehicles (EVs) on Irish roads.
It was an ambitious target, yet eight years later, despite the building of infrastructure to support electric cars, and financial incentives, there are only 2,000 EVs on our roads – that’s a mere one percent of the Government’s original target.
So why is it that sales of electric cars have not taken off in Ireland, compared to some other countries and is this likely to change any time soon?
The infrastructure supporting electric cars is good, and one of the most advanced in the world, so that’s not an issue.
There are 1,400 charge points between the Republic of Ireland and Northern Ireland. These have been set up by the ESB e cars unit on an all Ireland basis. The idea is that with one electric car access card you can use any of the charger access points throughout the country – north or south.
This is a better system than in the the UK where different councils and different regions would have developed their own infrastructure, and there is no inter operability between them. The charger plugs are the same, but the driver of an electric car in Britain would need five or six different access cards to use the EV charge points around the UK.
Each charge point in Ireland has intelligence built in so that information is sent back to the ESB e car charge point management system. This system monitors the availability of chargers, whether they are currently in use or not.
If there is an issue such as a cable gets blocked the system can unblock the cable. The ESB from the start decided to install a standard electric charge point in every town with 1,500 people or more.
The ESB have realised since that a lot more people are looking for fast chargers than had been anticipated at the start of the infrastructural roll out. There are 22kw chargers with two points in each one – and the Renault Zoe can charge in an hour off that. Then there are the 50kw fast chargers that can charge a car up to 80% in 25 minutes. There are about 75 of these, and one every 50 km of motorway on the main roads.
The idea is that if you leave your house in Dublin heading for Galway and you drive with a full tank, you can stop, get a fast charge and keep going. Most of the in car Sat Navs on cars are linked into the latest information on the nationwide network of charge points which is constantly updated by ESB e cars.
The ESB has a 24-hour call centre in Cork, and there are maintenance teams, response units if anyone breaks down. The charge points can all be operated remotely now – one card for all of Ireland – and in the near future the plan is to have an app that lets you know not just where the nearest charge points on, but whether it is currently in use.
The three main turnoffs people cite when it comes to their reluctance to buy EVs come under three headings: performance, range and cost.
There is an idea out there that EVs are slow and cumbersome, like the old milk floats we saw around Dublin in the 1980s, but, I know, from driving a Nissan Leaf, that this is not the case. The performance of the car is excellent, and there is more than enough zip and acceleration to make electric cars ideal around the city.
You could put somebody into the smallest electric vehicle up beside a Ferrari at a traffic lights and the electric car will get away quicker. The high powered Ferrari will catch him after couple of seconds but there is great zip in an electric car, and overtaking is no problem.
The latest Model S Tesla electric cars can go from 0-100 in 2.6 seconds if you put a Tesla car onto its so called ‘ludicrous’ mode; better than the most powerful Ferrari with an IC engine.
People are concerned about range, and, while surveys of electric car users show that range issues are manageable, it is still an issue for potential buyers.
The industry experts believe that maximum range, which is around 150 or 160km for many electric cars needs to reach 300 or 400 km before ‘range anxiety’ is no longer an issue. That could happen as early as 2018, the experts tell me.
The range of the current Nissan Leaf, which I drove myself a few weeks ago, is between 160 and 165 km after a full charge at home. The home charge points, which are installed for free by the ESB currently for anyone purchasing an electric vehicle, are 16amp, single phase chargers.
A full charge is, however, not enough to get the car from Dublin to Galway (208 km) so anyone planning that trip, must plan to stop at a motorway charge point for about 20 minutes to get a ‘top up’ charge.
For range to improve the existing battery technology must be improved. There has been huge investment in this area, in laboratories around the world, particularly in Japan, Korea and the US, but even a little here in Ireland.
The flamboyant US-based science entrepreneur, Elon Musk, who is the Chief Executive Officer of Tesla Motors, a hugely innovative and dynamic electric car company, is building what he calls a battery ‘gigafactory’ in Arizona. This is due to go into full production in 2020 when it will produce enough lithium-ion batteries, like the ones in our smartphones, to power 500,000 new electric cars per year. All the raw materials required will be brought to Arizona, and when this factor opens it will double the world’s output of lithium ion batteries.
This will provide some of the economies of scale that have been lacking in the electric car industry up to now, and it should be a ‘game changer’. The electric car is more expensive to build than a ‘normal’ car, even without the battery taken into account, because of this issue of economies of scale.
The average car has about 2,000 moving parts, while the average electric has something like 200. The electric car should be cheaper to manufacture!
The prediction is that somewhere between 2020 and 2025, after Musk’s gigafactory opens, the costs of batteries will go down, and the economies of scale for electric will improve so that there will be cost parity.
That is, for the first time, an electric car will cost the same as a car based on the internal combustion engine. This will be a historic moment for e cars.
In summary then, performance is not an issue, and anyone that gets into a modern electric car will quickly realise that. Range is still an issue for some people, but from 2018, it is expected that electric cars with a range of 400 km will be here, so that issue will disappear.
Cost will remain an issue, until cost parity is reached somewhere between 2020 and 2025. In terms of running costs, the electric car is already far ahead of cars powered by the internal combustion engine.
Many people charge their electric car overnight and, at nighttime rates, the cost works out to be between 10 and 15% of the cost of petrol. Even when people charge at the daytime rate for electricity, it works out to be about 25% of the cost of petrol.
It costs less than €5 to run an electric car for 100 miles. The cost to run the car for 17,000 miles per annum (average mileage for residential car use in Ireland) will thus, be less than €850.
There have been difficulties with some local authorities in terms of having the road marked as an e car space reserved for electric vehicle charging. At the moment someone could find a petrol car parked at the e charging location and there is little that can be done about it, unless the local authority has agreed to mark the space as a space set out for electric car charging only – making it an offence for any other car to park there. Some local authorities have done this, others haven’t. Dun Laoghaire has gone further and offered electric cars free parking for up to four hours.
The ESB is trying to sort out all the questions around people booking charging spaces in advance. These are free, so, if electric sales pick up they are likely to become very busy. There are outstanding questions such as how long in advance should people be permitted to book a space? What should the ESB charge for a booking? What happens if someone books and doesn’t show up? What if someone hooks their car up to a charge point, and goes off to dinner, only returning several hours later, or the next morning, blocking up the space for others?
London is one of the leading cities in the world, when it comes to supporting electric vehicles, and certainly Dublin and other Irish cities and towns could learn a lot about what is going on there, and the picture is changing fast.
London is looking to introduce an ultra low emission zone in central London from 2020. This will be in addition to the congestion charge. There is a £10 charge to drive into central London as things stand, and if you are driving a pre-2015 diesel or a pre-2006 petrol car there is another £10 added on top of that. This is to try and reduce congestion and to improve air quality, primarily.
The London taxi company has been bought out by Geely, a Chinese electric vehicle company, who have built a new factory in Coventry. Geely have invested £300 million on that factory, and this will churn out new London taxis, which will all be plug in ‘hybrids’ – or mixtures of conventional internal combustion engine and electric.
In the UK as a whole there are now 70,000 electric vehicles on the road which is far ahead of where we are, at 2,000 in Ireland, even accounting for the population difference.
The new Mayor of London, Sadiq Khan, is talking about extending the low emission zone beyond central London, while the central government at Westminster has allocated £600 million to incentivise the purchase of EVs, build infrastructure and support pilot projects, such as electric bus schemes. There are grants available for the manufacturers and purchasers of EVs and an Office of Low Emission Vehicles, or OLEV, has been set up under the control of the UK’s Department of Transport.
Meanwhile, in Norway 25% of all new car sales are now electric. The Norwegians are proposing to ban conventional vehicle sales in 2025. The proposal is that from 2025 on, cars powered by an internal combustion engine using petrol or diesel will no longer be permitted to be sold. This is extraordinary for a nation that has built its wealth on oil reserves in the North Sea, and shows that the days of the internal combustion engine are numbered at least here in Europe.
There have been 25,000 electric vehicles sold in Norway so far this year. It is the transport department that has proposed to the Government that the new policy to be announced in the Spring. The report to the Government, which is being discussed in the Norwegian parliament at the moment has recommended that there be a ban on IC vehicle sales from 2025. It hasn’t been decided yet, however.
There is a grant which takes€5,000 off the initial purchase price of the electric car, and VRT relief up to €5,000. The ESB provides free home charge point with the purchase of an EV as well, as well as free public charging (public) and a 24 hour backup call centre should problems arise.
But, clearly these measures have not enough to encourage a higher level of electric vehicle purchases in Ireland and more needs to be done if EVs are to move out of the niche market situation here.
The car market has recovered and we are on target for 155,000 cars to be sold this year, which is still down on the 2008 figure of 187,000.
The market, which survived a near death experience, is probably secure enough to look at new technology like electric again, so that’s positive.
A revised target for EVs in Ireland of 50,000 has been mentioned in the National Energy Efficiency programme, but that, experts believe, will not be reached with the current level of incentives for EVs. More is needed.
Ireland could perhaps look at the US where there are 400,000 EVs on the road. The US gives a Federal tax credit of $7,500 per electric car purchased. On top of that certain states add their own incentives. For example, California gives an additional $2,500 grant, while Colorado gives a tax credit of $6,000.
The US moves seem to be working, in some places at least. For example, 6% of new car sales in San Francisco are now EVs.
Some believe that giving executives incentives to buy electric cars here by reducing their Benefit in Kind is something that might kick start things.
Executives in the US are buying the latest Tesla Model S, which is outselling BMW and Mercedes in that luxury class in California.
These executives buy a new car every three years, and are helping to generate a second hand market for electric cars there too.
The Tesla Model S is outselling BMW, and Mercedes in that luxury class in California. This has grabbed the attention of the German car companies. Berlin has been resisting the tightening of regulations in Brussels on the car industry, particularly on non greenhouse gas causing CO2 emissions.
However, they won’t be able to hold the line forever, as more cities and countries move to improve air quality for its urban citizens. The situation where diesel cars are pumping carcinogenic substances into the air, and risking the health of children in particularly, can’t continue. The car companies have woken up to this, and they are all working on hybrids if not full electric vehicles in anticipation of what is to come.
The big picture, however, is even more threatening for the existing car companies, as driverless technology begins to become reality. The Mercedes E class in its latest ads in Ireland talks of a move towards the autonomous, or driverless car.
The Tesla Model S already has all the technology it requires to be driverless and in a test on the Stillorgan dual carriageway it changed lanes without a hitch. The vision of the future is that the transport needs of society is built around a fleet of driverless electric cars, which can be called on demand by phone apps.
This will reduce the need for car ownership, and provide disabled, elderly or children with the means to safely call for a car to get from A to B. The huge amount of space in our cities given over to parking can be used for something else, noise will be eliminated, and air quality vastly improved.
Medical research in Ireland, led by doctors and nurses, is discovering new ways of doing things that are improving health outcomes for sick people, and helping prevent illness arising in the first place (Source: http://www.ucd.ie)
The evidence shows that the best hospitals – the ones where patients have the best medical outcomes – are those that are most actively engaged in medical research.
This is the kind of practical hospital based research that saves people’s lives and it is often led by doctors or nurses seeking better ways of doing things, with no commercial motivation.
People at the frontline may have an idea of how a tried and tested way of doing things with certain patients can be improved upon. Then trials or tests are setup to test the new idea.
If the idea works, and an improvement in patient medical outcomes is proven, then changes are made in medical practice to ensure that patients fully benefit from the new knowledge.
It is called ‘bench to bedside’ research where doctors or nurses use science to test out their ideas, and if they work, then the new ways are translated from lab bench to patient bedside.
The evidence shows, from decades of work all around the world, that hospitals are safer and generally better where the doctors, nurses and medical professionals are ‘research active’.
Medical practice doesn’t stand still, or it shouldn’t, and there are always ways of making improvements in patient care. Sometimes there is a big leap forward, with a dramatic new advance, while lots of other times, it’s a case of steady, gradual incremental gains.
The important thing is that medical professionals are in a mindset where they are constantly challenging how they do things, and never believe that existing methods can’t be improved.
The research that we are talking about here could be as simple as a better, or more, timely way of delivering a medicine, or a radical new method of performing difficult surgery.
One of the great advantages that hospital researchers have over laboratory scientists is that they can carry out tests and trials on humans, who have agreed to take part in such trials.
The individual patient can be asked to sign up for a ‘clinical trial’ to advance the state of knowledge in a particular field, such as cancer research or cardiovascular disease.
Taking part in such trials offers patients, sometimes very sick patients, the chance to help their fellow man (and woman) that come behind them, who may have the same illness.
But, as well as helping to improve the prognosis for future patients, there is plenty of evidence that an individual has a long to personally gain by taking part in a clinical trial.
The evidence suggests that people on clinical trials in hospitals have better long-term health outcomes that those that aren’t, and have earlier access to new drugs and treatments.
The people on clinical trials are watched very closely by medical staff, and they get the very best of care and attention, so that any issues that arise are picked up quickly and addressed.
There are more and more clinical trials taking place in Irish hospitals and this is a very good thing for our patients there, young or old, as the more trials, the better the health outcomes.
All of the major Irish hospitals have significant research programmes going on at this stage, and many people will have been offered the opportunity to take part in a clinical trial.
It was long recognised that Ireland needed to be done more hospital based research, and in 2006 the Irish Clinical Research Infrastructure Network was setup to facilitate this.
Clinical trials, and studies are best done across a number of hospitals, at home and abroad, to increase the numbers that take part, and make the results more meaningful. The Network is now supported by the Health Research Board, the HRB, and the HSE.
There is also a lot more paediatric research taking place in Irish paediatric hospitals such as Our Lady’s Children’s Hospital Crumlin, and around the country, than ever before.
There is also a paediatric research network being set up between medical researchers at Irish paediatric hospitals, and this is very good news for sick children in Ireland.
Generally speaking then, there is a lot more hospital based research taking place in Ireland than there was say, 20 years ago, but we have a long way to go to catch up with the best.
Many people may have the impression that a lot of research done in hospitals is being by pharmaceutical companies who want to test our new drugs and products on patients.
That kind of industry led research does happen, and, in fairness, it can occasionally lead to the development of a wonderful new drug, or to the different use of an already existing drug.
However, the kind of research that is having a more sustained impact on patients’ health is the type of research that is called ‘investigator led’ research with no commercial motivation.
The genesis of this type of research is a doctor, or nurse, physiotherapist, spotting a potentially better way of doing things in their daily work, and setting up a trial to test this out.
This requires a culture to be established in Irish hospitals, where new ideas, or ways of doing things are encouraged, and they don’t always have to come from the consultant.
The important point is that it is not the pharmaceutical industry calling the shots here, it is the medical professionals on the ground, who have no axe to grind but trying to help patients.
The one issue that we have in Ireland, however, compared to the leaders in hospital research is that not enough time is freed up for consultants and others do do research.
In the US, clinical researchers might spend half their time working with patients and the rest of the time doing research. That kind of freedom is not the norm, here in Ireland.
I visited the UCD Clinical Research Centre last week to talk to some medical researchers about their work. This is just one of many research centres attached to Irish hospitals.
Dr Alistair Nichol, a consultant anesthestist told me about a research project called TRANSFUSE. The goal here is to test out whether using new blood to transfuse patients leads to better outcomes than older blood.
Irish blood products can be 35 to 42 days old by the time they are used for a transfusion, and there is some evidence emerging that ‘using fresh blood is better.
Dr Nichol is testing this out in a study on 5,000 people that receive fresh blood against blood that is ‘standard’ (older). They have gone through 4,000 patients so far.
They plan to publish the results in about one year, and whether the fresh blood is found to be better, or not, the information that is obtained from this trial will change clinical practice.
Dr Nichol is also involved in a study that aims to get Ireland better prepared for the next major flu outbreak, as we weren’t ready for the H1N9 outbreak in 2009 he said.
The idea is to be ready to move fast when the next major flu outbreak happens here, and we are due one he said, by having everything in place to capture information on the flu.
The idea is that the doctors, nurses, and paperwork are all in place so that when people come in with a dangerous flu that UCD is ready to start a trial to capture information on it.
UCD is linked with researchers in Australia and New Zealand, in this major effort to prepare for the next flu outbreak so that information on its first appearance is properly captured.
A flu pandemic hits in waves, so that when the first wave comes through Ireland, the UCD trial will capture the information needed so that it can be tackled on the second wave.
I also met Professor Carel Le Roux, a South African doctor and researcher now based in Ireland who is doing important work on obesity and diabetes.
The work of Professor Le Roux, and colleagues around the world, has found that there is a gene in some people which means they are always hungry, even soon after a meal.
This genetic link to obesity shows that obesity, and related conditions such as diabetes Type 2 are not due to some moral weakness, but due to measurable genetic differences.
This finding means that for some, it may be better for doctors to try and maintain people’s health at their current weight, as trying to get big weight reductions might not be effective.
It also means that for some, said Prof Le Roux, the best option may be to have gastric bypass surgery, which is a proven method of reducing people’s appetite in the long run.
There is also important research into children’s diseases – paediatric research – happening in Ireland, in areas such as leukaemia, eczema, controlling pain and childhood diabetes.
What Irish paediatric researchers are doing is identifying the very earliest signs of diabetes, or allergies, for example, and this means treatment can also begin much earlier.
The goal in the future is to be able to identify children or infants that are at risk from a condition, or that have a condition, even in the womb and then prevent or treat it.
This preventive approach to medicine which is investigator led is far different from a world where the pharmaceutical industry wants to simply test drugs and products on already sick people.
Tax incentives for those buying diesel cars over the last decade has fueled a move to diesel on Irish roads, with diesel cars now outnumbering petrol cars.
This has been widely regarded as a welcome move, as diesel cars are considered ‘better for the environment’ because they produce less carbon dioxide gases than petrol cars – the gases that have been linked with causing global warming.
However, scientific evidence is emerging which shows that the level of diesel particulates, which are damaging to human health, has increased in line with the growing popularity of diesel and that Irish people are dying as a result of this. The European Environment Agency has, for example, estimated that 1,200 people in Ireland per year are dying as a result of diseases caused by particulate pollution.
Until relatively recently, there has not been a significant amount of research into the impact of diesel pollution on public health, particularly in Europe, but the Volkswagen diesel emissions scandal certainly gave it an added push.
The evidence that is emerging from the US primarily – where research has been going on for longer – suggests that there is real reason for concern when it comes to health effects, and environmental effects, or air pollution from diesel engines. The US Environmental Protection Agency (EPA), the World Health Organisation and the UK Department of Transport have all produced reports in the last year or two which point to a real problem here.
As well as pointing to increased emissions of particulate matter (PM) and Nitrogen Dioxide gas, which are known to damage human health, the authorities in Europe and the US have started to make a direct link between an increase in numbers of people dying from respiratory diseases and cancers, and this increase in pollution.
The US EPA, who support a lot of work in this area, has led the way with publication of figures of increased numbers of premature deaths, cancers and respiratory diseases due to air pollution from diesel vehicles. There is a tangible link, a ‘smoking gun’ if you link that is linking cause and effect.
There has been little research into subject in Ireland until this year. In January 2016, a research project began at Trinity College Dublin, with funding from the Irish EPA, which is looking to precisely determine the amount of a certain type of damaging particulate, called PM 2.5 which is produced by diesel vehicles here.
It is a multi-disciplinary research effort, involving experts in air pollution, chemistry and transportation and will take place over 24 months. At the end of it, they say they will be able to determine precisely, using computer software modeling, how many deaths and illnesses here are caused by diesel vehicles.
One of the researchers involved, Dr Bidisha Ghosh, is a transportation expert, and said that the plan is to look at diesel particulates first, and to then to a follow up study where the impact of NO2 is measured and assessed.
The Irish EPA has a number of monitoring sites around Ireland that will be used as measuring points. One of the key challenges – and this is the first time anyone in the world has done this – will be to distinguish the percentage of PM 2.5 (particulate matter 2.5, a size of particulate) that is from diesel cars as opposed to other potential sources, such as sand, or the burning of coal.
The measuring sites will be near to roads as that is where diesel fumes are strongest, and another part of the study will determine how quickly dangerous diesel pollution dissipates as you move away from a busy road.
The researchers will be looking closely at what comes out of the diesel particulate filters that are attached to diesel cars. This is in order to get the chemical composition, or signature of PMs to better identify those PMs that are from diesel cars or other diesel vehicles. This is a difficult task and will involve using specialised machines to look at tiny quantities of polluting chemicals.
Dr Ghosh said that by the end of their project, in the latter part of 2017 they will be in a position to give precise numbers on the health effects of the growing use of diesel cars in Ireland. At that stage, she said they will have precise numbers on how many extra deaths, or premature deaths are being caused or what kind of extra number of lung cancers and other respiratory diseases are happening in Ireland due to us driving more diesel cars.
The calculations are based on knowledge of the car fleet, the type and age of cars on Irish roads, and knowledge of what the standard pollution emission from a certain vehicle of a certain age will be. This makes it possible to do comparison such as comparing the 2000 level of emissions versus the 2015 levels and matching the increase in pollution with the increase in deaths and diseases.
The project will also make it possible to predict, based on a number of scenarios – such as increasing use of diesel cars at the current rate – what Ireland can expect in 2020 or 2030 in terms of death rates from air pollution. This, it is hoped, will produce a solid basis for policy makers to address this problem.
The new new diesel cars on the market have very good particle filters and if you are sitting inside one of these cars you wouldn’t get a whole lot of this PM pollution, and the newer models may not pollute the atmosphere that much. The old diesels is where the big problem lies, and there are still a lot of old diesel cars being driven on Irish roads today, as they have vastly inferior emissions control technology to more modern cars.
It is also true that the bigger diesel car engines are far more polluting. The researchers at TCD, who have access to pollution figures in Ireland between 2010 and 2015 said there was a very significant increase in diesel PMs in those years, and this finding was what prompted a more detailed air pollution study.
The researchers also strongly suspect that the VW scandal wasn’t just a VW issue, and that many other diesel car makers have been cooking the books, in the sense that the emissions reported in the car manual does not bear much resemblance to the real on road emissions. The real figures, I was told, are likely to be far, far higher than what we see in the new diesel car manuals.
The Irish government started to actively support diesel from 20o8, with various tax incentives, in order to help Ireland meet its carbon dioxide ‘greenhouse gas’ targets. In fairness to the Irish government back then, the extent of the public health risk from diesel cars was not widely known.
It was initially thought that certain types of PMs were not harmful, but that thinking has changed, and now scientists are looking at the damage caused by diesel particulates that can remain wedged in the lungs. For example, the particulate, PM 1, is very hard to remove from the lung once in.
The evidence that is now emerging, however, is that not only is diesel bad for public health, it is also, by producing NO2, bad for the environment.
The science around this is all still quite new, and emerging. It is only in 2015 that a report was published by the UK authorities which stated that NO2 can also be very harmful to children, their respiratory development, their lung development and that it can cause irreversible changes.
The initial findings about the problem with diesel took time to emerge, as they didn’t perhaps fit with the green image of diesel, especially in Europe. However, the more research on this that is being done, the clearly the scientific picture becomes, and eventually, governments will have to act on the results.
Nitrous oxide, and nitrous dioxide gases from diesel cars and vehicles are also linked with health problems, and the data can be collected again by using standard emissions and examining the national car fleet. This is likely to be supported by specific EPA funded research in future, which will, like the TCD project looking at PMs, look into NO2 levels at certain EPA monitoring sites, near busy roads around the country.
Aside from being linked with respiratory disease and death, NO2 is known to have a negative impact on vegetation and acts to break down the ozone layer.
There are emerging fuels out there, such as hydrogen gas, which is being made available at existing petrol stations in the UK this summer.
However, experts believe that because the infrastructure and global distribution network is built for diesel and petrol cars, and that huge investment has been made in this system, that it will be impossible to envisage a change to any other fuel or transport type in the near, or even distant future.
Electric cars are still rare in Ireland despite significant government support, as people don’t like some of the unanswered questions that remain on it, such as how long does an electric car last, and what to do should a battery die out?
There is also the fact that a very high amount of energy can be liberated from diesel or petrol, and there is nothing that can rival petroleum on that score.
The solution, some suggest, is to truly move towards a sustainable transport system, where people walk if they can, and only use a car when they have to. Those countries that do this, and that promote public transport have far less emissions from petroleum car engines. It is also very important to think about where we locate our busy roads, as studies have shown that irreversible damage can be done to schoolchildren from air pollution in schools near such roads.
For those that need a car, the advice is to look at getting rid of the old diesel and replacing it with a new one, with better a particulate filter. Also, to avoid buying one of the high performance diesel cars and go for a more modest option.
There is also the issue in Ireland of people removing diesel particulate filters when they start to affect car performance. They can be expensive to replace, and some garages in Ireland are openly offering services on the internet to remove and not replace the filters.
A diesel car can run without a filter, and not replacing a malfunctioning filter can save hundreds if not a few thousand euros. However, from a public health and environmental perspective removing a filter is “disastrous, really, really bad” according to Dr Ghosh.
Actively preventing the removal of diesel particulate filters from diesel cars, and insisting on a high standard of operation of diesel filters as part of the NCT test, might be how the Irish government might start trying to tackle this important public health issue.