Archive for category: Disease

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Malaria 101 and Key Facts

Malaria 101 and Key Facts
Malaria is caused by the parasite called Plasmodium and is transmitted through four different types of mosquitoes. It occurs in tropical and sub-tropical areas, though it is most common in the African Region. Malaria causes high fever, chills and other flu-like symptoms. Plus, if left untreated, this parasitic disease can cause death. Many global health and humanitarian aid organizations are focused on fighting malaria in developing countries while significant scientific research investigations into possible cures for this parasitic disease are also being done.

The World Health Organization (WHO) reports that in 2012, there were 217 million malaria cases and  627, 000 malaria related  deaths, mostly in African children. In fact, one child dies every minute from this disease in the African continent.


Where is Malaria Found?

Malaria is found in tropical and sub-tropical regions where there are warm temperatures, high humidity and lots of rainfall. In order for malaria to occur, the climate must be one in which anopheles mosquitoes can survive and multiply. The Plasmodium parasite must also be able to complete their life cycle inside the mosquitoes.

For example, the most severe strain of malaria cannot be transmitted in temperatures under 68 degrees Fahrenheit because the parasites themselves cannot complete their life cycle inside the mosquitoes. The warmest climates close to the equator thus have the highest rates of malaria transmission. In effect, this parasitic disease occurs year-round in endemic levels within sub-Saharan Africa, New Guinea and South America.


How is Malaria Spread?

Malaria is typically spread through the female anopheles mosquitoes. This particular mosquito is a “dusk-to-dawn” mosquito, meaning it only comes out at night, which is why people in warm climates are encouraged to use sleeping nets. When the mosquito bites someone already infected with malaria and ingests their blood, the parasite is taken in as well, developing inside them and infecting their saliva. Once the parasite has completed a full life-cycle within the mosquito, the disease will be spread to the subsequent humans bitten by the mosquito.


What are the Symptoms of Malaria?

Symptoms can range from mild flu-like symptoms to severe disease and death. However, if this parasitic disease is caught and treated effectively and promptly, it is usually not severe.  Malaria is split into two categories, complicated and uncomplicated. Symptoms of uncomplicated malaria include fever, chills, sweating, headaches, body aches, nausea and vomiting as well as fatigue. In countries where malaria is not common malaria is, in fact, often misdiagnosed as influenza.

Complicated malaria occurs when the organs, blood or the metabolic system are impaired. This can cause severe anemia, acute respiratory distress, low blood pressure, acute kidney failure or cerebral malaria which then causes abnormal behavior, seizures and loss of consciousness.


How is Malaria Treated?

The WHO recommends all suspected malaria cases be tested using parasite diagnostic testing. The most common treatment for malaria is the artemisinin-based combination therapy (ACT); however, resistance to antimalarial drugs is a recurring problem. Furthermore, access to testing and drugs often does not reach the poor communities where this parasitic disease is more prominent.


Who is Vulnerable?

People with delicate immune systems are the most vulnerable to malaria; this includes young children, pregnant women and people infected with HIV. International travelers traveling to warm climates are also particularly susceptible, as are the friends, family, neighbors and co-workers of people who immigrate from countries where malaria is endemic.

– Elizabeth Brown

Sources: CDC, Public Health Agency of Canada, World Health Organization
Photo: Global Biodefense

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Not Impossible Foundation

Not_Impossible_Fund
The impetus for the trail-blazing Not Impossible Foundation took place when Mick Ebeling befriended the gifted street artist Tony “Tempt One” Quan, who was suffering from the onset of Lou Gehrig’s disease. Lou Gehrig’s would eventually paralyze his entire body, stripping Tempt of his ability to communicate through artistic expression or any other means of expression other than the careful movement of his eyes.

Moved by the tragedy of Tempt’s situation, Ebeling recruited a team of talented individuals from Graffiti Research Lab, Free Art and Technology Lab and other hackers to create a device that would enable Tempt to create artwork again. In April 2009, after seven years of laborious research, experimentation and refinement, Ebeling and his team presented Tempt with their creation, the EyeWriter. The EyeWriter is an astonishingly innovative device that allows paralyzed individuals to communicate using only his or her eyes.

Recounting his perseverance in creating the EyeWriter, Ebeling said, “When I feel a spark, I commit wholly to the idea, without necessarily having a sense of how, or if, I will be able to complete it…when presented with a challenge, I find it incredibly hard to back down.”

Not surprisingly, after the launch of the EyeWriter, Ebeling and his team were soon the recipients of multiple honors in the technological world. For instance, Time Magazine honored the device by declaring the EyeWriter as one of the 50 best inventions of 2010. The recognition that Ebeling and his team received after Time’s illustrious title enabled the launch of Ebeling’s next endeavor, the Not Impossible Foundation.

The Not Impossible Foundation provides a self-description so to-the-point and succinct that it is composed of a mere six words. The Foundation Having establishes itself as a technology-oriented lab by breezily describing itself as “technology for the sake of humanity.”

Adhering to the standard of innovation and promise of the 2009’s EyeWriter, Ebeling and his team is tackling the previously impossible by working to create smart canes for the blind along with 3D-printed prosthetic limbs for amputees. The Not Impossible Foundation strives to construct new yet affordable technology to revolutionize healthcare.

– Phoebe Pradhan

Sources: Atlantic Meets Pacific, Not Impossible Labs, Mick Ebeling, BBC
Photo: Facebook: Not Impossible Fund

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A Picture of Polio

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Since 1979 the United States has been free of the disease that at one point crippled 35,000 people per year. Although Polio has now been stopped in the United States, several countries continue to suffer from the Polio virus. This infectious disease spreads rapidly to the spinal cord and can ultimately lead to paralysis. Unfortunately there is no cure for the disease but thanks to the Polio vaccination, its spread is better controlled. Many are unaware of what causes Polio so an overview including symptoms will be presented. 

“Polio” is short for Poliomyelitis which is caused by a virus that infects the nervous system. Though the virus is usually transmitted through person to person contact, 95% of those infected don’t have any symptoms. The virus tends to remain inside the human body, reaching the environment through either a fecal or oral route. Infection is rampant in areas that are extremely unsanitary and where children are exposed to the fecal material of other infected people. Since the Poliovirus enters humans, for the most part, through the mouth or nose, it is inclined to spread easily. Once in the throat, the virus multiplies until reaching the bloodstream, possibly even infecting the nervous system. Complications that arise from the virus include the following:

  • Pneumonia
  • Shock
  • Urinary tract infections
  • Paralysis
  • Loss of intestinal function
  • Lack of movement
  • Muscle weakness

Several treatments in developing nations have been adopted to help counteract these symptoms including antibiotics for infections, painkillers for muscle pain, physical therapy and surgery for muscle complications. Additionally, the Polio immunization prevents the spread of the virus in over 90% of the population though cases in which the spinal cord and brain are not involved have a positive outlook from the start. This vaccination has proven to be extremely effective as illustrated through the fact that global immunization campaigns have diminished thousands of cases worldwide. Polio outbreaks are, however, still seen in Asia and Africa, but several organizations are continuing to campaign for vaccine accessibility.

Polio

– Maybelline Martez

Sources: Centers for Disease Control, Mayo Clinic, NIH,
Photo: Foreign Policy

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Sochi, Brazil and a Global Health Nightmare

Brazil_Sochi_Global_Health
The passing of four years signifies the completion of an important unit of time for the sporting world, a marker that brings the World Cup and the Olympic Games back, blissfully, to the forefront of the global stage with 2014 being no exception. This year, Brazil will host the FIFA World Cup and Sochi will host the Winter Olympics, to begin June 12 and February 6, respectively.

Headlines anticipate security concerns for both events, which include the threat of terror attacks, widespread protests and general mayhem.

In Sochi, officials have mobilized thousands of security cameras, instituted new security checks and passport screenings, deployed scores of military personnel and amped up surveillance to ensure that “everyone in the city… feel[s] at home and safe.”

Authorities in Brazil are making similar arrangements in hopes that extensive precautionary measures will entice tourists despite the nation’s — particularly, Rio de Janeiro — volatile and violent history. Furthermore, Colonel Alexandre Augusto Aragon, head of the Brazilian National Security Force, recently revealed that 10,000 hand-selected riot troops would police the 12 cities hosting soccer matches this summer.

These reports serve as reminders that mass gatherings, even of sportsmen, can spell danger for participants and fans alike. These events are, moreover, virtual breeding grounds for another invisible threat: pathogens.

The less-publicized public health risks inherent in occasions similar to the Olympic Games are familiar to virtually every global health organization. The World Health Organization (WHO) maintains a Global Alert and Response page dedicated to mitigating risks associated with mass gatherings, which top officials consider “a stress test for public health.”

Even nations with well-established health services and fully-briefed support staff can be overwhelmed by the burden associated with an unexpected outbreak in a mass gathering situation. Not only do gatherings draw visitors from a variety of geographic areas (read: different regions of germs) but they are also, by nature, densely packed and fraught with opportunities for transmission.

WHO officials employ the International Health Regulations to govern disease surveillance programs in the 196 countries that have agreed to certain legal rights and obligations described in the regulations in applicable circumstances. Should unexpected cases of influenza, polio or respiratory illness surface, Russia and Brazil will undertake highly targeted, pre-mediated actions to prevent a public health nightmare.

Unfortunately, very real risks to traveler and fan health go generally unmentioned by the press, whose stories generally touch on political and public interest stories associated with the Olympic Games and the World Cup. Any participant in 2014’s festivities should ensure that they are up-to-date with annual and seasonal vaccines, including the flu and measles.

Appropriate action and active awareness will spell gold for Russia and Brazil, nations hoping to leave a positive public health legacy on the landscape of sports history.

– Casey Ernstes

Sources: CBS News, The Huffington Post, The New York Time, The World Health Organization

Photo: The Age

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5 Most Common Neglected Tropical Diseases

5 Most Common Neglected Tropical Diseases
Neglected tropical diseases (NTDs) affect 1 billion people, or one out of every six individuals, every year. Half a million people die from NTD related effects, the majority of whom are impoverished children, women and persons with disability. Although methods of prevention and treatment are available, these diseases remain extremely common in parts of Africa, Asia, Latin America and the Caribbean.

The following list of NTDs represents approximately 90% of the global NTD burden, along with methods of treatment and prevention.

1. Onchocerciasis

Also known as “river blindness,” this disease is transmitted via black flies carrying the onchocerca volvulus parasite. The parasite causes debilitating itching and upon reaching the eyes, visual impairment and eventually blindness. It is the second leading cause of infection-induced blindness, behind Trachoma, with 37 million people infected with the disease.

A single, annual dose of Mectizan controls the disease and relieves symptoms. Some countries in Latin America successfully eliminated disease transmission after administering the drug for twenty years which lends hope to its possible elimination in the African continent.

2. Trachoma

One of the oldest infectious diseases known to mankind and the leading source of global blindness, is caused by the bacterium Chlamydia trachomatis. Eye-seeking flies transmit the disease from an infected person’s eye discharge to uninfected hosts.

Repeated infections result in a scarred interior eyelid thereby forcing eyelashes to turn inward thus scratching the cornea, all of which is followed by blindness. It affects about 21.4 million people, of whom 1.2 million are blind.

It is hyperendemic in remote poor rural areas of Africa, Central and South America, Australia and the Middle East.
The World Health Organization (WHO) recommends the SAFE strategy (Surgery, Antibiotic treatment, Face washing and Environmental changes) to limit its spread.

3. Schistosomiasis

Or, snail fever, is a parasitic disease transmitted by freshwater snails to bathing or swimming humans. Urniary schistosomiasis progressively damages the bladder, ureters and kidneys. Intestinal schistosomiasis enlarges the liver and spleen, damages the intestines and creates hypertension of the abdominal blood vessels. It affects 200 million people, and in children can impair growth and cognitive development.

A single dose of praziquantel with repeated community distribution treats and controls the disease.

4. Soil-transmitted helminthes

Affects more than 880 million children around the world. The intestinal worms may result in diarrhea, abdominal pain, anemia, general malaise and severe infection can impair growth and cognitive development.

Improved sanitation, health education and the periodic administration of anthelminthics to at-risk groups limits the rate of transmission.

5. Lymphatic filariasis (LF)

Also known as elephantiasis, is a mosquito-borne disease which results in painful swelling of the limbs and genitals. Over 120 million people are currently infected and nearly 1.4 billion people are at risk in 73 countries.

The WHO recommends yearly large-scale Mectizan and albendazole doses for four to six years to interrupt transmission.

This information was compiled from the Neglected Tropical Disease NGDO Network, World Health Organization and the Center for Disease Control.

– Emily Bajet

Sources: Neglected Tropical Diseases (NGDO) Network, WHO, WHO Programmes, Center for Disease Control and Prevention(CDC)
Photo: Bullion Street

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Sanitation and Poverty

Sanitation and Poverty
Two and a half billion people – over a third of the entire world’s population – have no access to adequate sanitation facilities, which leads to the rapid spread of disease and heightened child mortality rates. Most commonly, poor sanitation practices lead to diarrhea: little more than an annoying byproduct of bad hygiene practices for first-world residents, it is often fatal in developing countries. In fact, it is estimated that 5,000 children die daily from complications related to the ailment. Consequently, one person dies every minute due to the lack of basic sanitation.

Why is the lack of well-formulated means of sanitation such a large problem in modern times, when technology has reached such an advanced stage? One reason is the negative stigma associated with it: the discussion of toilets simply feels dirty or inappropriate and is not as popular nor does it appear at first glance as urgent as, for example, the issue of access to drinking water. However, the two are related and equally pressing; disease control is an impossible goal without proper sanitation adjustments. In many places around the third world, toilet stalls are completely nonexistent. Essentially, this means that people are forced to defecate in public, populated areas, leaving waste behind which will remain on the ground spreading disease. Just a gram of human feces may contain as much as ten million viruses and a hundred parasite eggs.

Besides the obvious health benefits, according to the World Health Organization (WHO,) improved sanitation in developing countries would provide $9 economic benefit per $1 spent. The year of 2008 was dubbed by WHO as the International Year of Sanitation. Through various conferences and seminars, five key principles of sanitation were determined: 1. Sanitation is vital for human health. 2. It generates economic benefits. 3. It contributes to dignity and social development. 4. It helps the environment, and most importantly. 5. It IS achievable. South-East Asia and Sub-Saharan Africa are two regions most affected by poor sanitation practices. Coincidentally, they are also the two areas with the highest death rates from various diseases. It is especially prevalent in rural areas, where open defecation is six times more likely and use of unimproved sanitation is four times higher than in urban areas. Being one of the 2015 Millennium Goals, improved sanitation should not be taken for granted. To heighten the quality of sanitation is to improve the quality of life as well as economic efficiency for millions of individuals worldwide. In this day and age, no one should have to defecate publicly; not only for reasons of dignity and civility, but also due to personal awareness and dedication towards reducing of the spread of deadly disease.

– Natalia Isaeva

 

Sources: The Global Poverty Project, World Health Organization: International Year of Sanitation, UNICEF: Progress on Drinking Water and Sanitation

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Rwanda Redefines HIV Care

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In a country where just 20 years ago, genocide claimed nearly one million lives, the Rwandan government has revamped HIV treatment for the poor by reforming the standards of successful care.

In Sub-Saharan Africa, there are now over 7.5 million people receiving antiretroviral therapy, 150 times as many as a decade ago. Medications have become easier to manage and overall, more effective, forcing some patients to take no more than one pill each day. Also, HIV testing has become much more widely available and the virus is being detected at an earlier stage before the circumstances are too dire.

In Rwanda, many HIV patients are taking their medications as directed, medication which suppresses the virus in their bodies to the point where it is essentially non-detectable. Success here is achieved when the HIV positive individual can earn a living, support their family and care for their community no differently than uninfected individuals. Furthermore, patients who would have previously been hospitalized with severe complications of HIV are now receiving regular preventive care.

The steps forward being taken in this small country are undeniable. Compared with 54 percent of medical patients worldwide, 91 percent of Rwandan patients who require HIV medications have access to life-saving treatment. Even more encouraging, 98 percent of women undergo HIV testing during their prenatal visits. In a country with only one doctor for every 17,000 people, nurses and community health workers have been trained to provide HIV services that were before, only available from physicians. Aggressive media campaigns by the government and other international organizations remind and encourage the public to “Know Your Status” while targeted outreach programs concurrently focus on the high-risk groups.

Rwanda is one of the first sub-Saharan countries to nearly eradicate the transmission of HIV from mothers to their newborns. Due to this, the number of new HIV cases has been cut in half during the last decade, and perhaps soon, it will fulfill the dream of accomplishing an “AIDS free generation.”

– Sonia Aviv

Sources: The Atlantic, The World Bank, BWH Global Health
Photo: AIDS Health

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WHO Reports Spike in Cancer Cases

Cancer Cases
The World Health Organization (WHO,) guardian of international health statistics, released new numbers last week indicating a major upturn in the number of cancer cases worldwide.

In 2012, 14.1 million people received cancer diagnoses in 184 countries across the globe, a nearly 10 percent increase from 2008. Unfortunately, this rise translates across the board to mortality rates as well, which saw a similar 9.3 percent increase over the same period.

Lung cancer, breast cancer and colorectal cancer round out the three most common forms of the disease, comprising 13 percent, 11.9 percent and 9.7 percent, respectively, of the aggregate number of diagnoses.

Breast cancer has seen the most rapid acceleration of any other manifestation of cancer and continues to be the leading cause of cancer deaths among women. In 2012, over 6.3 million women were living with cancer diagnoses from the previous five years alone. Incidence increased 20 percent from the beginning to the end of that five-year period (2008-2012); 1.7 million women received initial diagnoses in 2012.

Unfortunately, the mortality rate for this common cancer has not slowed down, increasing by 14 percent in the study period.

The International Agency for Research on Cancer (IARC) forecasts the upward trend of aggregate cancer incidence will likely continue through and beyond the year 2025. By that time, over 19.3 million new cancer cases will lob on to the current cancer burden each year.

The increase is not inherently problematic for global health: these statistics reflect an aging global population and the planet’s sustained population growth. As more adults celebrate birthdays in their 70’s and 80’s, it follows that more are alive to receive diagnoses of cancer, a disease largely believed to arise from the effects of aging on the error-prone process of cellular reproduction.

Similarly, advances in technology have increased the accuracy and applicability of diagnostic techniques. Early detection of cancer raises incidence rates but ultimately benefits cancer patients by improving outcomes.

Unfortunately, inequalities in global death distribution fall unfavorably on developed nations. The WHO estimates over 55 percent of all cancers and nearly 65 percent of all cancer deaths in 2012 occurred in lesser-developed regions of the world. The IARC expects that this trend will continue (and likely deteriorate) as 2025 approaches.

Dr. David Foreman, Head of the IARC Section of Cancer Information, urges the global community to “develop effective and affordable approaches to the early detection, diagnosis, and treatment” of cancers in the developing world. Funds allocated toward research and development in these areas will likely generate significant returns on investment; each year, cancer-related deaths and disability cost the global economy $1 trillion in economic losses.

If properly managed, the recent rise in cancer cases will inspire focused improvements in cancer control strategies that will bridge the gap between morbidity and mortality, improve outcomes for the developed world and turn the trend on its head.

– Casey Ernstes

Sources: The American Cancer Society, Voice of America, International Agency for Research on Cancer
Photo: News at Jama

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Vaccine Logistics: Typhoon Haiyan

vaccine_typhoon_haiyan
Mere weeks after the confirmation of the first ten cases of poliomyelitis in Syria, Mother Nature dealt the global health community another powerful blow in the form of Typhoon Haiyan.

Some areas of the Philippines are nearly 95 percent destroyed; Doctors Without Borders staff has described the aftermath as reminiscent of the Haitian earthquake of 2010. Hospitals have been ruined, so aid workers have set up temporary health centers to treat wounds and provide much-needed vaccines to locals and returning residents who chose to flee the oncoming storm.

The World Health Organization and the Philippine Department of Health have spearheaded a campaign to vaccinate children under five against measles or polio outbreaks and provide Vitamin A drops to boost immune system strength. All children under 15 years will then receive care if resources allow.  Hard-hit areas are the campaign’s priority. Immediate needs include the set-up of immunization stations, volunteer deployment and acquisition of all necessary vaccines.

Philippine Secretary of Health Enrique Ona guarantees that since “system is shaken but not broken,” a re-launch of widespread vaccinations should not prove impossible.

Nonetheless, in some regions such as Guiuan (to the east of Samar island,) the “cold chain” required for vaccine delivery and preservation has not yet been implemented. This mechanism involves gas and generator powered refrigerators, cold boxes, ice packs and vaccine-cases for areas without power. In the words of Dr. Johan von Schreeb of Doctors Without Borders, the devastated islands “do not have time to wait.”

This refrigeration conundrum arises with each civil conflict or natural disaster that leaves affected regions without power. Though the cold chain concept is effective and familiar to health care providers, current supply and logistics systems were designed thirty years ago, prior to the development of cold chain equipment. Project Optimize (a task force of the WHO and PATH) and UNICEF’s Cold Chain and Logistics Task Force have identified innovative funding for cold chain equipment as a key opportunity for improvement upon today’s vaccine systems.

In order to achieve the Project’s 2020 goals, cold chain equipment, efficiency and monitoring must improve. Health care managers must be able to access performance figures to make informed purchasing and allocation decisions given the limited time span and resources available in health care emergencies; in other words, the current Philippine situation. If local or national health departments allot too many or too few resources to any single immunization station, lives will be lost (due either to a vaccine shortage or to spoliation of vaccines that should have been administered in other areas). Striking this delicate balance requires widespread cooperation between the public and private sector.

Similarly, manufacturers of equipment must be kept abreast of product performance in the field. The implementation of a feedback loop between manufacturer and user would improve product packaging and design. The Project’s 2013 Action Plan suggests beginning with a redesign of cold boxes to maximize the “refrigerant-to-vaccine” ratio to hold more vaccines and insulate them more efficiently.

Improvements to vaccine logistics that reflect needs expressed explicitly by those on the front lines of vaccine campaigns will ensure that doctors such as von Schreeb have the tools to work their magic when disaster strikes.

– Casey Ernstes

Sources: Doctors Without Borders, PATH, The World Health Organization, The World Health Organization
Photo: BBC

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Malaria: The Enemy

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What is Malaria?

Malaria is a life-threatening blood disease caused by a parasite known as plasmodium. This parasite is transmitted to human by the anopheles mosquito. An infected person of this disease shows signs of dizziness, loss of appetite, anemic, high fevers, dehydration and loss of body weight.

The History of Malaria: The word malaria comes from the 18th century Italian “mala” meaning “bad” and “aria” meaning “air”. Most likely the term was first used by Dr. Francisco Torti in Italy, where people thought the disease was caused by foul air in marshy areas. It was not until the 1880’s that scientists discovered that malaria was a parasitic disease.

The Socioeconomic Effect of Malaria: Malaria kills a child somewhere in the world every minute; it infects approximately 219 million people each year with an estimated 660,000 deaths mostly being children in Africa. Ninety percent of malaria death occurs in Africa. It is one of the most dreadful diseases reducing the populace on the large scale. The sickness also contributed greatly to anemia among children-a major cause of poor growth and development.

Malaria also has some serious economic impact in Africa, slowing economic growth and development and perpetuating the vicious cycle of poverty. Malaria is truly a disease of poverty afflicting primarily the poor who tend to live in malaria-prone rural areas. Nevertheless, the rich cannot be left out with the infection of this sickness.

Prevention and Control: Malaria, many say, is no respecter of person. Irrespective of one’s social status, malaria can indeed infect many people.  It is in this light that people must take precautionary measures to protect themselves, family and friends from this dreadful sickness. Those living in malaria prone regions like Ghana should make sure they follow certain precautions, some of which are as follows:

  • The use of effective mosquito repellent cream.
  • Cover legs and wear long sleeves at night.
  • Ensure windows and doors are screened to avoid mosquitos from entering rooms.
  • The use of treated mosquito bed nets whiles sleeping.
  • Spraying homes and surrounding with insecticides.
  • Clear shrubs, stagnant waters and weed surroundings of areas that help the breeding of mosquito.

Get Involved in the Fight Against Malaria: It is high time all stakeholders globally, be it governments agencies, health institutions, policy makers, developmental agencies and individuals, get involved in the fight against Malaria. Government and other developmental agencies should formulate realistic policies, carry them out, monitor the progress of these implementations and evaluate their final outcomes.

These programs, in effect, when implemented, will help the fight against malaria and help improve the living conditions of the rural poor. Just as the adage goes, “brighten the corner where you are” the individual cannot be left out in the fight as well. Gutters or drains and the environment need to be free from the breeding of mosquitoes and as such, the onus also lies on us as individuals to practice personal and community hygiene. People should not wait for government agencies and other non-governmental organizations to help clean their environments; they must take responsibility of their actions and outcomes and ensure they genuinely support the fight against poverty through the prevention and control of malaria.

– William Annang

Sources: UNICEF, Medical News Today
Photo: The Guardian