Global Health

Ambulance response time can vary widely across cities, depending on traffic patterns and the location of the emergency situation. As a volunteer medic in Jerusalem, Elli Beer witnessed firsthand how a few minutes can make a significant difference in saving a life. His frustration with poor ambulance response times led him to develop an all-volunteer rescue service called United Hatzalah.

In this recently posted TEDMED talk, Beer talks passionately about how a small neighborhood group dedicated to responding to nearby emergencies evolved into United Hatzalah’s network of 2,000 volunteers. Today, volunteers respond to incidents on “ambu-cycles,” motorcycles carrying the same equipment as a conventional ambulance but lacking the ability to transport patients, and have treated more than 200,000 people in the past year. Beer has rolled out the service in Brazil and Panama and plans to expand to India.

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims and On using social media to improve emergency-preparedness efforts

Last week’s C-IDEA global health symposium here at Stanford featured 20 presentations on low-cost ideas for preventing disease in developing nations. As I wrote in an Inside Stanford Medicine article on the event, one of the more clever ideas was “EZPZ,” a method for treating latrine waste with alkalizing lime so that pathogens that might leak into the water supply can be eliminated and the waste can be recycled as crop fertilizer. Developed by a Stanford team from the “Design for Extreme Affordability” course offered at the Hasso Plattner Institute of Design, this solution not only reduces diarrheal diseases, but it also provides Cambodian farming households with about $40 of fertilizer each year.

Another highlight of the conference was the keynote speech delivered by Jeffrey Sachs, PhD, director of The Earth Institute at Columbia University and author of the bestselling book The End of Poverty. Sachs’ call to action for the packed hall of global health innovators was this: The developing world needs you to create smart phone apps that connect people in isolated rural villages to good medical care, clean water and medicine.

Previously: What I did this summer: Stanford medical student helps India nonprofit create community-health maps and A story of how children from Calcutta’s poorest neighborhood became leaders in improving health

Although Coca-Cola products are readily available for sale in remote African villages, many of the life saving medicines needed for easily treatable diseases can only be obtained at health clinics located a day-long walk, or further, away. So an innovative nonprofit called ColaLife developed packaging and a method for using the Coca-Cola distribution network to distribute medicines, specifically anti-diarrhea kits, in Zambia.

The nonprofit’s work is highlighted in a new documentary film titled “The Cola Road.” In the above film trailer, ColaLife founders Simon and Jane Berry discuss the project and Tim Llewellyn, designer of the Aidpod device used to deliver medicines in Coke crates, explains how the medicines are packaged and transported. Scientific American’s Talking back blog reports on the success of the project:

Tiny village shops, always stocked with Coke, have now started to receive oral rehydration Kit Yamoyos (kits of life)—and, no, Coke itself is not a particularly good rehydration fluid, despite the lore. Thousands of the kits have been sold already in Zambian rural districts and the Ministry of Health, the film points out, now has plans to use the same supplier network to distribute other types of medicine. The income for the shopkeepers provides an incentive to keep the kits on the shelves.

Last week at TEDxChange 2013: Positive Disruption, Melinda Gates brought to stage Salim Shekh and Sikha Petra, two of the children featured in the Stanford-produced documentary “The Revolutionary Optimists.” The award-winning film, which was co-directed and co-produced by Maren Grainger-Monsen, MD, and Nicole Newnham, tells the story of a lawyer-turned-social entrepreneur who worked to empower children living in Calcutta’s poorest neighborhood to become leaders in improving health. As described on the film’s website, the youth have “painstakingly track[ed] and collect[ed] data around health issues that impact them – water, sanitation, and infectious diseases” and then made improvements in each of the areas.

The TEDXChange video was recently made available on Facebook (log-in required); scroll to the 1:20 mark to view the movie trailer and to 1:22 to meet Salim and Sikha, who are embarking on a U.S. tour to talk about their work. An amazing figure from the talk: Before the group began promoting polio vaccination, only 35 percent of children in their community were vaccinated. Now 85 percent are.

Previously: Stanford documentary wins award from the Sundance Film Institute, A story of how children from Calcutta’s poorest neighborhood became leaders in improving health and Stanford filmmakers to debut documentary at TEDxChange

Tonight, Stanford will host a screening of a new documentary titled “Extreme By Design.” The film chronicles the story of three groups of students from the Design for Extreme Affordability course as they create innovative products and services to solve problems in developing countries.

The teams featured in the film, which are composed of business, engineering and medical students, are working on three distinct projects: developing a breathing device to keep infants in Bangladesh from dying of pneumonia, creating an IV-infusion device for Bengali hospital patients and designing a new method for storing drinking water for Indonesian villagers. The documentary begins on the first day of the Design for Extreme Affordability class and concludes a year later when one group returns to Asia to test their project in the field amid plans to launch a start-up company.

Below, producer and co-director Ralph King discusses the catalyst for making the film, which will air later this year on PBS, and what impact he hopes it will have on audiences.

What inspired you to make a film about the Design for Extreme Affordability course?

I first heard about [the course] while playing squash with a Stanford undergrad who applied, but hadn’t gotten in. As a result, he and a few friends planned to go to a village in Mexico to investigate local needs and design some kind of product for them. I was struck by his gumption and the motivating effect of the course. I figured that for those students who did get in to the course it must be a powerful experience. I confirmed this during the next six months that I spent auditing the course. I travelled to Myanmar with one of the student teams and had a moment of self-discovery there that I will never forget. Once it became clear that many of the Extreme students had had similar moments, I decided I had to try to capture those moments on film. That was my inspiration, but of course the film would not be what it is without my team, co-director and executive producer Michael Schwarz, executive producer Kiki Kapany, and a host of others.

How did you select which teams to feature in the film?

We started by interviewing all 40 students before the class started. From these, we picked a dozen or so contenders because of their openness, background and comfort in front of a camera. We followed most of them through the first quarter of the course. Then once they chose their international projects, we narrowed the field to half a dozen students on four teams. We sent camera crews to three locations simultaneously — Bangladesh, Indonesia, and an Arizona Apache reservation — to cover their field research during spring break, and continued to follow the four teams through the course’s second quarter. In the editing room, we made the final cut to three teams because their stories were most compelling.

The overarching narrative of the film focuses on a group of students determined to build a better world through the entrepreneurial process. But what can it teach us about why global health is important beyond those living in developing countries?

In the film, the students use the creative process of Design Thinking to find solutions to seemingly impossible problems, some of which are health-care related. There are many aspects of health care right here in the U.S. that can benefit enormously from the application of Design Thinking and, in fact, several courses at Stanford do just that.

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I admit to a certain sense of mounting dread about the news of the new H7N9 influenza virus arising in China. And the never-ending supply of Tweets (alarmist and otherwise) are not helping one little bit. That’s why I appreciated this article posted today by Wired reporter and author Maryn McKenna (she’s sometimes referred to as Scary Disease Girl, due to her focus on global health and infectious diseases).

McKenna breaks the current news down into a quick primer, based on her past experiences reporting on that ‘other bird flu’ H5 N1 (remember that one?) ten years ago. She follows with a caution to beware- or at least to be aware- of the sources of news of this quickly moving story, and an explanation of some peculiarities in Chinese media that may hamper or distort reporting. She also draws a parallel between what’s happening now with H7N9 and H5N1- pointing out that the latter never erupted in humans as it was first feared. Says McKenna:

And H7N9 might not, as well. It is far too soon to say, despite the rapidly escalating case count and the reports — which came in while I was writing this — of a possible animal reservoir in pigeons and a possible human-to-human case. I have been writing about flu and possible pandemics since 1997 — for what it’s worth, I wrote the first story in the US in 1997 about that first H5N1 case in Hong Kong — and so at this early point, what I most want to say is this: We all love scary diseases. (If you didn’t, you wouldn’t be reading this blog.) But there is a fog of war in disease emergencies, just as there is in military ones, and it is very easy to get lost in it.

It will take a while for this story to become more clear. Anticipating that, I want to suggest some things to think about as you follow the news.

She ends with this great advice:

[...] Don’t assume that everyone who is loading information onto their blogs or pushing it onto Twitter is doing it in a sharing spirit of helpfulness. There are people — you can see this already — who are opportunistically using this to feed their egos, angle for jobs, or generally to stir up trouble. More than ever, it’s important to be skeptical about the sources of the information you consume.

McKenna makes it easier for us to practice what she preaches by listing several reputable news sources-traditional, web-based and, even on, Twitter- that should be reliable sources of information. You can follow McKenna on Twitter at @marynmck.

Previously: “Superbug” author discusses dangers, history and treatment of MRSA and Image of the week: What H5N1 looks like

In this recently posted TedxStanford talk, Sherry Wren, MD, a general surgeon at Stanford, offers some staggering statistics about surgery and global health. One particularly eye-opening fact she shares is that two billion people lack basic access to surgical care. Wren goes on to discuss reasons why surgery is not part of the global health agenda and argues we need to reject the current dogma that surgery is not cost effect or part of basic health. The video is worth watching and offers compelling evidence on why investment is needed to fund surgical training in low-income countries.

Previously: Teaching surgeons new skills for medical missions and Intervention program helps reduce pneumonia among surgery patients

Sugar consumption and diabetes risk may be more closely linked than anyone realized.

For years, research has supported a roundabout path from excess sugar intake to type 2 diabetes. Eat too much of anything, including sugar, and the resulting weight gain raises your diabetes risk, the theory goes. There’s lots of evidence to support this pattern, but also a big hitch: A small but noteworthy proportion of people with type 2 diabetes aren’t overweight or obese. And up to 40 percent of normal-weight people show signs of the metabolic syndrome, a constellation of metabolic disturbances that predisposes people to diabetes.

So what’s going on? New epidemiological evidence, published today in PLOS ONE, suggests that sugar intake may be directly associated with diabetes risk. This research doesn’t refute the sugar-to-obesity-to-diabetes pathway; instead, it suggests that eating too much sugar promotes diabetes in more than one way.

The researchers, who are from Stanford, UC-Berkeley and UC-San Francisco, analyzed a decade’s worth of data on sugar availability in the food supplies and diabetes rates in the populations of 175 countries. They used new statistical methods derived from the field of econometrics to control for several factors that could provide alternate explanations for the relationship between sugar intake and diabetes, including obesity, overweight, sedentary behavior, other calorie sources, and a long list of socioeconomic measures. The statistical controls were more sophisticated than those typically used in biomedical research, the study’s lead author, Sanjay Basu, MD, PhD, explained to me when I interviewed him about the findings. (And for those who want more information about the statistics, Basu has written an interesting post on his personal blog to explain the methods in detail.)

After all the statistical crunching was done, the research showed that every 150-calorie increase in available sugar was associated with a 1 percent increase in the population’s diabetes rate. A 12-oz soda contains about 150 calories of sugar.

From our press release on the study:

Not only was sugar availability correlated to diabetes risk, but the longer a population was exposed to excess sugar, the higher its diabetes rate after controlling for obesity and other factors. In addition, diabetes rates dropped over time when sugar availability dropped, independent of changes to consumption of other calories and physical activity or obesity rates.

The findings do not prove that sugar causes diabetes, Basu emphasized, but do provide real-world support for the body of previous laboratory and experimental trials that suggest sugar affects the liver and pancreas in ways that other types of foods or obesity do not. “We really put the data through a wringer in order to test it out,” Basu said.

…

“As far as I know, this is the first paper that has had data on the relationship of sugar consumption to diabetes,” said Marion Nestle, PhD, a professor of nutrition, food studies and public health at New York University who was not involved in the study. “This has been a source of controversy forever. It’s been very, very difficult to separate sugar from the calories it provides. This work is carefully done, it’s interesting and it deserves attention.”

Previously: Nature/nurture study of type 2 diabetes risk unearths carrots as potential risk reducers and Fighting a fatalistic attitude toward diabetes
Photo by La Piazza Pizzeria

Surgeons practice drilling burr holes during Stanford course

Sherry Wren, MD, a general surgeon at Stanford, has volunteered multiple times for humanitarian missions in Africa with Doctors Without Borders. There, she has treated patients for everything from head traumas to difficult births to gunshot wounds; in the process, she has learned to use hand drills for brain surgery and papaya paste as a salve for severe burns, as well as how to serve as her own anesthesiologist while operating on a patient.

This month, Wren taught a continuing medical education course at Stanford to pass along the skills she learned from these first-hand experience to other surgeons and physicians interested in volunteering for similar medical missions. She recruited experts in neurosurgery, ob/gyn, and other fields to help teach the course, and she drew a large and appreciative crowd of students.

In today’s issue of Inside Stanford Medicine, I describe the course (which she calls a “labor of love”), Wren’s “MacGyver-like skills,” and her ability to “make do” with whichever supplies are available:

Developing countries may not have well-stocked supply closets; there may be no blood bank nearby; anesthesia may be limited; sonograms may be nonexistent.

“We wanted to make physicians understand that it’s all about somehow ‘making it work,’ Wren said. ‘You survive on your wits, making do with what’s on hand.”

…

The course itself was something of a lesson in MacGyver-like inventiveness. Students used pigs’ feet to practice ligament repair. Breech births were simulated from sleeping bags. An orthopaedic company donated thousands of dollars worth of fake bones; hand drills ordered online were used for bone-drilling practice.

Previously: What I did this summer: Stanford medical student works to improve pediatric surgical care in Tanzania
Photo by Sherry Wren

IUDs, despite being safe, effective and relatively inexpensive, aren’t widely embraced by women in the developing world. There are likely several reasons why, including, as Stanford’s Paul Blumenthal, MD, tells me, “myths and rumors about the IUD, uncertainty or inadequate information about where a woman could get one, and an inadequate number of providers trained and ready to provide a quality service.”

Many women face challenges in obtaining other forms of birth control, as well, and a group of researchers recently launched a two-year initiative to increase women’s contraceptive options and improve reproductive health in 13 developing countries.

[Our] experience with promoting a contraceptive previously believed to be unsuitable… should encourage both public and private providers

I describe the effort, which was led by the nonprofit Population Services International, in a press release:

The initiative focused on both creating demand and improving service delivery. A group of community “mobilizers” conducted outreach in many of the countries, going door to door or gathering in group settings to educate women on family planning options and linking them with local providers. Media activities, including radio and TV spots, printed educational materials and billboards, were also done in many areas to address misconceptions about reversible contraceptives and to educate women on the potential benefits of using them.

Project leaders also improved access by training local clinic staff on counseling, complication management, side effects, removals and referrals, and by offering IUD insertion at a variety of clinics throughout each of the countries. Outreach clinic event days were held in six countries, during which IUD insertions were offered to local women over a one- to three-day period.

Between January 2009 and December 2010, 575,601 women across the 13 countries were provided with IUDs. The typical woman who received an IUD was in her 20s, married, had at least one living child and was primary-school educated. Twenty-four percent of women who received an IUD said they previously had been using no modern birth control method.

Blumenthal, who worked with PSI on the project and is lead author of a study appearing in Contraception, told me that a “success at this scale has not been previously reported.” And the researchers, who are continuing their project and expanding to other countries, wrote in the paper that their “experience with promoting a contraceptive previously believed to be unsuitable for these contexts should encourage both public and private providers.”

Previously: Using family planning counseling to reduce number of HIV-positive children in Africa, Access to contraceptives best way to cut maternal and newborn deaths in developing world, advocates argue and Africa and the pill