Rural Health

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

Statistics often don’t tell the whole story. In the case of the Rosebud Indian Reservation in South Dakota, where I traveled last month to write an article for today’s issue of Inside Stanford Medicine, statistics tell a horrifying story. The average life expectancy among the 9,000 residents of the Lakota Sioux tribe is 47 years for the average male, compared to 77 years nationwide. That’s one year younger than Haiti’s 48. Unemployment rates range from 65-80 percent; diabetes, alcoholism and suicide are at epidemic levels.

A group of Stanford students traveled there to spend the week building homes for Habitat for Humanity, volunteering in the Indian Health Service hospital on the reservation, and meeting community leaders in one of the poorest places in the nation. My story describes their experiences:

Each morning, students sat in on the hospital meetings, hearing firsthand the daily struggles of the staff. They heard about the pregnant patient with diabetes who lost her baby the night before, her wails echoing down the hospital halls; they heard about yet another suicide victim, a 25-year-old man who hanged himself two days before. They listened to the staff triaging what levels of care they could afford to provide.

But my article doesn’t nearly tell the whole story. It doesn’t describe the close-knit community on a reservation that has survived a tragic history, the sense of pride and determination among those struggling against the hopelessness that has taken so many young peoples’ lives. One of those Native Americans, Rebecca Foster, PhD, a psychologist at the Rosebud Indian Health Service Hospital, told me about her determination to get an education so that she could return to the reservation to give back. She and her husband are parents to 14 children, seven of them with special needs whom the couple adopted from relatives on the reservation. She talked to me in her office while holding her newborn grandson:

What I tell the young people here is, there is a difference between having to stay here because you are trapped. And choosing to be here because you have something to give. One is a prison, the other is a home… I see a lot of kids who are depressed, who talk about suicide, but they are still resilient. They still have a desire to have a good life, to be happy, to accomplish things. You can never destroy that. There are still a lot of wonderful things on the reservation.

I hope to tell more of these stories in the fall edition of Stanford Medicine magazine.

Previously: Getting back to the basics: A student’s experience working with the Indian Health Service, Lessons from a reservation: Clinic provides insight on women’s health issues, Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a reservation: Visit to emergency department shows patient care challenges
Photo by Layton Lamsam

I spent my spring break on the Rosebud Reservation, in South Dakota, as part of a joint Stanford undergraduate and medical school class studying health disparities in a rural, reservation setting. For two days, I shadowed doctors and other health-care professionals at the local hospital, which is run by the Indian Health Service (IHS).

I myself am an enrolled Osage from the Osage reservation in Oklahoma. I’m a pre-medical student, and one of the reasons I want to go into medicine is to improve health in Indian Country. I knew the patient’s side of the IHS already, but I wanted to get a perspective from the provider’s side, which made this trip a no-brainer.

Healthcare at the hospital is free – paid for through the U.S. Federal Government’s discretionary budget – because of a long history of treaties in which Indian tribes exchanged land with the United States in return for food, education, and health care.

Being familiar with Stanford Hospital, I was amazed by the breadth of responsibility that IHS doctors had. The family physician I shadowed ran an outpatient clinic, managed the medical ward (which it seemed she took calls for almost every night), served as first assistant in some surgeries, and was about to also take shifts in the emergency room.

I wondered about the wisdom of this until the doctor reminded me that she was trained for everything she did. The legal pressure in mainstream America conditioned me into a mindset of medical specialization, but on a rural reservation there are no specialists. And, it soon dawned on me that my doctor’s wide scope of practice developed out of necessity. Poor equipment, an overload of seriously ill patients, and a lack of access to higher-level care demanded that the already short-staffed IHS doctors go above and beyond what is normally required.

When I asked the nurses how often they had to ‘MacGyver’ equipment, the answer was not just “sometimes” or “often” – ad hoc solutions were a way of life.

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Past studies suggest that exercise can boost immunity and decrease risk of illness. But it may also strengthen the potency of the influenza vaccine, according to a new research.

As the New York Times reports, Iowa State University researchers conducted two experiments to determine if hitting the gym after getting a flu shot would prove beneficial.

In the first study, healthy individuals were given a flu shot and then assigned to either go for a 90-minute moderately paced jog, ride a bike for 15 or rest quietly for 90 minutes. A month later, researchers measured participants’ influenza antibodies. Gretchen Reynold writes:

Those volunteers who had exercised after being inoculated, it turned out, exhibited “nearly double the antibody response” of the sedentary group, said Marian Kohut, a professor of kinesiology at Iowa State who oversaw the study, which is being prepared for publication. They also had higher blood levels of certain immune system cells that help the body fight off infection.

To test how much exercise really is required, Dr. Kohut and Justus Hallam, a graduate student in her lab, subsequently repeated the study with lab mice. Some of the mice exercised for 90 minutes on a running wheel, while others ran for either half as much time (45 minutes) or twice as much (3 hours) after receiving a flu shot.

Four weeks later, those animals that, like the students, had exercised moderately for 90 minutes displayed the most robust antibody response. The animals that had run for three hours had fewer antibodies; presumably, exercising for too long can dampen the immune response. Interestingly, those that had run for 45 minutes also had a less robust response. “The 90-minute time point appears to be optimal,” Dr. Kohut says.

Although more research is needed to understand how working out after receiving a flu shot may increase your resistance to the flu, researchers say the effects could be attributed to exercise increasing blood circulation and pumping the vaccine away from the injection site to other areas of the body. Another explanation could be that physical activity invigorates the body’s overall immune system, which may increase the vaccine’s effects.

Previously: Can exercise and meditation prevent cold and flu? and CDC report shows exercise becoming a popular prescription among doctors
Photo by Mr. T in DC

Earlier this year, first-year medical student Bonnie Chien and classmates visited the Rosebud reservation in South Dakota as part of their Rural and American Indian Health Disparities class. In a series of posts on Scope, she chronicled her trip and how a lack of funding and resources forced physicians to take on numerous roles and do a little bit of everything from performing circumcisions to treating rheumatoid arthritis.

So I was interested to read an Atlantic post today about Avera Health Network, a long-distance critical-care center where doctors use two-way video conferencing to provide much needed support to rural hospitals in South Dakota, North Dakota, Minnesota, Iowa, Wyoming and Nebraska.

Averna Health Network’s four main services — eConsult, eICU Care, eEmergency, and ePharm — are designed to provide some relief for the 10 percent of physicians in the U.S. who currently serve 25 percent of the nation’s population residing in rural areas. As writer Lindsay Abrams explains, the nonprofit allows local emergency medicine physicians to immediately connect with specialists who can consult in treating patients as well as help in monitoring them:

When the call comes in the middle of the night, with the push of a button — mounted right on the ER’s wall — the nurses on-duty are able to connect with ER doctors in Sioux Falls, who have been waiting, in their patient-less hospital, for their call.

…

Of course, physical hands are needed to carry out virtual orders, and real doctors and nurses are always on hand to provide that. But even IRL (in real life), crisis situations require someone at the head of the room, keeping tabs on everyone and calling the shots. In emergency situations, where every second counts, the long-distance physician is able to be in the room an average of 14 minutes sooner than the local doctor.

The doctors back at the hub spend their time monitoring ICU patients — they have virtual access to 60 percent of the beds in South Dakota. Pharmacists are on-hand to review prescriptions, make sure doctors aren’t missing any allergies or medical history, and keep them abreast of the newest recommendations and standards of care.

Previously: How a Stanford dermatologist is using telemedicine to reach underserved populations in California, Phoning in your specialized medical tests and Can telemedicine work for dermatology patients?
Photo by U.S. Department of Agriculture

Last night I went to an inspirational talk by Melinda Gates, chair of the largest philanthropic organization in the world, where she discussed innovative approaches to reducing infant mortality in the developing world.

To the crowd of mostly Stanford engineering students, Gate’s message was somewhat surprising. She said that sometimes the most effective solutions to global health problems are low tech and the hard part is figuring out how to spread these life-saving ideas in a culturally appropriate way.

She shared a story about a typical birthing procedure in northern India to illustrate her point. In remote villages there, newborns are placed on the bare ground for extended periods of time while a birth attendant tends to the mother’s well-being. After the mother’s condition is stable, the attendant scrubs the birthing debris off the newborn with a gritty, sandy paste from a nearby river and then rubs mustard oil over the baby’s skin for protection. While most people well versed in germ theory would blanch at this scenario, it is a generations-old tradition in this region that is hard to change.

Gates and her global health partners discovered that by convincing the power brokers in this culture — the mother-in-laws — to make four simple changes in their birthing procedures, they could reduce newborn deaths by half. The list:

1. Immediately place a newborn on the mother’s chest and wrap both mother and child in a sari, a protocol often referred to as “kangaroo care.” This protective pouch keeps a newborn warm and stimulates the mother’s breast milk production.
2. Clean the infant with a more sanitary solution.
3. Rehydrate the newborn with breast milk rather than river water.
4. Use sunflower oil on the infant’s skin rather than the more astringent mustard oil, which can often cause allergic reactions.

To spread the word on the success of this checklist, the foundation is leveraging the most efficient social network available in this region — the women who talk while cooking, washing and tending their children.

In addition to reducing infant mortality, Gates has also launched a campaign to expand access to contraception. She discussed the initiative and why family planning looms so large in both her heart and her mind in the latest issue of Stanford Medicine.

Previously: Simple program shown to reduce infant mortality in African country and Simple program shown to reduce infant mortality in African country
Photo by DFID - UK Department for International Development

An article (subscription required) in the latest issue of Nature provides an in-depth look at the prevalence of unregulated health markets in developing countries. Problems within these health markets include unqualified practitioners, inappropriate diagnoses and counterfeit medicines. A graph shows that high percentages of health providers in Asia and Africa - 87 percent in Bangladesh, for example - are poorly trained.

Authors David Peters, MD, DrPH, with the John Hopkins Center for Public Health, and Gerald Bloom, MDCM, with the University of Sussex, write:

The rapid expansion of health markets in Asia and Africa has made medicines, information and primary-care services available in all but the most remote areas. But it also creates problems with drug safety and effectiveness, equity of treatment and the cost of care. Poorly trained practitioners often prescribe unnecessary pills or injections, with patients bearing the expense and the costs to their health. Counterfeit drugs are rife and drug resistance is growing.

Bringing order to unruly health markets is a major challenge. Yet the problem is largely ignored by governments and international agencies. The World Health Organization (WHO) continues to highlight a shortage of primary health workers as the main barrier to accessing health care in low- and middle-income countries. It neglects the growing presence of drug sellers, rural medical practitioners and other informally trained health-care providers.

Peters and Bloom go on to outline how government, firms, and citizens can become more involved in working to solve these problems.

In much of the developing world, health hazards involving food extend beyond the edible substances being consumed. Makeshift stoves fueled by crop scraps and animal dung emit plumes of black smoke that fill homes and can cause pneumonia and other acute respiratory infections. Such cooking methods are used by nearly three billion people and contribute to an estimated two million death a year, according to data from the World Health Organization.

In a paper published today in the Proceedings of the National Academy of Sciences, Grant Miller, PhD, associate professor of medicine at Stanford’s Center for Primary Care and Outcomes Research, and colleagues explore why people are reluctant to switch to safer cookstoves, many of which have chimneys that funnel smoke out of a home. A Stanford Report article describes the work:

In the first of two studies, Miller - joined by Yale researchers and Lynn Hildemann, a Stanford engineering professor affiliated with the university’s Woods Institute for the Environment - surveyed about 2,500 women who cook for their families in rural Bangladesh.

Nearly all of the women use traditional stoves, and 94 percent of them said they know the smoke from their stoves can make them sick. But 76 percent said the smoke is less harmful than polluted water, and 66 percent said it wasn’t as dangerous as rotten food.

“People know their cookstoves are bad, but they don’t think cookstoves are the most important problem they face,” Miller said. “They’d rather spend their money fixing those things and getting their kids into a good school than buying a new cookstove.”

Investigators found among the Bangladeshi women they surveyed that concerns such as fuel costs and cooking time held more importance than reducing pollution when considering a stove. Miller, senior author of the study, commented on the findings, saying:

A big implication is that the health education and social marketing approaches aren’t going to work… You need to get inside the heads of the users and figure out what they really want and value - even if unrelated to smoke and health - and then give it to them.

Previously: New insight into asthma-air pollution link

Physicians in rural areas in California are in short supply, and some fear the scarcity could grow more severe. But telemedicine might prove beneficial in these parts: Research has shown increased use could help reduce health disparities between rural and non-rural areas.

David J. Wong, MD, PhD, a Stanford dermatologist and cofounder and CEO of Direct Dermatology, stands among health-care providers working to increase the reach of telemedicine. His company brings medical dermatology expertise to poor and underserved populations in California to treat serious and even life-threatening conditions including melanoma, psoriasis and problems of the skin, hair, and nails.

A panelist at last week’s Healthcare Innovation Summit at Stanford, Wong believes a social mission driving a for-profit company can deliver healthy results. He discusses his company’s work and how it fits into broader efforts to improve rural medicine in a Stanford Graduate School of Business Q&A.

On explaining how Direct Dermatology visits work, he says:

The interaction is asynchronous. It’s not a live interactive visit over Web cams. A patient takes a picture of their skin problem, then sends in that picture along with their medical history. And then a dermatologist will review it, and send back a report and any prescriptions that are needed. We have a two-day turnaround. Dermatology is such a visually based specialty that dermatology consultation works well through images.

Later in the interview, he talks about how his work is relevant to other medical specialties:

While some specialties will always require some live interaction, nearly every specialty can provide better access, higher quality care and lower cost by integrating telemedicine in some fashion. Dermatology is a great one to start with as a proof of concept, because it is so visually based. But we believe similar concepts can be spread to other specialties.

In ophthalmology, for example, much of the exam is based on images of the retina. Cardiologists are looking at EKGs and echocardiograms. A lot of those types of images you’d have to first acquire at a lab or clinic, and then send them in. That being said, there is a growing number of home consumer appliances that will take your EKG, for example. And consumers will be soon able to send those in directly to their physicians.

A 2010 study showed that online dermatology visits, similar to those described by Wong, can be as effective as office visits and can save patients time.

Previously: Ask Stanford Med: Stefanos Zenios taking questions on health-care innovation and entrepreneurship, Phoning in your specialized medical tests and Can telemedicine work for dermatology patients?
Photo by mysiana

During the last day of our trip to South Dakota’s Rosebud Reservation, I had the opportunity to observe and learn from a physician working in the women’s health clinic. The clinic provides a wide range of services to women throughout the area, including perinatal and family planning resources.

The main office of the clinic is covered with posters, brochures, and photographs to provide women with information about reproductive health. Although many of the materials were not culturally specific, several materials included graphics that were. For example, the hospital is becoming more nursing-friendly in accordance with Michelle Obama’s 2011 initiatives to promote breastfeeding. Several of the materials included Native American women breastfeeding their infants as well as information about the benefits of breastfeeding. Rosebud Indian Health Service is also instituting a nursing center at the hospital.

The front desk offers male condoms and female condoms available at no cost to patients. Despite these resources, we were told that sex education and safe sex are not widely practiced on the reservation. We also learned from him that sexually transmitted diseases are common among patients there.

During several patient visits, the doctor explained the birth delivery process to women who had a clear lack of knowledge. As I learned throughout the health-disparities course and during my observations at the emergency medicine department, alcoholism is a major problem on the reservation - even among pregnant women. Later in the day, I met several young people who were born with fetal alcohol syndrome and grew up on the reservation.

Amaya Cotton-Caballero is a senior at Stanford majoring in human biology. She recently visited the Rosebud Reservation in South Dakota as part of her Rural and American Indian Health Disparities class. The goal there was to learn about socioeconomic determinants of health through visits with various Indian Health Centers, community members, and tribal educational institutions. Cotto-Caballero is interested in public health and medicine.

Previously: Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a reservation: Visit to emergency department shows patient care challenges