Researchers here warned today that one of the most widely trusted sources of data on global health could be mistaken, leaving countries ill-prepared to deal with the economic and health-care burdens of aging populations.

“We could be getting something really wrong on chronic diseases for older people,” said Benjamin Seligman, a student Stanford’s medical school and lead author of the study appearing today in PLoS One.

Since 1996, the World Health Organization has organized global health statistics in a publication called the Global Burden of Disease. More than 90 countries lack reliable data on births and deaths, forcing the WHO to calculate estimates for these basic health statistics, which appear in the book. Many health agencies in poorly resourced countries rely upon these estimates to plan for the future health-care needs of their citizens.

“These estimates are created based on data from rich countries,” Seligman told me. “It’s an open question whether they really represent what’s going on in modern developing countries.”

Seligman, along with co-authors Mark Cullen, MD, a Stanford professor of medicine, and Ralph Horwitz, MD, former chair of the Department of Medicine and now with GlaxoSmithKline, turned to the Human Mortality Database, a collection of international population records known to be reliable, to check whether the WHO formulas applied to these data would produce numbers that matched the observed historical patterns of births and deaths.

The team assembled data from 37 countries, generally those with the highest level of development today, focusing on the period between 1900 and 2000. The researchers reasoned that that the rapid changes sweeping developing countries today – such as people moving to cities and changing lifestyles – resemble the forces that swept through the countries in their data set during the 20th century. This would provide a good test for how well the WHO methods work during times of rapid social change.

“If the model can capture that kind of change in rich countries, then we would feel better about how it works in modern developing countries,” said Seligman. “But the model didn’t accurately estimate survival at older ages. After 1970, the formulas substantially overestimated the number of deaths among those 60 to 80 years old. Survival actually got better.”

This means relying upon the Global Burden of Disease statistics may saddle already poor countries with an unexpectedly large population of elders, many requiring expensive health-care for chronic diseases that strike late in life. Seligman hopes a correction to the WHO estimates now will prevent these developing countries from being caught flat-footed in the future. He also hopes it will spur these countries to collect complete records of births and death, to better divine the health-care challenges to come.

“If we had better vital statistics – even just the age of death – those countries would have a much clearer picture of how to prepare their health-care systems,” he said.

Many of the more than 2.2 million men struck with prostate cancer in the U.S. may perk up – and get up to move around – when they hear the results of a study published today in the journal Cancer Research.

The researchers, led by UC-San Francisco’s Erin Richman, Sc.D., followed men for at least 15 months after a prostate cancer diagnosis, tracking each man’s exercise habits and monitoring whether their cancer worsened. The men who engaged in at least 3 hours of vigorous physical activity per week had a 57 percent slower rate of cancer progression to more worrying states than those who exercised less.

Urologist and prostate cancer researcher Joseph Presti, Jr., MD, said he was excited to see that the study had revealed an association between physical activity and better clinical outcomes. He said the findings seemed sound and should inspire further research on the benefits of exercise for men with prostate cancer. But Presti warned that until until such additional studies confirm the current findings, he will be left with some lingering questions about whether exercise is the best explanation of the lower levels of cancer progression.

Presti already urges his Stanford Cancer Center patients to exercise, but primarily to improve their cardiovascular health, a fairly common additional threat to their well-being.

“If the exercise happens to improve their cancer outcomes as well, even better,” he said.

Photo by Dominic Alves

A very lucky stroke survivor tells his story in this month’s Stanford Health Notes and in the video above.

Minutes after slumping over, paralyzed in mid-conversation, Chris McLachlin was taken to the hospital and given life-saving blood clot-busting medicine. A fellow stroke survivor in the room had recognized the signs and called 911.

Strokes, which are the number one cause of adult disability, starve parts of the brain of blood and oxygen. The quicker blood flow can be restored, the less permanent damage occurs. “Time is brain,” according to physicians who treat strokes.

McLachlin’s speedy treatment made all the difference for him. He’s now back working as an assistant coach for Stanford University’s men’s volleyball team. His youngest son, Spencer McLachlin, captains the team.

A study of human vision published today shows that our perception of the world around us may rest on what amounts to a sketch.

The scientists took images of real life scenes and boiled them down to only the barest of outlines; participants viewed the images while they were being monitored by a brain scanner. The minimal sketches triggered the same patterns of brain activity as the original full-color photos – enough for the scientists to detect what sort of scene was being displayed from the brain image alone. Stanford Report’s Dan Stober writes that the scientists sometimes refer to this as “mind reading:”

The subject looks at the photos, but says nothing. The researchers, however, can usually tell which photo the volunteer is watching at any given moment, aided by sophisticated software that interprets the signals coming from the scan. They glean clues not only by noting what part of the brain is especially active, but also by analyzing the patterns created by the firing neurons.

Fei-Fei Li, PhD, a computer scientist at the Stanford Vision Lab and senior author of the study, spoke to me about what the study might mean for medicine and the design of computer-assisted vision devices for the blind. “To help the visually impaired, we need to understand how vision is processed by the brain,” she said. “This study takes us a step closer to understanding the neural mechanisms we’d need to simulate in a device that would fill in for part of the vision pathway.”

The researchers also reflected in their paper (subscription required) on what the work says about minimalist art throughout human history, from cave paintings to Zen-inspired art – even children’s drawings:

Although line drawings lack many of the defining characteristics seen in the real world (color, most texture, most shading, etc.), they nevertheless appear to capture some essential structure that makes them useful as a way to depict the world for artistic expression or as a visual record. In fact, children use “boundary lines” or “embracing lines” to define the shapes of objects and object parts in their first attempts to depict the world around them.

Photo by nitrohepcat

Many medical schools now offer classes and programs with overseas field experiences or international internships – and demand for global health education appears to be rising (.pdf). But sometimes students find themselves in questionable situations when they work in other countries.

Michele Barry, MD, Stanford’s director of global health initiatives in the School of Medicine, wants to fully prepare educators, students, physicians, and researchers for the thorny questions that can arise when they head overseas. Last Friday, at the long-running Stanford Ethics at Noon public seminar, Barry introduced several real-life conflicts faced by global health students and researchers for discussion and debate. She’ll use the dialogue to shape an online training module for soon-to-depart students around the globe.

Barry said some poorly resourced sites have pushed students into providing health-care services far beyond their training. Adding to the complexity of the issues, hosts sometimes expend a lot of precious money and effort to bring students, interns, or medical residents from overseas.

Global health research can land scientists and physicians in hot water as well, especially when the topic concerns behaviors or diseases that carry a lot of stigma. Problems can also arise if the foreign hosts have a more casual approach or an incomplete understanding of the research ethics that govern the research.

For more information about the talk, and to read the student-written responses to the issues Barry raised, head over to the Ethics at Noon website.

Photo by Keith Rozendal

Imagine a time when you teleconference with doctors, fill prescriptions at pharmaceutical kiosks, swallow pills embedded with computer chips that transmit health metrics to your mobile phone and play social games based on the data to help you meet health goals. Surprisingly, such a digital model of health-care delivery is closer than you think.

Low-cost pharmaceutical kiosks resembling ATMs are already up and running in parts of the United Kingdom and Canada. In California, teleconferencing kiosks connect patients of select health-care providers with a pool of general practitioners and specialists who can diagnose them and deliver prescriptions to their phone. Andy Thompson, co-founder and CEO of Proteus Biomedical, is working on the digital drug piece of the puzzle.

A presenter at the Healthcare Innovation Summit at the Stanford Graduate School of Business, Thompson opened his speech with a scolding tone. “The business of modern medicine excludes 85 percent of the world’s people.” He went on to explain how his company aims to flip the current health-care business model on its head to “provide health care for everyone, everywhere.”

Last year, the number of mobile phone connections surpassed 5 billion. Thompson says this means the best way to offer health care to those that lack it will be to provide therapeutic tools alongside mobile communication and entertainment apps people already carry in the pockets.

Proteus has developed computer chips made from food-grade materials to be embedded in pills of proven medicines. The chip pulls double duty, guarding against counterfeit drugs-a serious global issue-and transmitting vital statistics to patients’ mobile phone. Together with mobile apps, the digital drug reports whether it’s taken according to instructions and monitors the patient’s heart rate and body position. The patient receives summaries of the data that can be customized for health goals such as weight loss or managing chronic conditions like diabetes. Games and social apps based on this information can provide fun and motivating ways to achieve goals and pursue other healthy habits.

“Your body is the ultimate game controller,” Thompson said. “The game provides the tools, recognition, rewards and incentives for people to manage their own healthcare.”

Previously: Medicine is about to be “Schumpetered” – and go through its biggest shake-up in history
Photo by Keith Rozendal

For those unable to attend the FutureMed program this week at Singularity University, you can catch daily recaps and in-depth pieces about key medical tech unveiled at the event on Medgadget. Here’s a taste of day one:

We heard from Health IT [Information Technology] guru Christopher Longhurst, who rolled out the EMR [Electronic Medical Records] at the Lucile Packard Children’s Hospital, and Daniel Riskin from Vanguard Medical Technologies….

Two pieces of information stood out most from Christopher’s talk. One was that Lucile Packard Children’s Hospital was one of the first to publish direct evidence of the reduction of all-hospital mortality after implementation of an EMR. The other was how insanely expensive it is to implement EMRs in an in-patient setting, and how he hopes and believes that these systems will become less expensive and more like commodities in the near future.

Daniel described how the most powerful analytics in health care will come from fully structuring a patient’s record. To this aim he spoke about and demonstrated an application called DocTalk that uses speech recognition to automatically translate a doctor’s dictation into structured clinical data. This allows physicians to avoid the painful process of categorizing and organizing every piece of information on patients by him- or herself.

Also presenting on the first day of the program were Wired executive editor Thomas Goetz, MPH, and Lawrence Sherman, MD. Goetz and Sherman are both scheduled to speak at the Medicine 2.0 Conference at Stanford on Sept. 16.

Up-to-the-minute updates on FutureMed can be found under the Twitter hashtag #FutureMed.

Why is the military technology company Lockheed Martin presenting at a health-care conference? To answer that perplexing question, I dropped in on the Healthcare Innovation Summit at the Stanford Graduate School of Business. This annual event brings together a high-power group to talk about the latest ideas set to transform the business and practice of medicine.

John Evans, PhD, MBA, a Lockheed Martin vice president, focuses on creating new business for the massive corporation. The company is “fundamentally a government partner,” according to Evans, explaining that it provides products and services to help the government achieve its goals for the country.

Some national goals could be threatened by ballooning health-care costs, though: Health care costs in the U.S. have doubled three times since 1980, rising from $253 billion to $2.3 trillion in 2008, and the government is struggling to keep up. So Lockheed Martin turned its attention to the problem for the same reason it builds fighter jets and naval combat ships.

“It’s a national security threat,” said Evans. “It crowds out expenditures for other national priorities.”

The same principles used to design complex weapons can be applied to reinventing the intensive care unit, argued Evans. When Lockheed Martin designs a warship or a spacecraft, the mission or purpose of the new technology comes first. Every element contained in the complicated collection of technology gets created fresh, so that the whole system works together to meet that mission.

“No one has ever really designed the ICU from scratch, from a clean sheet of paper,” said Evans.

As a result, the current state-of-the art ICU is merely a collection of devices – all designed separately and not intended to work together. This can lead to mistakes, Evans said. For instance, merely raising or lowering the patient’s bed can prevent monitors from detecting life threatening changes in blood pressure. Patients have died because the bed, pumps that deliver medicine, and patient monitors don’t talk to one another.

Evans presented a video game-like simulation where the new integrated ICU the company is designing can be tested. It’s a safe proving ground where physicians and hospital staff can put the new technology through its paces, without having a patient’s life hang in the balance. Think of it as war games for emergency medicine.

Photo by Keith Rozendal

When a cancerous tumor takes hold in a patient, the cure can seem worse than the disease. Patients suffer nausea, hair loss and suppressed immunity following radiation or chemotherapy because a naturally occurring protein called p53 has been activated in response to the DNA damage caused by the treatments. If p53 detects DNA damage or tumor growth and tries to shut down the runaway growth, it can trigger the deaths of many noncancerous cells.

A new discovery by researchers here suggests a way to help the tumor-suppressing protein distinguish between healthy cells and cancerous cells.

It seems that p53 leaps into aggressive action in any cell with DNA damage, regardless of whether or not the cell has started runaway growth. By disabling one part of the p53 protein called TAD1, the team created a version of p53 with a more nuanced reaction. It tolerates cells that have DNA damage but haven’t begun to grow into a tumor.

Laura Attardi, PhD, senior author of the study, explained in a press release why this could help reduce the side effects of radiation and chemotherapy:

“Separating these responses may allow the identification of ways to inhibit the detrimental effects of radiotherapy and chemotherapy – both of which damage DNA -without putting a patient at risk for developing new tumors.”

The release provides more details that helped me understand why the discovery could lead to more tolerable tumor-shrinking treatments:

If the two distinct activities of p53 in healthy cells can be decoupled – say, by a drug impairing TAD1′s function but sparing TAD2′s – it might be possible to avoid the massive healthy-cell die-off responsible for nausea, hair loss, immune deficiency and nerve damage that usually occur during radiotherapy or chemotherapy, without promoting new tumor development. Disabling p53′s TAD1 region would allow cells that have sustained DNA damage in the course of these therapies to live to another day, but TAD2′s still-intact tumor-suppressor function in those otherwise normal cells would guard against those cells becoming cancer cells.

Previously: Facing the hard reality of cancer treatment

Despite the powers of the immune system to fight disease, there’s no better defense than not getting sick in the first place, right? Washing our hands after contact with someone who has germs is a behavior most of us know can prevent infection. But shunning somebody with a sniffle altogether can also head off a nasty illness.

Scientists have begun to define some of such disease-wary actions – and the emotions and thinking behind them – as examples of what could be called a psychological immune system. A recent Current Directions in Psychological Science paper (.pdf) by psychologist Mark Schaller, PhD, of the University of British Columbia, provides a brief introduction to the fairly new concept, which he prefers to call the behavioral immune system:

The behavioral immune system consists of a suite of psychological mechanisms that (a) detect cues connoting the presence of infectious pathogens in the immediate environment, (b) trigger disease-relevant emotional and cognitive responses, and thus (c) facilitate behavioral avoidance of pathogen infection.

In other words, we’re constantly on the lookout for the signs of infection in the world (such as blood, greenish or yellowish oozes, and foul smells) and also signs of sickness in the people around us (such as skin blemishes, coughs, and sneezes). Seeing these signs triggers negative emotions like disgust or anxiety, which make us more alert to the danger of infection. In turn, we seek to avoid the disgusting or anxiety-causing infection-risk by any means possible.

Schaller says that evolution probably set our behavioral immune system to be triggered according to the “smoke detector principle,” which means it tends to produce many false alarms because the cost of missing something that might make us sick is so high compared to the cost of avoiding a potential threat:

The system responds to an overly general set of superficial cues, which can result in aversive responses to things (including people) that pose no actual threat of pathogen infection.

Social and evolutionary psychologists like Schaller have been conducting odd experiments detailing how easily this set of disease avoidance mechanisms can be triggered. Did you know that a bad odor makes people more likely to practice safe sex? Or that exaggerated media coverage of disease outbreaks seems to make people less outgoing (.pdf) and perhaps more prejudiced (.pdf)? Schaller’s research has shown that simply looking at disease-y photos immediately kicks the immune system into a higher gear (pdf).

Photo by Oscar Gustave Rejlander from Charles Darwin’s The Expression of the Emotions in Man and Animals

When it comes to global public health, there’s plenty of news supporting optimists and pessimists alike. But the balance tips towards hope, said Donald Shriber, JD, MPH, who – as mentioned below – gave a talk yesterday at the Stanford Graduate School of Business.

In 2011, millions of people will die needlessly from preventable diseases, but the global public health community has plenty of simple and cheap interventions that could save most of them, Shriber, who works in the Centers of Disease Control‘s Center for Global Health, argued. In the subtitle to his presentation, which was part of the business school’s Global Health Series, he concluded that “the glass is half full.”

Shriber said the biggest long-term gains in global health will come from the efforts – of the CDC and other international agencies – to help build up public health agencies in foreign countries. Such initiatives include training epidemiologists and “disease detectives” overseas. But some simple and powerful reforms like recording births and deaths in official records can also be helpful in understanding and tracking the success of public health efforts.

Shriber also provided an eye-opening list of key low-cost, high-impact efforts that could together eliminate the majority of preventable deaths worldwide:

• When a country passes laws to guarantee clean air and water, control toxic substances, and provide for food and drug safety, massive gains in public health follow. Providing clean water and sanitation to the more than 2.5 billion people who lack it could prevent two million deaths from diarrheal diseases every year and cut cholera deaths more than 30 percent.
• Male circumcision is “as close as we’ve come to a vaccine for HIV,” said Shriber. There’s conclusive evidence that circumcision can cut HIV infection rates by 60 percent in countries where it isn’t already the norm; one HIV infection is avoided for every four circumcisions performed, according to this data.
• Pneumonia rates could be cut by as much as 67 percent with a combination of simple efforts, such as encouraging exclusive breastfeeding for the first six months of life, which reduces pneumonia infections by 15 to 23 percent.
• “Tobacco is the agent of death that exceeds all others,” said Shriber. Tobacco kills more people than HIV, tuberculosis, and malaria combined. Shriber argued that we know what to do about tobacco, but it takes simple policy interventions that may prove politically difficult: pushing through laws that protect people from the tobacco smoke of others, providing programs to help tobacco users quit, warning about tobacco’s dangers, and enforcing bans on tobacco ads and sponsorship.
• Ninety percent of all deaths on the roads occur in low-income countries, and these accidents are the leading cause of death of Americans living and working abroad. Again, proven prevention efforts are well known: limits on drunken driving and laws mandating seat belts, helmets, and speed limits.
• Nearly half of all cancers are preventable, with the use of vaccines for hepatitis and HPV, for instance. But simply working to increase fruit and vegetable consumption would also significantly reduce cancer numbers, according to Shriber.

Previously: A packed Stanford agenda on global health issues
Photo from the Stanford Graduate School of Business

This week brings to Stanford a packed slate of events that focus on the changes sweeping medicine and healthcare across the globe. Last night Donald Shiber, JD, MPH, who works for the Centers for Disease Control, gave a talk on government engagement in global health as part of the Stanford Graduate School of Business’ Global Health Series. And local readers might be interested in putting a few other events on their calendar:

• Later today, Stanford Biodesign presents a conversation with Ezekiel Emanuel, MD, PhD, a widely published and lauded bioethicist at the National Institutes of Health. This is the second From the Innovator’s Workbench event of the year, which features biomedical technology leaders in conversation with journalist David Cassack. It’s free for current Stanford faculty, staff and students who register for the event; Stanford alumni get a discount.
• Wednesday brings an all-day conference on healthcare innovation, sponsored by the Graduate School of Business. Scholars, physicians, and business leadership from a wide range of healthcare enterprises will explore new technologies and business innovations set to change global healthcare delivery.
• Finally, Friday brings Michele Barry, MD, FACP, to the Stanford Ethics at Noon speaker series. Barry is director of Global Health Programs at the School of Medicine, and she’ll discuss the ethical issues faced by medical researchers and students who work overseas in poorer countries.

Photo by Jim Ceballos

The good news: Childhood lead poisoning cases have been cut enormously. The bad news: Preventable lead poisoning robs America of $50.9 billion in lost economic productivity as the pollutant destroys the intellectual potential of affected children.

That’s only one of the cost estimates coming out in a new paper by Leonardo Trasande, MD, of the Mount Sinai School of Medicine and Yinghua Liu, MD, a scientist with the National Children’s Study. Starting with the dollars that a healthy person would generate in their lifetime, the scientists calculated how downtime and early death resulting from toxic chemicals like lead and mercury in the environment costs the whole society.

The economic productivity losses that pollution causes totalled $76.6 billion at the end of the analysis, or 3.5 percent of all U.S. healthcare costs in 2008. Trasande commented in a press release that:

despite previous efforts to curb their use, toxic chemicals have a major impact on health care costs and childhood morbidity… The prevalence of chronic childhood conditions and costs associated with them may continue to rise if this issue is not addressed.”

The study updates a previous estimate based on 1997 data conducted by Philip Landrigan, MD. In a separate article in the same issue of Health Affairs, Landrigan suggests three efforts that, if pursued seriously, could greatly reduce the effects of toxic chemicals on children’s health and the associated costs to society:

• Require the examination of chemicals already on the market for potential toxicity, starting with the chemicals in widest use, using new, more efficient toxicity testing technologies.
• Check all new chemicals for toxicity before they are allowed to enter the marketplace, and maintain strictly-enforced regulation on these chemicals.
• Increase ongoing research and monitoring of children’s environmental health to better understand, and prevent, the health impact of chemicals on children.

Previously: Home can be a toxic playground for babies
Photo by HaPe_Gera

The crowd that packed the sweltering geology lecture hall last night came to hear the wisdom and word-craft of Stanford physician and bestselling writer Abraham Verghese, MD.

The conversation touched on all of Verghese’s work, including the memoirs The Tennis Partner and My Own Country, and his most recent novel, Cutting for Stone. Verghese spoke as a part of the long-running How I Write series, free public author interviews offered once a quarter and hosted by author and Stanford lecturer Hilton Obenzinger, PhD.

Some choice quotes, featured on the Stanford School of Medicine’s live Twitter feed from the event:

• “I see myself entirely as a physician. I don’t wear two hats, doctor and writer, like some people think.”
• On life in India, Ethiopia, Tennessee, and Texas: “There [are] advantages to the writer to be an exile, to feel like you don’t belong.”
• “I think an important ritual takes place when interacting with a patient – it can mark a departure, a transformation. One individual comes to another, says things they wouldn’t tell anyone, disrobes, and allows touch.”
• “It is a great privilege to witness the compressed lives of the dying. They can’t postpone the search for the meaning to life. The dying ask ‘where does meaning reside?’ Most find relationships – love of parents, children, friends – most important.”

Verghese, who will be the Stanford Summit@Medicine2.0 opening keynote speaker in Sept., leaves on a book tour tomorrow. You can download a free recording of his How I Write talk through Stanford’s iTunesU offerings in a few weeks.

Previously: Hands on: Abraham Verghese teaches bedside skills, Abraham Verghese at Work: A New York Times profile, How a battle with Napoleon helped Abraham Verghese write his novel and Physicians turn to books to better understand patients, selves

A new technology developed with the help of Stanford immunologist Garry Nolan, PhD, could help accelerate cancer and immune system research. The instrument improves upon a cornerstone method in immune research that catalogs and counts large numbers of cells according to the proteins they specialize in producing.

By swapping rare-earth metals like neodymium with the fluorescent dyes usually used, the new approach provides a big leap in the number of ways cells can be sorted the new approach provides a big leap in the number of subtypes and activation states of cells can be indentified simultaneously. The method also provides a much more detailed look at the interior of cells, providing even more ways to distinguish cell types. From our release:

In [a study appearing in Science], Nolan and his colleagues simultaneously monitored 34 different substances found inside and on the surface of different cell types produced in human bone marrow, the place where all immune and blood cells, as well as blood disorders such as leukemia, originate.

By measuring large numbers of cell features all at once with the new technology – called mass cytometry – the team could capture subtle transitions between cell states in, essentially, a high-resolution snapshot of the entire blood-forming system, he said.

…

“In essence,” said Nolan, “we are interviewing or interrogating the cells, forcing them to reveal their inner thought processes.”

Photo of the mass cytometer and Garry Nolan by Norbert von der Groeben