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Events, Global Health, Health Policy, Public Health, Stanford News

Using innovation to improve health in the developing world

Using innovation to improve health in the developing world

Ramano RaoHow can Silicon Valley-style know-how help improve health and lift up the lives of the poor in the developing world? That question was the focus of a panel discussion among four distinguished speakers last week at a Stanford conference on global development and poverty.

Panelist Ramana Rao, MD, described one technologically-based solution he helped develop with colleagues in Hyderabad, India:  a 911-type emergency care system which now serves some 750 million people across the South Asian country.

Though the system, users can call a single number – 108 – to summon an ambulance and team of skilled providers who can provide treatment en route to the nearest hospital.  The system, a public-private partnership known as GVK EMRI (Emergency Management and Research Institute), uses advanced call center technology, in which trained operators typically respond to calls within the first ring and relay them immediately to paramedics and emergency medical technicians on ambulances in the field, Rao told an audience of more than 200 people at the Stanford Graduate School of Business.

The system uses Google maps to help quickly locate patients. And the designers have introduced a mobile device app, which can be easily downloaded to call the service and which can be used to track the location of a caller during the first hour, the critical “golden hour” for treating trauma patients, he said.

Panel moderator Paul Yock, MD, PhD, noted the system is far more effective than the fragmented, 911 emergency system in the United States. “It’s a marvelous example of technology leap-frogging what we do here in this country,” said Yock, founder and director of Stanford Biodesign.

The Indian system was made possible in part by the soaring popularity of cell phones in India, used by 950 million people, including the poor.

“The mobile phone has been the most transformational technological advance in the developing world in the last 15 years,” noted panelist Rajiv Shah, MD, administrator of the U.S. Agency for International Development.

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Mental Health, Public Health, Public Safety, Sleep, Stanford News

From A to ZZZZs: The trouble with teen sleep

From A to ZZZZs: The trouble with teen sleep

go_to_bed_fullWhen I recently began working on a story on teen sleep for Stanford Medicine magazine, I was afraid I might not find teens who were troubled by sleep issues and willing to talk about them. I need not have worried: Virtually every teen I encountered had a story to tell about consistently having late nights stressing out over tests or papers or texting friends and cruising the web. It also wasn’t unusual for teens to say that they kept their cell phones on at night in case they got a message from a friend who needed to talk.

Some were tortured by the lack of sleep, often nodding off in class, but said they felt compelled to stay up in order to compete academically in these high-pressure local communities that worship at the altar of academic achievement.

“I’ve heard horror stories of being sleep-deprived,” one 17-year-old told me. “You’re not able to focus on homework, you feel moody and are not able to pay attention in class.”

Another teen reinforced what the National Sleep Foundation found in a recent poll – that 87 percent of American teens are chronically sleep-deprived. “You could probably talk to any teen when they reach their breaking point,” she told me. “You’ve pushed yourself so much and not slept enough and you just lose it.”

In my research, I learned that these students pay a heavy price, potentially compromising their physical and mental health. Study after study in the medical literature sounded the alarm over what can go wrong when teens suffer chronic sleep deprivation: drowsy driving incidents, poor academic performance, anxiety, depression, suicidal thoughts and even suicide attempts.

“I think high school is the real danger spot in terms of sleep deprivation,” Stanford’s William Dement, MD, PhD, the famed sleep researcher, told me. “It’s a huge problem.”

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Ebola, Events, Global Health

From bedside to patient: an Ebola survivor’s remarkable journey

From bedside to patient: an Ebola survivor's remarkable journey

Crozier in Sierra LeoneWhen Ian Crozier, MD, volunteered to treat Ebola patients in West Africa last year, he couldn’t possibly have imagined that he would become a case report in the New England Journal of Medicine and a living example of the serious, long-term consequences of Ebola infection.

Crozier described to a Stanford audience last week his extraordinary journey of survival from Ebola infection after suffering a shutdown of his vital organs and several hemorrhagic strokes.

“If I you had told me on day one that I would develop multisystem organ failure and asked me to predict my chances of survival, I would have said my chances were zero,” he told a School of Medicine audience of more than 100 people. “They [the Emory caregivers] really changed the game… I really think they were walking on the moon, but in a different kind of space suit.”

Crozier, who was a World Health Organization volunteer physician in Sierra Leone, was evacuated to Emory University Hospital in Atlanta, where he spent 6 weeks undergoing intensive treatment. As he began to recover from the infection, he had to relearn some basic functions, such as walking and talking.

Two months after he was discharged from the hospital, he was beset by serious eye problems and was found to be harboring billions of viral particles in his left eye. The infection also left him with some hearing loss and ringing in the ears, sleep issues and some neurologic complications, including seizures and short-term memory loss.

But none of this was apparent during his talk, in which he delivered a detailed, rapid-fire discussion of his remarkable medical journey.

“It must be odd to hear me talking about my own case… in what may seem a detached manner,” he told the audience. “This was not theoretical. I’m standing here, and I’m alive, and yet I’ve described some of the worst disease we’ve seen with Ebola.”

Colin Bucks, MD, a Stanford emergency physician who was a volunteer in Liberia during the Ebola crisis, says Crozier’s experience has given him a new perspective on how best to treat infected patients. Previously it was not standard practice to put patients on ventilators or dialysis machines, as Crozier was, as these were considered impractical and ineffective.

“It made me endorse the aggressive treatments that were previously considered futile,” Bucks told me during Crozier’s visit to Stanford. “So I consider his case pivotal in the way we view this disease.”

Crozier’s visit was sponsored by the Stanford Center for Innovation in Global Health, Stanford Immunology and the Stanford Medical Scientist Training Program.

Previously: Ebola: It’s not overBack home from Liberia, Stanford physician continues to help in fight against EbolaStanford physician shares his story of treating Ebola patients in Liberia and Experience from the trenches in the
Photo, of Ian Crozier with children in Sierra Leone, courtesy of WHO

Emergency Medicine, Global Health, Health Policy, Stanford News, Videos

A look at “India’s medical miracle,” the largest ambulance service in the world

A look at "India's medical miracle," the largest ambulance service in the world

A patient in shock arrives via ambulance at Gandhi Hospital in Hyderabad, India with a gaping wound in his right hand, blood spattered on his blue jeans and T-shirt. Emergency medical technicians wheel him into a dark room in the government-run hospital, where clinicians move quickly to irrigate the wound and pump fluids into the man, who appears to be in his 20s.

With luck, the patient might survive. Ten years ago, he would not have had a chance.

Thanks to some passionate philanthropists, businessmen and medical experts, India today has what we have long taken for granted in the United States: a modern, emergency 911-type system and a cadre of trained emergency responders who have helped save an estimated 1.4 million lives. Begun in 2005, it is now the largest ambulance service in the world and serves more than 750 million people in cities and villages across the Indian sub-continent.

I saw the system in action first-hand in August when I traveled to India, together with about 10 other faculty and staff from Stanford’s School of Medicine, including Dean Lloyd Minor, MD, to celebrate its 10th anniversary amid much color and fanfare. I was there to write a story about the new system for Stanford Medicine magazine.

Begun in August 2005 in the south Indian metropolis of Hyderabad, the service, known as GVK EMRI (Emergency Management and Research Institute), is operated as a public-private partnership, providing its services free of charge, mostly to the very poor. It is a remarkable achievement, given the diversity of India, with its 29 states and more than 120 major languages, and the bureaucracy and corruption that can sometimes impede progress in this vast country of 1.2 billion souls.

“It’s hard to fathom what this system has done in 10 years,” S.V. Mahadevan, MD, interim chair of Stanford’s Department of Emergency Medicine, told me while stationed in one of EMRI’s ambulances. “It could be regarded as one of the most important advances in global medicine in the world today.”

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Global Health, Health Costs, Health Policy, Stanford News

Pharmaceutical adventures in India

Pharmaceutical adventures in India

medication in IndiaIn the course of a recent trip to India, I developed some minor health problems and found myself doing what many locals do: consulting with a pharmacist. India’s cities are peppered with these modest little storefronts, some the size of a large closet, which sit along the street, the pharmacists stationed on a stool behind a counter awaiting customers.

The pharmacies are stocked floor-to-ceiling with a plethora of remedies for whatever ails the human body and spirit. My husband and I sought treatment for an affliction common both to travelers and local Indians, caused by contamination in food and water: diarrhea. Despite our best food precautions, we managed to contract a case of the runs after eating at a very elegant restaurant in Jaipur in the northern province of Rajasthan. When a dose of Lomotil did not prove entirely effective, we decided to turn to a pharmacist for advice, as my experience traveling abroad is that local practitioners often know best how to treat common local problems.

The pharmacist asked us several questions in perfect English: Did we have a fever? Any vomiting? Any stomach cramps? No to the first two, yes to the last. He radiated a sense of confidence. He then produced two sets of pills in silver and green packages. We were advised to take these twice a day. He also gave us an electrolyte replacement solution, to be mixed with purified water and consumed twice daily as well. The pills had names I did not recognize, so I largely took them on faith, explicitly following his directions. The total cost for both of us: the equivalent of $2.50.

“You actually behaved in many ways like a many locals would – like a person who doesn’t have easy access to a health-care provider,” Nomita Divi, program manager of the Stanford India Health Policy Initiative, told me recently when I related my experiences.

Divi took a group of Stanford students – one med student, one masters and two undergraduates – to India for 8 weeks this summer to study this very phenomenon: the role of pharmacists in healthcare delivery in India, where a dire shortage of physicians, particularly primary care physicians, severely limits access to care. These pharmacists often serve as first-line providers, she said. Some have formal training, but many do not and operate on the basis of experience, as the students observed this summer, she said.

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Research, Stanford News, Women's Health

Measuring how military service affects women’s longevity and overall health

Measuring how military service affects women's longevity and overall health

16044566446_77b89745de_zDespite the large numbers of women who serve in the military, there is a dearth of information about their postmenopausal health risks and how military service might impact their longevity. Now comes a study of more than 3,700 female veterans, led by a Stanford-affiliated psychologist, which is the first to examine the postmenopausal health of women veterans who participated in the Women’s Health Initiative (WHI) and who, given their ages, likely served in World War II or the Korean War.

The study, which appears online in the journal Women’s Health Issues, shows these women have higher all-cause mortality rates than non-veterans, even though their risks for heart disease, cancer, diabetes and hip fractures were found to be the same.

“The findings underscore the salience of previous military service as a critical factor in understanding women’s postmenopausal health and mortality risk, and the value of comparing women veterans to appropriately selected groups of non-veteran women, rather than benchmarking their health against that of the general public. It also reminds us of the importance of including women veterans in research,” said Julie Weitlauf, PhD, the study’s lead author and a clinical associate professor (affiliated) of psychiatry and behavioral sciences at the School of Medicine.

The Women’s Health Initiative is one of the most comprehensive research initiatives undertaken on the post-menopausal health of women, involving more than 160,000 women, including nearly 4,000 veterans.

Women can only serve in the military if they are deemed to be in good health, and military service stresses physical activity and many other elements of a healthy lifestyle, thus contributing to the concept of a “healthy soldier effect,” Weitlauf said. That explains why research typically shows that veterans, including women, have better health and lower mortality risk than non-veterans from the general public, she said. While the women in the study, most of whom who were likely military nurses, were probably very fit and healthy during their time of service, this effect may not be sustained throughout their lifetimes.

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Global Health, Health Costs, Health Policy, Stanford News

Exploring the cost-effectiveness of treating parasitic-worm diseases

Exploring the cost-effectiveness of treating parasitic-worm diseases

A group of tiny worms are the source of great distress – and sometimes death – for a staggering 1.5 billion people in the developing world. Yet a small percent of affected people are treated for these ailments, which include helminth infections, such as hookworm, roundworm and whipworm, and schistosomiasis.

The offending worms, found in soil and water, can latch onto people while they walk barefoot in contaminated soil or bathe in infested lakes and streams. The parasitic worms then slither their way into the intestine or into the blood vessels around the intestines or bladder, where they cause great discomfort and disease.

Children commonly develop anemia and stunted growth and cognitive problems. Adults may also have abdominal discomfort and pain, wasting and sometimes more serious complications, such as a bowel or bladder obstruction or renal failure, which can be deadly.

WHO guidelines mostly target school-aged children for treatment, which costs pennies to administer, because children are heavily affected and are easily treated as they congregate in schools, says Stanford’s Nathan Lo, author of a new study on treatment of these parasitic worm diseases. The study, which appears online in Lancet Global Health, shows that treating an entire community, including adults, reaches many more people and is highly cost-effective.

Lo, a third-year Stanford medical student and research associate, said he decided to do the study after he realized the WHO guidelines hadn’t changed for decades and had never been rigorously analyzed. He and his colleagues modelled patterns of these diseases in four different communities in the Ivory Coast to see whether it was worthwhile and cost-effective to expand drug treatment, which is cheap and readily available. The drug albendazole costs about 3 cents and a pill and significantly reduces the number of worm eggs from the soil-transmitted helminths, while praziquantel costs 21 cents a pill and effectively reduces egg production in cases of schistosomiasis, he said.

“Most of the money spent on treating these diseases is focused on helping kids,” Lo told me. “But there are a lot of symptoms of disability in adults as well, and our results support the expansion of treatment to this adult population.”

Moreover, he noted, “If you only treat children, it might help them, but they often come home to neighbors, parents and teachers who may be infected, and the children can once again become infected. It’s more effective for children if you treat them and the people around them.”

In fact, the researchers’ findings show that community-wide treatment is highly cost-effective, even if it’s assumed that costs are 10 times what the researchers assumed. They also found that it’s worth the investment to treat people more frequently – at six-month intervals – and to do the drug treatments together, rather than as separate programs.

Given the findings, the scientists strongly urge the WHO to re-evaluate its guidelines to expand treatment to communities as a whole.

Photo of hookworms from Wikipedia

Global Health, Health Policy, HIV/AIDS, Infectious Disease

From Bollywood actress to social activist

From Bollywood actress to social activist

TeachAIDS classDuring a recent trip to India, I had the great fortune to spend the day with Amala Akkineni, a beloved south Indian actress who is using her celebrity to advance the greater public good.

A trained dancer and once a major Bollywood star, Akkineni has turned her attentions in the last few decades to the nonprofit world, where she works on behalf of women and girls, people with HIV/AIDS and other vulnerable members of society.

She is still a widely recognized movie idol, attracting gawkers and autograph seekers wherever we went in Hyderabad, a south Indian city of some 7 million people. Despite her fame, she is a modest woman, who dressed simply that day in a blue cotton sari, delicate necklace and no make-up as she took us on a tour of some of the many social projects that are dear to her heart.

I met Akkineni through a friend at Stanford, Piya Sorcar, PhD, who founded a remarkably successful project, TeachAIDS, which began as her graduate thesis in the School of Education. The nonprofit disseminates video materials around the globe, using animated figures of well-known celebrities to convey simple messages about transmission, treatment and prevention of HIV/AIDS. The videos are now available in 81 countries and in 14 languages, including 7 dialects common in India, where AIDS is still a major public health problem.

Akkineni first took us to her nonprofit, Blue Cross of Hyderabad, an animal shelter that she founded in 1992 after her garage had filled up with disabled and abused creatures she had rescued from streets and homes in Hyderabad. Akkineni works regularly at the shelter and is not afraid to get her hands dirty as she comforts dogs with missing legs or feeds camels rescued from the slaughterhouse.

As she became known in Hyderabad for her work with animals in the 1990s, she was approached by Karl Sequeira, an activist in the world of AIDS and addiction, who wanted her help in starting a hospice for AIDS patients. “I was already known as this notorious ex-actress who was running this hospice for animals. So he thought I was a kindred soul,” she told me in an interview in her small office at the shelter. At the time, HIV/AIDS was such a stigmatized condition that people with full-blown disease were literally being tossed in the trash, she said. “AIDS was everywhere but nobody knew how to deal with it. It was spreading like wildfire,” she told me. She, Sequeira and other activists raised enough in one evening to open an AIDS hospice run by the Freedom Foundation, which offers a wide range of HIV services today (Sequeira died in 2004).

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Mental Health, Research, Stanford News

Animal study hints at potential treatment for skin-picking disorder

Animal study hints at potential treatment for skin-picking disorder

A condition known as skin-picking disorder may sound obscure but it’s one of the more common mental health disorders and can have devastating effects on its sufferers. An estimated 4 percent of the population – or roughly 1 in 25 people – suffer from the condition, in which they repeatedly pick or scratch the skin, sometimes leading to scarring or disfigurement.

People suffer in complete silence. They think they are the only one who has it, despite the fact that it’s very common, and it kills people.

“Skin-picking disorder is a surprisingly common condition, yet many patients avoid seeking help because of the shame and embarrassment,” says Joseph Garner, PhD, associate professor of comparative medicine at Stanford. “People suffer in complete silence. They think they are the only one who has it, despite the fact that it’s very common, and it kills people.”

The condition may lead to serious infection, requiring oral or intravenous treatment with antibiotics, he says. Patients may benefit from cognitive behavioral therapy, but there are precious few practitioners in the United States who are equipped to do this form of therapy, he says.

In a new study, Garner and his colleagues tested two antioxidants in mice with a form of skin-picking and found both compounds to be effective in treating the condition. Laboratory mice commonly suffer from ulcerative dermatitis, in which they excessively groom themselves, often leading to serious infection. These mice serve as a good model for the disease in humans.

In the study, mice who were fed the antioxidant N-acetylcysteine (NAC) all showed some improvement,   and some 40 percent were cured, though the results took up to eight weeks. Another group of mice given glutathione, the body’s naturally occurring antioxidant, got better much faster; about half who got this treatment were fully cured, the researchers found.

NAC has been used in humans in a number of experimental settings, and some case reports suggest it could be useful in people with skin-picking disorder. However, it can be hard to tolerate, as it causes gastrointestinal side-effects, Garner says. Intranasal glutathione, on the other hand, bypasses the gut and liver and goes directly to the brain. In doing so, it may avoid these potential side-effects.

“It’s clearly working differently, or at least more directly,” Garner says. “This different response profile gives us some hope that there may be some non-responders, or people who can’t tolerate NAC, who may be helped by glutathione.”

He says it represents the first potential new treatment for the condition in years. He now hopes to test intranasal glutathione in a clinical trial among human patients with skin-picking disorder.

The latest study appears online in the journal PLOS ONE. The experiments were conducted by researchers at the University of North Carolina at Chapel Hill.

More on skin picking and related disorders can be found at

Pediatrics, Public Health, Public Safety, Sleep, Stanford News

Rolling through campus and talking sleep with famed researcher William Dement

Rolling through campus and talking sleep with famed researcher William Dement

Dement in shuttle2 (RS) - croppedRenowned sleep researcher William Dement, MD, PhD, is maneuvering his way in his “Sleep and Dreams Mobile” through the Stanford University campus, en route to the Jerry House, site of some of the early, landmark studies in sleep. The house, a sprawling Mediterranean-style dormitory, housed Stanford’s Summer Sleep Camp in the 70s and 80s, where Dement and his colleagues planted the seed for some of the most important findings in the field of sleep among adults and teens.

Three years ago, the house was immortalized with a plaque and a party in which Jeff Chimenti of Grateful Dead fame performed for a crowd of 60 celebrants (the building is named after the Grateful Dead’s Jerry Garcia). Dement, now 85, says he often passed the house on his way to his ever-popular Sleep and Dreams class and thought it was important to mark the spot.

“I’d go by this house and think, ‘What happened here is the biggest thing in sleep disorders.’ So I thought something should be done to create a memorial,” he says, leaning on the banister in the living room of the house.

I’ve asked him to give me a tour of the house as background for a story on teen sleep that I’m writing for the next issue of Stanford Medicine magazine. He points to the backyard of the house, now a barren Lake Lagunita, where young volunteers played volleyball, all the while carrying a nest of wires on their heads to monitor their brain waves. Inside, researchers would monitor the youngsters’ brain activity 24 hours a day to better understand their patterns of sleep.

“The electrodes would stay on their heads because it was too difficult to take them off,” Dement explains. When the volunteers would trudge off to Tresidder Union to go bowling or do other activities, he says, “People would say, ‘Here come the trodes.’”

Dement and his colleagues followed the youngsters for ten successive summers, observing patterns in how their sleep changed as they matured.

A major goal of the study was to confirm the popular belief that as teens get older, they need less sleep. To the researchers’ surprise, they found that as the youngsters aged, the number of hours they slept stayed the same – roughly 9 hours.

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