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Global Health, LGBT, Public Health, Public Safety, Women's Health

Advocating for the rights of women and LGBT individuals in the developing world

Advocating for the rights of women and LGBT individuals in the developing world

Randy Barry - smallLast spring, I traveled to Washington, D.C. for my first experience as a citizen-activist, lobbying in Congress for the rights and well-being of women and LGBT individuals in the developing world. I recently returned there to see some of the impact of that work – crucial new appointees, new legislators in support of key issues and new words of encouragement from both sides of the political aisle.

I visited Washington as part of a 170-person delegation from the American Jewish World Service (AJWS), an international organization that promotes human rights and seeks to end poverty in developing countries. Our goal was to advance several initiatives, including passage of the International Violence Against Women Act, and changes to ensure that U.S. foreign contracts and foreign aid programs do not discriminate against LGBT individuals.

I was thrilled to hear a talk by Randy Berry, the State Department’s first-ever Special Envoy for the Human Rights of LGBT Persons, who assumed the new post in February. Just a year ago, AJWS had made the appointment of a special envoy one of its priority issues, and many of us, myself included, had met with our Congressional representatives to push for the position. I had been motivated by my experiences as an AJWS Global Justice Fellow in Uganda in 2014, when we met with LGBT activists who were living in a climate of terror because of the country’s impending anti-gay law. We heard stories of people who had been raped, beaten, harassed, evicted from homes and jobs and subjected to summary arrest.

I realized it was important to make LGBT rights a priority issue for U.S. foreign policy. Berry, the new U.S. envoy, said AJWS had been a “prime mover” in the creation of his new office – gratifying news indeed. He said he views LGBT rights as a “core human rights issue.”

“We are talking about equality, and it should go hand-in-hand with what we are doing in gender equality and in the disabled community,” he told us. “One of the most disturbing elements of discrimination is that it’s the first step to denying one’s humanity.”

He acknowledged that he has a daunting job ahead; while the U.S. is making swift progress on gay rights, these rights are just as swiftly being eroded in other parts of the world. Nearly 80 countries now criminalize same-sex behavior, with penalties that include death or life in prison. Yet the fact that the U.S. has made so much progress in recent decades suggests it’s possible to change the climate elsewhere as well, he said.

“Who would have dreamed 20 years ago that we would be where we are today in the United States,” he said. “I am sitting here today with the support of the State Department, the president and members on both sides of the aisle.”

We also saw progress on the International Violence Against Women Act, which would make ending violence against women worldwide a top U.S. diplomatic and development priority. Violence against women and girls is alarmingly pervasive, with as many as one in three being beaten, coerced into sex or subjected to other abuse in her lifetime.

The legislation was reintroduced in the House of Representatives in March with a record 18 co-sponsors, including many more Republicans than in the past. On the morning of our lobbying visits, we heard from seven Members of Congress, including Chris Gibson (R-NY), Richard Hanna (R-NY) and Lee Zeldin (R-NY), all of whom expressed strong support for the bill. David Cicilline (D-RI) described a trip to Liberia in which he met a group of young girls who had been subjected to “hideous, indescribable sexual violence.”

“It made me realize we need to do everything we can to change the lives of these young girls,” he told us.

I couldn’t agree more.

Previously: Stanford study shows many LGBT med students stay in the closetChanging the prevailing attitude about AIDS, gender and reproductive health in southern AfricaLobbying Congress on bill to stop violence against womenPreventing domestic violence and HIV in Uganda and Sex work in Uganda: Risky business
Photo of Randy Berry by Ruthann Richter

AHCJ15, Ebola, Events, Global Health, Stanford News

Ebola: It’s not over

Ebola: It's not over

Ebola may have receded from the headlines, but the challenges and threat of the disease persist. The epidemic, which has killed more than 10,700 people in West Africa, exposed glaring weaknesses in the local health-care systems, including the critical shortage of workers, poor infrastructure, lack of agreement about best practices and poor coordination among caregivers, Stanford global health expert Michele Barry, MD, told a crowd of health writers Friday.

These are among the problems that still have to be tackled to limit vulnerability to Ebola – and other diseases – in West African communities, said Barry, director of Stanford’s Center for Innovation in Global Health.

There is no consistent, united leadership on how to care for Ebola patients… That’s not an effective way for a workforce to tackle a major epidemic.Though the number of reported Ebola cases has fallen to 40, the epidemic “is really not almost over – we need to keep pushing that line,” Barry said. She spoke to some 60 medical at the Association of Health Care Journalists conference, which was co-hosted by Stanford Medicine.

She noted that Africa carries 25 percent of the global disease burden, yet it has only 3 percent of the world’s health workers. In Liberia, for instance, there are just 117 doctors for a population of 4.3 million. The country’s only trained internist, a colleague of hers, died of Ebola in the course of treating an infected patient.

“Some of us have been campaigning for a long time about this (extreme shortage of health care workers),” Barry said. “We need to take responsibility for workforce, not just within our borders.”

When the epidemic struck, she said many well-meaning, outside organizations rushed in to help fill the health care gap, but there was a tremendous lack of coordination, as well as some competition, among these groups. They didn’t even agree on some basic principles of care, such as whether patients should be rehydrated by intravenous lines or orally.

“To this day, there is no consistent, united leadership on how to care for Ebola patients. No one is really in charge,” she said. “That’s not an effective way for a workforce to tackle a major epidemic.”

She argued for the creation of a Global Health Workforce Reserve, a cadre of trained nurses and doctors who could be called upon to help during crises like Ebola. She has floated the idea with World Bank officials, who are supportive and are working on developing a way to fund the reserve, she said.

At the same time, West African countries need assistance rebuilding their fragile health care systems to manage not just Ebola but the many other noncommunicable diseases that afflict them today and that have largely been ignored during this crisis, she said.

Previously: The Ebola crisis: an ethical balancing actExperience from the trenches in the first Ebola outbreakDr. Paul Farmer: We should be saving Ebola patients and Should we worry? Stanford’s global health chief weighs in on Ebola

Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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Ebola, Ethics, Global Health, Stanford News

The Ebola crisis: an ethical balancing act

The Ebola crisis: an ethical balancing act

Ebola in GuineaShould Ebola patients in West Africa be given unproven treatments? How should clinicians decide which patients to treat, given the limited availability of some drugs? Should Ebola patients who are dying be given palliative care to relieve pain and suffering?

These are among the ethical questions addressed in a special issue of the American Journal of Bioethics, devoted to the many challenges involved in caring for patients with Ebola.

“Obviously, the Ebola crisis galvanized lots of different health care professionals and academics, but it was very important to the bioethics community,” David Magnus, PhD, director of the Stanford Center for Biomedical Ethics, told me. “From the very beginning, there were the usual public health ethics. But when the time came to give the scarce drug, ZMapp, to a small number of health care workers, there was a huge amount of controversy.”

“That also led to a major debate on the conduct of clinical trials and whether we should give unproven treatments to patients,” he said. “There’s a very big split in the biomedical ethics community.”

Magnus is editor-in-chief of the monthly journal, which is housed at Stanford. He said the special edition of the journal is particularly relevant now, given the recent launch by the NIH of a clinical trial involving ZMapp. The experimental drug, manufactured by a San Diego, Ca. company, was given to a very small number of clinicians in the United States who had been exposed to Ebola in West Africa.

In the journal, a group of ethicists led by New York University’s Arthur Caplan, PhD, argue that the gold standard in drug testing – the randomized, placebo-controlled trial – may not be the most practical and morally defensible approach in an emergency like the Ebola crisis.

A conventional trial is hard to justify, given that patients in the West were given the drug without any placebo controls; West Africans should be treated no differently. Nor can it be justified if the drug is compared against the usual standards of care in Africa, which may be ineffective and carry a high probability of death. That approach could just engender further mistrust in West African communities, they say. Rather, Caplan and his colleagues argue for an alternative approach – a side-by-side comparison of various experimental drugs to see which one is superior in helping rescue patients.

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Global Health, HIV/AIDS, Infectious Disease, Stanford News

Spread of drug-resistant HIV in Africa and Asia is limited, Stanford research finds

Spread of drug-resistant HIV in Africa and Asia is limited, Stanford research finds

In the last decade, millions more people in the developing world have gained access to anti-viral drugs to treat HIV, with nearly 12 million now on this life-giving treatment. But with more people on medication, there’s concern about the spread of drug-resistant strains of the virus, which can be transmitted from one individual to the next.

A new, multi-center study led by Stanford researchers offers some good news on this front: The transmission of drug-resistant strains thus far has been fairly limited in the hard-hit regions of Africa and Asia. The research involved more than 50,000 patients in 111 countries.

It is inevitable that transmitted drug resistance will increase further, so we need to continue ongoing monitoring to ensure successful, long-term treatment outcomes

“What we are showing is that the rates of transmitted drug-resistant HIV in the low- and middle-income countries most affected by HIV have increased modestly,” Stanford infectious disease expert Robert Shafer, MD, principal investigator on the study, told me. “The rate of increase in sub-Saharan Africa has been low, and an increase has not been detected in south Asia and Southeast Asia.”

Shafer is nonetheless cautious, as drug resistance remains a problem in these regions, where patients are prescribed drug regimens that are not as effective as those used in the West. And adhering to a daily regimen can be challenging for these patients, as transportation, drug supply and other issues may get in the way. Resistance can occur when there is a gap in treatment.

“It is inevitable that transmitted drug resistance will increase further, so we need to continue ongoing monitoring to ensure successful, long-term treatment outcomes for the millions of people on therapy worldwide,” Shafer said.

In the study, he and his colleagues identified four mutations that were linked to resistance to two HIV drugs, nevirapine and efavirenz. That result points to the possibility of creating a simple test that could be used to detect these mutations, he said. Clinicians then could tailor their treatment accordingly.

Another key finding was that the drug-resistant strains that did occur were not from a single line of resistant viruses, but were quite distinct. That means they developed independently, not as a result of a single transmission chain. That differs from some other microbes, such as malaria and tuberculosis, where resistant strains can move very quickly through the population.

“We are finding that the strains being detected in low-income countries are pretty much unrelated to one another,” Shafer said. “So that suggests these have not yet gained a foothold in the population and are less often being transmitted among people who have never received the drugs before.”

The study appears online today in PLoS Medicine.

Cancer, Global Health, Patient Care, Stanford News

New global cancer map aims to improve care in developing countries

New global cancer map aims to improve care in developing countries

cancer map2

Most people don’t associate cancer with the developing world, yet 60 percent of new cancer cases and 70 percent of cancer deaths occur in less developed parts of the world, according to the World Health Organization. Now, the nonprofit Global Oncology, Inc. has launched a Global Cancer Project Map, a first-of-its-kind resource that will connect cancer experts around the world in an effort to advance cancer research and care in low-resource areas.

The interactive map includes more than 800 projects on six continents. With a few simple clicks, users can search for cancer experts and research projects and then contact the investigators and program managers. The goal is to spur collaboration among people in the field and enable experts to share their collective knowledge.

“Before it was difficult or often impossible to find information about cancer projects or experts, especially in limited-resource settings,” said Ami S. Bhatt, MD, PhD, an assistant professor of medicine and genetics at Stanford and co-founder of Global Oncology, Inc. “The map now makes it possible to connect colleagues in the global cancer community with a maximum of six clicks of a computer mouse.”

Bhatt, who directs global oncology for Stanford’s Center for Innovation in Global Health, and GO co-founder Franklin Huang, MD, PhD, have been working with the National Cancer Institute on ways to bring multidisciplinary teams together to solve complex problems in cancer. While there are many dedicated scientists and caregivers doing innovative work in cancer in the developing world, there’s been no single place where they could share knowledge or reference the work of their colleagues, she said. The cancer map is a first step in this process.

“We have the ambitious goal of providing access to every cancer research, care and outreach program in the world through the map,” said Huang, who is an instructor at the Dana-Farber Cancer Institute.

A collaboration with the NCI, the map was developed by GO volunteers, who are scientists, policymakers, public health experts, lawyers and other highly skilled individuals. It covers a wide range of projects, from prevention and screening to clinical programs and palliative care. For instance, it includes a project in Turkey to improve diagnostic accuracy of mammograms to detect breast cancer; development of an early screening test for gastric cancer in Mexico; and use of supplements to prevent arsenic-induced skin cancer in Bangladesh.

“The map is an important and innovative step forward in our effort to reduce health disparities and strengthen human capital in underserved areas of the world,” said Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health. “With cancer rates rapidly increasing in low-resource settings, the map creates a place where the global cancer community can share and access information that is critical to providing better treatment and care.”

Bhatt and Huang unveiled the new map today at the Symposium on Global Cancer Research, being held in Boston. The symposium is co-sponsored by the NCI, the Consortium of Universities for Global Health and the Dana-Farber Cancer Institute.

Image from Global Oncology, Inc.

Behavioral Science, In the News, Medicine and Society, Research

Research prize for helping make mice comfy – and improving science

Research prize for helping make mice comfy - and improving science

OLYMPUS DIGITAL CAMERAA Stanford researcher has won accolades for a research paper that could help ease the lives of millions of laboratory mice – and improve the outcomes of research studies.

Joseph Garner, PhD, an associate professor of comparative medicine, and his colleagues observed that mice are routinely housed in cold conditions, which put stress on the animals. The mice compensate with physiologic changes that can skew the results of laboratory studies. For instance, temperature has been shown to affect immune function and tumor development in mice, among other factors. So cold stress in mice raises concerns not only for animal welfare but also for science.

Garner and his colleague, Briana Gaskill, PhD, proposed a simple solution: Give the animals some nesting material, and they’ll build a cozy home to regulate their temperatures. These comfy mice would be more physiologically comparable to humans, making them better research subjects, the researchers said. But one obstacle to adopting this simple solution was the question of how much nesting material is enough? In their prize-winning experiment, the researchers asked the mice how much nesting material they needed to give up a warm cage for a cold cage with a nest. The scientists found that between 6 and 10 grams of nesting material could effectively reduce cold stress in the animals – a standard now starting to be adopted in labs around the world.

The paper, published in 2012 in PLoS One, won a high commendation recently from the National Centre for the Replacement, Refinement & Reduction of Animals in Research, a leading, UK-based scientific organization that supports research which aims to minimize the need for animals in research and improve animal welfare.

The group said that the research results “have the potential to positively impact the welfare of millions of laboratory mice all over the world.”

Garner and Gaskill both traveled to London to receive the prize.

Previously: Stanford students design “enrichments” for lions, giraffe and kinkajou at the San Francisco Zoo, Nesting improves mouse well-being, could aid research studies and Stanford researcher’s easy solution to problem of drug testing in mice
Photo, which originally appeared in Stanford Medicine magazine, by Brianna Gaskill

Global Health, Health Policy, Infectious Disease

“Made-in-India” vaccine could save thousands of children

"Made-in-India" vaccine could save thousands of children

5559524166_510ebb57a0_zIndia reached a milestone this week with the introduction of a novel rotavirus vaccine, the first vaccine designed entirely in the developing world. The vaccine is not only safe and effective, but also affordable; the manufacturer, Bharat Biotech, has pledged to make it available for $1 to governments in low-income countries.

The vaccine, known as ROTAVAC, will be used to fight a disease that kills 80,000 children a year in India alone. On a global scale, rotavirus, which causes severe diarrheal disease, is responsible for some 450,000 childhood deaths and 2 million hospitalizations.

The vaccine was developed through a unique partnership supported by the Indo-U.S. Vaccine Action Program, which was chaired until recently by Harry Greenberg, MD, senior associate dean for research at the School of Medicine. Greenberg was a lead inventor of the first-generation vaccine for rotavirus.

“The ROTAVAC project is a beautiful example of the great power of team science,” Greenberg told me. “The vaccine is a culmination of a very large and disparate group of people and organizations, all working together for a common goal: to produce a safe, effective and affordable vaccine to prevent severe, rotavirus-associated diarrhea in Indian children.”

During a three-day visit to India in January, U.S. President Barack Obama and Indian Prime Minister Narendra Modi had praised the “highly successful collaboration” that lead to the development of the vaccine. Prime Minister Modi was on hand for ceremonies Monday announcing the launch of the vaccine, which the Indian government will make available in public clinics across the country.

The vaccine originated from a weakened strain of rotavirus that was isolated from an Indian child in the mid-1980s. It went through a long development process which included investigators from 13 institutions and culminated in a randomized, double-blind clinical trial involving nearly 6,800 infants in India. The results, published in the Lancet in 2014, showed it was as effective as two other licensed, commercial oral rotavirus vaccines.

The vaccine was developed with support from the National Institutes of Health and the U.S. Centers for Disease Control and Prevention, among others.

“The impact of this vaccine to improve child survival is enormous,” said Roger Glass, MD, PhD, director of the Fogarty International Center at the NIH. “Our groups at the CDC and NIH are proud to be an integral part of this longstanding and enormously successful collaboration with our Indian colleagues.”

Previously: President Obama and Indian Prime Minister praise partnership that led to rotavirus vaccine, Life-saving dollar-a-dose rotavirus vaccine attains clinical success in advanced India trial and Trials, and tribulations, of a rotavirus vaccine
Photo by The Bill and Melinda Gates Foundation

Emergency Medicine, Medicine and Society, Patient Care, Public Safety, Stanford News

A young child, a falling cabinet, and a Life Flight rescue

A young child, a falling cabinet, and a Life Flight rescue

ticktockLife in the air rescue business is highly unpredictable. You can spend many hours idling away the time in an obscure, basement office. But when an emergency call comes, you literally don’t have a second to grab a pen on the way out the door.

So it was on one November day, when I did a ride-along with Stanford’s illustrious Life Flight air ambulance service, the oldest in California. The team graciously agreed to let me accompany them on a flight for a story for Stanford Medicine magazine, whose current issue is focused on the role of time in medicine. Life Flight, I figured, would give me a sense of the split-second timing that can sometimes make a difference between life and death in an emergency situation. I was scheduled to fly with the crew in late October, but instead I spent that day learning about the service in what proved to be a leisurely day with no calls.

On my second ride-along day, it appeared that history was about to repeat itself when, just as my shift was about to end, the emergency call came in at 3:39 p.m. I became an eye witness to the rescue of a toddler who suffered a serious head injury when a heavy, ill-secured cabinet at her preschool crashed down on her head during naptime. The story was so dramatic that it made the local news. The school was shut down several days later by local officials because of code violations.

Things could have gone poorly for little Aeshna, the 3-year-old victim of the accident, who was left dazed, not fully conscious and vomiting as a result of her injury – clear signs of head trauma. She could have suffered significant bleeding in the brain and permanent brain damage – a prospect that was a major concern for her parents and caregivers.

The two Life Flight nurses, who have a breathtaking array of skills, and their veteran U.S. Navy pilot made it to the scene at the Fremont, Ca. preschool across the bay within 23 minutes of the call and were able to bring Aeshna back to Stanford for quick assessment and treatment.

You can read the minute-by-minute scenario of Aeshna’s rescue in the the magazine, which came out last week.

Previously: Stanford Medicine magazine reports on time’s intersection with health, Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims, Stanford Life Flight celebrates 30 years and Ask Stanford Med: Answers to your questions about wildnerness medicine
Illustration by Lincoln Agnew

Immunology, In the News, Medicine and Society, Pediatrics, Public Health, Stanford News

A discussion of vaccines, “the single most life-saving innovation ever in the history of medicine”

A discussion of vaccines, "the single most life-saving innovation ever in the history of medicine”

vaccine and syringeIn a recent, in-depth interview with KCBS Radio, now available online, Stanford immunologist Mark Davis, PhD, called vaccines “the single most life-saving medical innovation ever in the history of medicine” and called not vaccinating children a real danger.

Davis was interviewed on air for 30 minutes following the announcement that he’ll direct a new, $50-million initiative at Stanford, funded by the Bill & Melinda Gates Foundation, which aims to speed discovery of vaccines for some of the world’s deadliest infectious diseases, such as malaria, tuberculosis and HIV.

Davis, who directs the Stanford Institute for Immunity, Transplantation and Infection, harked back to the time when cemeteries were filled with the graves of young children who fell victim to diseases such as measles and mumps that were virtually wiped out with the advent of vaccines. In the pre-vaccine era, about half of all children died of infectious diseases that are readily preventable today, he noted.

“One day I wandered through Union Cemetery in Redwood City, which started around 1850,” he said. “What was telling about the earlier graves is how many graves you have where they are two large headstones for the mother and father and a lot of little headstones for the children who died in infancy from measles and mumps and all these diseases that had also vanished with childhood vaccination but that are now coming back because people say, ‘I’ve heard something bad about these vaccines. So we are not going to give them to our kid.’”

Parents who chose not to vaccinate their children “are putting your kid at risk and also putting other young children at risk, as children don’t get vaccinated for measles until they are one year old. So kids die. Older people – a population we study here at Stanford – don’t respond very well. Their immune system often deteriorates with age… So even if they had a measles shot in their youth, they might still be vulnerable. So if you don’t vaccinate your child, you are putting your kid at risk, anyone with an immune deficiency at risk, little babies at risk, old people at risk. It just shouldn’t be permitted.”

Measles, he noted, is a “very ambitious” virus that spreads through the air, surviving on droplets of water vapor, so coughing can readily spread the disease. As a matter of public health, the disease can be controlled through the principle of “herd immunity” – the idea that if most people are vaccinated, a disease will be less likely to move through the population, he said.

“So it’s not just about you and your child. It’s about society… If more and more people are not vaccinated, it gives a virus, like the measles virus, an opportunity to run through the population very quickly, which it does, and endanger many more people,” he told listeners.

As to whether California should require parents to vaccinate their children, Davis was adamant on the subject:

I wouldn’t want unvaccinated kids in a classroom with my kids. I think it’s a danger. These are decisions made by parents that could affect the health of their children for the rest of their lives… The government is totally correct to say you should not kill your child, you should not starve your child, you should not beat your child, and you should not deprive your child of vaccines.

Previously: With a Gates Foundation grant, Stanford launches major effort to expedite vaccine discovery, Infectious disease expert discusses concerns about undervaccination and California’s measles outbreak and Side effects of childhood vaccines are extremely rare, new study finds
Photo by NIH

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