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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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Global Health, Health Policy, Stanford News, Videos

Stanford journalist returns to old post in India – and finds health care still lagging

Stanford journalist returns to old post in India - and finds health care still lagging

Three Stanford seniors and a second-year School of Medicine student spent their summer investigating India’s complicated health-care system — and I got to go along for part of the ride.

It had been a decade since I’d been back to India. I was the South Asia bureau chief for The Associated Press from 2000 to 2005, based in New Delhi. It was among the best assignments of my life.

The posting took me from the Himalayas to the valley of Kashmir, from the deserts of Rajasthan to the lush tea plantations of Sri Lanka. I traveled across Bangladesh with the director of the CDC to document the world’s last push against polio. I wrote about the medical horrors that still plagued those in Bhopal who had been poisoned by gas 20 years before.

And now I was back, this time as a journalist for Stanford Health Policy, comprised of the Center for Health Policy/Center for Primary Care and Outcomes Research and the Department of Medicine.

As I wrote in this story about the student’s research among the poor communities on the outskirts of Mumbai: India is a land of extremes.

I found that little had changed, on the surface, for the rich and the poor. The wealthy still live lavishly, which the students saw for themselves as they looked up at a billion-dollar home in the heart of Mumbai. And the poor remain among the unhealthiest in the world, as witnessed by the students who spent seven weeks in Mumbai’s surrounding slums.

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Global Health, Health Disparities, Pediatrics, Stanford News, Technology

Sunshine solves a life-threatening newborn health problem — with a little help from Stanford experts

Sunshine solves a life-threatening newborn health problem — with a little help from Stanford experts

jaundice-greenhouseWhen pediatrician Tina Slusher, MD, began caring for newborns in Nigeria in 1989, she saw two big threats to the babies’ health: severe jaundice and tetanus.

“I thought, ‘Tetanus will go away with immunization, but nobody really seems to understand this jaundice problem,'” Slusher, a global pediatrics expert at the University of Minnesota, told me recently. In developing countries, well over 150,000 babies a year currently die or suffer severe brain damage from jaundice. “They still aren’t getting treated,” Slusher says.

But now, thanks to Slusher and her colleagues, that is set to change. She is the lead author on a scientific paper in the New England Journal of Medicine that evaluated a low-tech, inexpensive method for treating jaundice with filtered sunlight. The technology was conceived and built at Stanford, by a team led by neonatal jaundice expert David Stevenson, MD.

Newborn jaundice is caused by a delay after birth in development of the baby’s ability to metabolize compounds released in the breakdown of red blood cells. In the U.S. and other developed countries, most cases are treated with phototherapy. But putting a baby under a blue-light-emitting lamp isn’t feasible in places that lack steady electricity. The team members, who also included doctors and researchers at the Massey Street Children’s Hospital in Lagos, Nigeria, wondered if they could safely use filtered sunshine instead.

From our press release about the new study:

Some mothers and babies sat under outdoor canopies that filtered out harmful wavelengths from sunlight, but still allowed jaundice-treating blue wavelengths to reach the babies’ skin. The filtered-sunlight treatment was as safe and effective as the blue-light lamps traditionally used to treat infant jaundice.

“This research has the potential for global impact,” said the study’s senior author, David Stevenson, MD, the Harold K. Faber Professor in Pediatrics and senior associate dean for maternal and child health at Stanford. “All babies can get jaundice. In settings with no access to modern devices, we’ve shown we can use something that’s available all around the planet — sunlight — to treat this dangerous condition.” Stevenson also directs the Johnson Center for Pregnancy and Newborn Services at Lucile Packard Children’s Hospital Stanford.

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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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Ethics, Global Health, Health Policy, In the News, Medicine and Society, Public Health

Thinking about “culture” as part of global well-being

Thinking about "culture" as part of global well-being

5294003888_300b57c958_zEffective and ethical global-health initiatives involve some acknowledgement of culture – that is, they take into account local practices, beliefs, and circumstances, and they recognize that medicine is not “one size fits all.” A recent post on the blog Anthropological Observations takes this one step further, asserting that “culture” should be seen as something that is always changing, rather than a static fact to be accounted for. As a medical and cultural anthropologist pursuing a PhD, I couldn’t agree more.

Culture is often seen as a barrier to health by global-health professionals, as in “it’s not part of the local culture to visit clinics” or “cultural beliefs about how medication works make patients non-adherent to drug regimens: they take pills when they experience symptoms instead of at regular intervals.” Such observations are useful and can help adapt health initiatives to specific locales. However, this attitude can also be paternalistic and limiting because it doesn’t give people credit for being able to adapt to new information or situations.

The post’s author, Ted Fischer, PhD, a professor of anthropology at Vanderbilt University who has been advising the WHO’s project on the cultural contexts of health, writes:

A human-centered approach to health and wellbeing should adopt contemporary understandings of culture as dynamicfuture oriented, and driven by agency. We in anthropology now see culture as much more of a fluid process, a process rather than a thing. Cultural actors are always improvising, actively creating meaning out of the resources at hand.

He concludes that it is more accurate is to see culture as an opportunity for health, instead of an obstacle to it.

Previously: Exploring the benefits of pursuing anthropology and medicine, What other cultures can teach us about managing postpartum sleep deprivation, Exhibit on health and medicine among indigenous cultures opens at US National Library of Medicine and It’s a small world after all: Global health field takes off in the US
Photo by Onasil Bill Badzo

Aging, Global Health, In the News, Public Health, Research

As life expectancy rises worldwide, many are living longer with illness and disability

10812180384_18496a55f3_zGood news: Average life expectancy has continued to climb over the past two decades. The downside is that those extra years are often marked by chronic disease or disability, according to a new analysis published in the Lancet.

In the study, an international team of researchers examined fatal and nonfatal health loss across countries in an effort to help direct global-health policies to improve longevity and quality of life regardless of where a person lives.

HealthDay reports:

The analysis of data from 188 countries found that life expectancy for both sexes increased from just over 65 years in 1990 to 71.5 years in 2013, while healthy life expectancy rose from almost 57 years to slightly more than 62 years.

“The world has made great progress in health, but now the challenge is to invest in finding more effective ways of preventing or treating the major causes of illness and disability,” study author Theo Vos, a professor at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, said in a journal news release.

The rise in overall life expectancy is due to significant declines in illness and death caused by HIV/AIDS and malaria, the researchers said, along with major advances in combating infectious diseases, nutritional deficiencies, and mother and baby health problems.

Earlier this year, Laura Carstensen, PhD, director of the Stanford Center on Longevity, spoke at the Big Data in Biomedicine conference about modern society’s gains in life expectancy and called it an “unprecedented” time in history. During her presentation, she presented data on the current aging population and what aging might look like in the future.

Previously: A look at aging and longevity in this “unprecedented” time in history, “Are we there yet?” Exploring the promise, and the hype, of longevity research and Living loooooooonger: A conversation on longevity
Photo by jennie-o

Global Health, Medical Education, Medicine and Society, Patient Care, Public Health

Exploring the benefits of pursuing anthropology and medicine

Exploring the benefits of pursuing anthropology and medicine

3470650293_60b27d6539_zAs a PhD student in medical anthropology, and having come from a very “medical family,” pursuing an MD has been a kind of shadow-dream of mine. For a year or two in high school, I was convinced that neonatology was the path for me; now I’m a doula and research the culture of childbirth.

Some people do live the double dream, and I recently interviewed two of them: Jenny Miao Hua at the University of Chicago and Rosalind Franklin University’s Chicago Medical School, and Stanford’s Amrapali Maitra, both of whom are medical anthropologists pursuing PhD/MD degrees. (Amrapali has brought an anthropological perspective to Scope through our SMS Unplugged series.)

The two came to their joint degree from different sides: Hua was an anthropology student interested in Chinese medicine and the body, while Maitra was enrolled in medical school and became serious about understanding the social context of illness. Each intends to pursue internal medicine, and each, incidentally, has family connections in the site she chose to research. We talked shop for quite a while, and what I found most interesting was their thoughts on what anthropology brings to clinical practice:

Maitra: On the broadest level, anthropology gives you an immense empathy for your patients and allows you to see them as people. It sounds cliché, but with the focus on efficiency and evidence-based medicine that has taken over American biomedical practice, even the most kind and caring individual can lose [his or her] empathy. And the kind of empathy you get from anthropology is not just sympathizing with the person, but really understanding where they’re coming from, historically and because of their life position: why they live in a certain neighborhood or have a certain diet. It allows you to think creatively about what they’re able to do or not do in pursuing their own health.

Hua: With anthropological training, students understand the various ways pathologies are dependent on larger socioeconomic forces. As a practicing physician, the person who comes through the door is never a textbook patient, so within a very short amount of time you have to pick up on this deep history, and when you’re not careful you end up stereotyping and profiling. Anthropology brings a more nuanced way of thinking about patients: they’re not just uniform biological entities, but hybrids of biology, society, and culture.

Maitra: I’ve seen so many clinic visits where I can tell, as the anthropologist in the room, that the attending physician and patient just have completely different agendas. There are simple questions like those Arthur Kleinman has laid out, asking what about the pain bothers her, why she thinks she’s having it, what she hopes to get out of the encounter. I see some doctors use these, and their visits go so much better. They’re able to build an alliance with their patient that’s very therapeutic.

That’s anthropology on the individual level, but on another level it allows you to recognize that certain things are trends. It allows you to think systematically about different kinds of structural violence. For example, why is it that so many people whose occupation is picking strawberries come in with knee and back pain issues? Treating pain is not going to solve the problem. It’s about getting to the root of the occupational hazards of being a farm worker.

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Global Health, Health Policy, Stanford News

E-cigarettes a growing cause for concern in the developing world

E-cigarettes a growing cause for concern in the developing world

11505926173_7be7ca343b_zIt is a common misconception that e-cigarettes are a problem only in wealthy nations, say two Stanford global health researchers in a commentary published today in the Journal of the American Medical Association. In the piece, co-authors Michele Barry, MD, FACP and Andrew Chang, MD, call attention to the widespread availability of e-cigarettes in the developing world and a growing concern over the potential health implications unique to low- and middle-income countries.

Chang, an internal medicine resident in Stanford’s Global Health track planning to specialize in cardiology, has been closely tracking the conversation around global tobacco control, but noticed e-cigarettes have been largely absent from the discussion. With support from Barry, director of the Center for Innovation in Global Health, Chang dug deeper and found that while U.S. health officials and researchers have been grappling with uncertainties around e-cigarette regulation and health impacts, the rise of e-cigarettes has in fact become a global threat.

The authors point to a 2014 survey from the World Health Organization suggesting that already, more than half of the world’s population is living in countries where e-cigarettes – or electronic nicotine delivery systems (ENDS) – are available. Public awareness in many of these countries is high and the devices are cheap.

But in some parts of the world, notably Africa and South Asia, there is little to no data on e-cigarette awareness and usage trends. This is of particular concern, say Barry and Chang, as regions like Africa and South Asia represent vast potential markets and are likely to be hit hardest by the growth of e-cigarettes.

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Global Health, Health Costs, Health Policy, Medicine and Society, Research

Chinese clinicians use inpatient visits to compensate for drug revenue loss

Chinese clinicians use inpatient visits to compensate for drug revenue loss

For decades, many doctors in rural China boosted their incomes by both recommending and selling drugs, often at steep markups. With mounting evidence of overprescription, in 2009 the Chinese national government largely banned markups, undermining doctors’ financial incentive to over-provide them. Instead, the government provided physicians with a subsidy to compensate for the loss in profits.

Since then, a number of scholars have examined the effects of the policy. But no one has looked at the unintended consequences — until now.

In a study published today in Health Affairs, a team of researchers found the policy had the unintended consequence of boosting hospitalizations and the provision of inpatient care.

“When you have a regulation that affects pricing, it’s like pushing a balloon in in one place — then it pops out in another,” said Grant Miller, PhD, director of the Stanford Center for International Development, senior fellow at the Freeman Spogli Institute for International Studies and an associate professor of medicine. The first author is Hongmei Yi, PhD, program manager of FSI’s Rural Education Action Program in China.

The team, which also includes Scott Rozelle, a senior fellow at FSI, examined data from rural Chinese clinics between 2007 and 2011. They found clinics that were most heavily reliant on drug revenues before the policy change more than doubled their provision of inpatient services when compared with the clinics least reliant on drug revenues before the change. These centers also experienced little change in revenue, which indicates they were able to offset the losses of drug revenue with income from inpatient stays.

Based on their analysis, the team also believes that this increase is not driven by demand for inpatient services, Miller said.

By also surveying and conducting follow-up phone interviews with patients, the researchers also found some evidence that clinics may be artificially boosting their inpatient tallies to increase their compensation from the government.

He said he was not surprised the policy had unexpected ramifications. “Humans are adaptive creatures and doctors are not categorically different than the rest of us. If you take away a source of livelihood, it’s not surprising they found another way to make it up.”

Rural primary care doctors in China “are also not at the top of the economic pyramid,” Miller said.

Health-care reform is on the national agenda in China and it’s possible that this study could inform future policies, Miller said. “It raises a much broader set of questions about how you design in a more holistic way a proper set of incentives for providers,” he said.

Previously: Seeking solutions to childhood anemia in China, Better school lunches — in China and Stanford India Health Policy Initiative fellows are in Mumbai — come follow along

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