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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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Health Policy, NIH, Research, Science Policy, Stanford News

NIH tries to reduce the gray in the grant pool

NIH tries to reduce the gray in the grant pool

This 45-second animation vividly illustrates the funding crisis that young scientists face as they work to launch their research careers: For the last three decades, large NIH grants have increasingly been awarded to older investigators.

“The average age of first-time, R01-funded investigators who have PhDs remains 42, even after seven years of policies at NIH to increase the numbers of new and early-stage investigators,” said Robin Barr, director of the NIH’s Division of Extramural Activities, in a recent editorial on the NIH website.

But there is hope on the horizon, as the NIH rolls out a series of funding mechanisms that aim to give new investigators a leg up. I recently wrote about one such program, the KL2 mentored career development award, and an inspirational Stanford physician-researcher, Rita Hamad, MD, MPH, who is taking full advantage of it.

Hamad is interested in studying the cause-and-effect relationships between poverty and health. The KL2 program helps Hamad’s research through salary support, mentoring, pilot grants and tuition subsidies. In just two years, she has produced actionable data that can be used by policymakers and by health-care providers to improve the overall health of populations, including a study exploring the impact of the earned-income tax credit on child health in the United States. It will be published this fall in the American Journal of Epidemiology.

Previously:NIH funding mechanism “totally broken,” says Stanford researcher, NIH director on scaring young scientists with budget cuts: “If they go away, they won’t come back” and Sequestration hits the NIH – fewer new grants, smaller budgets
Animation by the NIH

Big data, Events, Health Costs, Health Policy, Medicine X

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach at MedX

The U.S. medical system is like a New England toll road: It’s designed to extract tolls from patients all along their health-care journeys, with a callous disregard for whether or not these travelers arrive at their desired destination, a place of better health.

This was the angry message delivered by Peter Bach, MD, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes, who was the keynote speaker at today’s Medicine X conference.

Dr. Bach is a physician, an epidemiologist, a researcher and a respected health-care policy expert whose work focuses on the cost and value of anti-cancer drugs. He was also a caregiver who has traveled down the patient side of the system as his wife died of cancer.

In his talk, Bach discussed three of the major toll takers in the system — pharmaceutical companies, hospitals and researchers — and how the public’s wielding of a growing body of health-care data could be used to reign in a process that is driven more by profit than health outcomes.

This week no discussion on escalating health-care costs could pass without mentioning Martin Shkreli, the 32-year-old hedge fund manager whose drug company raised the price of a decades-old anti-parasite drug by more than 5,400 percent. “He made it clear that the system is so broken even a child could manipulate it,” said Bach.

But Bach went on to show some promising quality improvement projects that are helping to bring accountability into the health-care system.

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FDA, Health Policy, Nutrition, Pediatrics, Public Health, Research, Stanford News

How much Bisphenol A is okay?

How much Bisphenol A is okay?


A new study came out this week that happened to remind me of one of my pet peeves about certain biomedical studies — choosing an “outcome” measure that doesn’t tell you what you really want to know. The study, which was led by Stanford postdoctoral fellow Jennifer Hartle, DrPH, and estimated the amount of BPA a child is exposed to in the course of a normal school day, was great. But her description of EPA safety tests on the plastics component Bisphenol A, or BPA — done back in the 1980s — made me think back to earlier work by University of California, Berkeley biologist Tyrone Hayes, PhD.

In the 1990s, the agricultural herbicide atrazine was safety tested by exposing frogs to low doses of atrazine as they developed from eggs to tadpoles to frogs. The adult frogs didn’t die or show obvious deformities such as extra legs, so the pesticide was deemed safe. But Hayes took a closer look and, in 2002, found that even at very low levels of atrazine exposure, male frogs were producing eggs instead of sperm.

So no gross deformities if you just looked at the frogs for 30 seconds. But in fact the animals had experienced a dramatic change in their health and biology. The lesson is that, in biology, sometimes the right outcome measure is something you have to really look for. There is a lot more to the Hayes-atrazine story.

But back to the current study: Hartle and her colleagues turned their attention to national school breakfast and lunch programs, which provide nutritious meals to 30 million kids every year but also deliver small amounts of BPA, an estrogen mimic that messes with hormones. Children’s meals are disproportionately packaged in tiny one-meal containers. Those tiny packages of apple sauce and juice have a greater BPA-emitting surface area than a big carton or can for the amount of food. And school kids often eat meals off plastic trays with plastic forks and spoons. For children who eat a lot of meals at school, it can add up.

According to Hartle’s paper, appearing today in the Journal of Exposure Science and Environmental Epidemiology, the question isn’t whether the kids are getting BPA in their meals — they are — but whether any of them are getting doses of BPA that could affect their long-term health. Based on those 1980s studies, the EPA estimates that BPA is safe at chronic exposure levels below 50 μg per kilogram of body weight per day. Happily, Hartle and her colleagues found that children are getting far less than that — as little as 0.0021 μg for a low-BPA breakfast to 0.17 μg for a high-BPA lunch. Everything should be hunky-dory, right?

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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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Big data, Cardiovascular Medicine, Health Policy, NIH, Precision health, Public Health

The diagnostic odyssey

The diagnostic odyssey

Sick-girl-christian-krohg-1881Imagine developing some odd symptoms, like a rash and an ache. You go to the doctor and she shrugs it off and says they are probably unrelated and to come back if the rash doesn’t go away. Two months later, the rash is gone but the ache is worse. You go back and she sends you to physical therapy and suggests a specialist. A month later, neither has identified a problem. The physical therapist suspects you aren’t doing the exercises and the specialist suggests you see a psychiatrist about depression. The rash is back, too. And you are tired all the time.

For some people this frustrating and scary lack of diagnosis and care can go on for years. Sometimes, doctors have overlooked a common disease that just manifests oddly. But often, the patient has a rare disease their doctors have never heard of, let alone seen.

Yesterday, NIH launched a new Undiagnosed Diseases Network, consisting of seven major medical centers where select patients with no diagnosis can go — at no cost — for the best diagnostic facilities available. Together, the seven centers, one of which is at Stanford Medicine, magnify that network of expertise to consider patients’ cases.

Euan Ashley, MRCP, DPhil, associate professor of cardiovascular medicine and of genetics at Stanford Medicine, is co-chair of the UDN steering committee. Recently, he spoke to me for a Q&A about the new network, which is open for business. And more information on the Stanford Center for Undiagnosed Diseases can be found here.

Previously: NIH network designed to diagnose, develop possible treatments for rare, unidentified diseases and Using crowdsourcing to diagnose medical mysteries
Photo by Christian Krohg, 1881, from Wikimedia Commons

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

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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