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Health Policy, In the News, Public Safety, Rural Health

The Navajo-Native Nexus: A chance to make history and improve health

The Navajo-Native Nexus: A chance to make history and improve health

Navajo kids

For the sake of history in the making, not another Tobacco Settlement disaster, please.

A month ago, the Obama Administration released the $554 million of “no-strings-attached” money to the Navajo Nation — the largest settlement to a tribe in history — as part of the resolution to a long-running land dispute. The Navajo Nation, with its size and political connections, is perfectly poised to demonstrate best practices for how tribes can leverage such funds after years of inadequate support. I know I’m not someone who’s in the place to suggest what would be best for the Navajo Nation, but I hope to see this community benefit from settlement money catalyzing positive change.

I write as a first-year medical student who lived on the Navajo reservation in Sanders, Arizona for the past two years as a high-school teacher. In Sanders, I’ve seen how access to preventive services, behavioral health services, and assistance navigating health-care service provision can have life or death implications. In our small school, every few weeks at least one of my students would miss class because of a funeral that could have been avoided. The 2014 report on a proposed Medicaid expansion for the Navajo Nation cites that for Navajos on the reservation, 60 percent have no phones, 32 percent live without plumbing, 28 percent without kitchen facilities, and many without electricity. Seventy-eight percent of roads are unpaved, so air emergency transport is used, and there is no accredited residential substance abuse treatment program. The Navajo Nation mortality rate is 31 percent higher than in the U.S.

If the Navajo Nation wants a lesson in what not to do with the money, it can look at the poor outcomes of another historic settlement for the U.S. back in 1998: The Tobacco Master Settlement Agreement. Recent reports indicate several states chose to invest in bonds when using settlement money from the tobacco industry, though the funds were intended to fuel prevention initiatives. Only 1.9 percent of funding per year was devoted to preventive services; unsurprisingly, today preventable tobacco-related deaths remain high in the U.S. Tempting as it may be for the Navajo Nation to use this money for miscellaneous expenses, this is a chance for the Navajo to set the precedent for other indigenous groups who might find themselves similarly empowered with a large sum of unmarked money.

Navajos are in the spotlight and could seize this timely chance to show how spending on one focused initiative implemented with outside partnerships could positively affect outcomes of societal welfare. Using settlement funds to more seamlessly integrate services that are starting to be provided by other health resources (like from a new potential Navajo Medicaid) into a navigable health infrastructure could enhance an entire sector of life on the Navajo Nation in measurable ways.

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Medical Education, Rural Health, Stanford News

Stanford internships provide Bay Area students with work experience, opportunity to discover passions

Stanford internships provide Bay Area students with work experience, opportunity to discover passions

14093-internyu_newsThis summer high school students from around the Bay Area are interning at labs and departments across Stanford. A recent Stanford Report story highlights the type of projects students are working on and how the internships provide them with valuable work experience and the opportunity to discover their passion. From the article:

Palo Alto High School student Catherine Yu [pictured to the right], for example, is interning at the Stanford Blood Center in the immunology and pathology lab. She described her task as gathering data to help her supervisor’s research project.

“Every intern is assigned to a supervisor who is working on an experiment, which will hopefully be turned into a paper submitted for a journal,” said Yu, who will be a senior in September. “My work consists of separating blood into T cells, monocytes, dendritic cells, and then culturing them together; it’s very neat.”

Yu said being the only high school student in her lab presents her with a series of challenges.

“It’s definitely a different dynamic where they expect you to learn a lot of information at a very fast pace,” Yu said. “I have to stay on my toes so I don’t fall behind.”

Previously: Internships expose local high-schoolers to STEM careers and academic life, Residential learning program offers undergrads a new approach to scientific inquiry, The “transformative experience” of working in a Stanford stem-cell lab and Stanford’s RISE program gives high-schoolers a scientific boost
Photo by L.A. Cicero

Global Health, Nutrition, Parenting, Pediatrics, Research, Rural Health, Stanford News

Seeking solutions to childhood anemia in China

Seeking solutions to childhood anemia in China

Chinese boyHow can health and nutrition education needs in rural China be addressed? Start by examining infant-feeding practices.

Scott Rozelle, PhD, director of the Rural Education Action Program, part of the Freeman Spogli Institute for International Studies (FSI) Center on Food Security and the Environment at Stanford, conducted a study on 1,800 babies in China’s Shaanxi province to address high rates of anemia and cognitive delays in children owing to poor nutrition, though not necessarily lack of funds for healthy food.

A recent piece on the FSI website describes the ongoing study:

One third of households were given a free daily supply of nutritional supplements for their children. Another third were given the same free supplements, and were enrolled in a text message reminder program. A final third of households served as a control group. The study is ongoing through April, 2015, but 12 months into the program, the researchers have found that the supplements have reduced anemia rates by 28 percent, although cognitive delays have persisted.

Text message reminders appear to have been modestly effective in improving program compliance. Caregivers who received the reminders gave their baby the micronutrient supplements, on average, 10 percent more often over the course of the first six months of the study. So far, however, this improved compliance has not led to a corresponding fall in anemia rates.

Rozelle commented in the piece, “To reach all of China’s at-risk babies – that’s our ultimate objective. And to do that, we need an effective government program.”

Previously: Who’s hungry? You can’t tell by lookingFeeding practices and activity patterns for babies vary with families’ race and ethnicity, study shows and Student inventors create device to help reduce anemia in the developing world
Photo by Kris Krüg

Public Health, Research, Rural Health, Stanford News

Stanford study finds Lyme disease among ticks in California parks

Stanford study finds Lyme disease among ticks in California parks

hikingHikers, beware: Ticks infected with the bacterium at the root of Lyme disease have been found roaming California parks, as described in a study to be published in Emerging Infectious Disease. The same paper by Stanford researchers, including ones associated with the university’s Woods Institute for the Environment, also identified a human pathogen, Borrelia miyamotoi, in black-legged ticks, which are carried by western gray squirrels in California and white-footed mice back east.

From a Stanford Report article:

The findings raise the question of whether B. miyamotoi has gone undetected in California residents. The research results are “an important step toward dispelling the perception that you cannot acquire Lyme disease in California,” said Ana Thompson, the executive director of the Bay Area Lyme Foundation.

B. miyamotoi has been known for some time to infect ticks; the first known human case of B. miyamotoi infection in the U.S. was discovered in 2013. Beyond Lyme-like symptoms such as fever and headache, little is known about its potential health impacts. In the Bay Area, low awareness of tick-borne diseases such as Lyme could heighten the risk of infection with B. miyamotoi for users of the region’s extensive natural areas and trails.

The piece notes that the School of Medicine’s interdisciplinary Lyme Disease Working Group “is exploring ways to improve diagnostic tests and medical understanding, evaluate the effectiveness of innovative therapies, expand clinical services and build greater public awareness.”

Previously: Add a tick check to your vacation checklistAsk Stanford Med: Answers to your questions about wilderness medicine and Piecing together the clues: Diagnosing and treating autonomic disorders
Photo by Ray Bouknight

Global Health, In the News, Medicine and Society, Rural Health

From the Stanford Medicine archives: A Q&A with actor Matt Damon on water and health

Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.

Old it may be, but The Rhime of the Ancient Mariner reminds us of our current global water crisis. As Californians batten down the hatches in the face of severe drought, progress is being made to distribute clean water elsewhere in the world.

Actor Matt Damon was recently honored by the World Economic Forum for his work with fellow Water.org co-founder Gary White to make clean water more accessible in developing countries. Last year, the two talked about their efforts and the connection between water and disease in a Stanford Medicine  Q&A. Read on to learn how their organization empowers women and girls to lead clean-water initiatives.

Previously: Factoring in the environment: A report from Stanford Medicine magazine and “Contagion” spreads across the nation on Friday. Will Hollywood get the science right?

Global Health, Orthopedics, Pediatrics, Rural Health, Stanford News, Technology, Videos

Two Stanford students' $20 device to treat clubfoot in developing countries

In the video above, Stanford graduate students Jeff Yang and Ian Connolly demo their design for a brace to correct clubfoot in a way that’s comfortable and functional for the children who need it, and reasonable for their families to afford. The $20 device uses injection molded plastic attached to cleats to hold a child’s legs in an upright position so that they can strengthen the muscles they need eventually to maintain the posture without assistance. It also allows them to stand and move around with ease, and the device looks more like a toy than a restraint.

Yang and Connelly visited Brazil to learn more about the birth defect that affects one in 1,000 children whose feet appear to be rotated internally. There, clubfoot is commonly treated using rigid, ineffective metal braces, notes this video and an article on Wired.com. The students began working with the organization Miraclefeet during a Stanford D.School course titled “Design for Extreme Affordability” and put their design into action at a hospital in São Paulo.

Previously: Support for robots that assist people with disabilities, New documentary focuses on Stanford’s Design for Extreme Affordability courseBiotech start-up builds artful artificial limbs and Improving treatment for infant respiratory distress in developing countries
Photo in featured entry box from Design for Extreme Affordability

Global Health, Infectious Disease, Public Health, Research, Rural Health, Stanford News

Stanford bioengineer developing an “Electric Band-Aid Worm Test”

Stanford bioengineer developing an “Electric Band-Aid Worm Test”

uganda-kids“Those children are sitting on the graves of their siblings,” said a Ugandan colleague, in a tragic reminder of the impact of childhood diseases in rural Africa.

Stanford bioengineering professor Manu Prakash, PhD, took this picture two weeks ago while conducting clinical field evaluations of his lab’s various ultra-low-cost disease diagnostics inventions.

His latest project is an electromagnetic patch that non-invasively detects live parasitic worms in infected patients.

To help test this novel idea, Prakash and co-investigator Judy Sakanari, PhD, a research pathologist at the UC San Francisco School of Medicine, received a $100,000 Grand Challenges Explorations award from the Gates Foundation.

The first prototypes will be used to detect the worm that causes onchocerciasis, or “river blindness,” which afflicts approximately 37 million people in Africa, Central and South America, and Yemen. Transmitted through repeated bites of blackflies, it is a major cause of preventable blindness.

Current diagnostic methods require the use of expensive ultrasound equipment to determine whether parasitic worms are alive under the skin or inside lymph nodes. Prakash’s more frugal design consists of a Bandaid-sized patch embedded with a sensitive sensor that detects minute electrical changes when worms wiggle under the skin or form calcified cysts. He expects that the final device will cost less than $10 and will be easier to use in rural settings.

Prakash and Jim Cybulski, a Stanford mechanical engineering PhD student, were also working at several sites to clinically evaluate “Foldscope,” an inexpensive microscope made of folded paper that is being mass produced and used for diagnosing diseases like malaria, schistosomiasis, African sleeping sickness, tuberculosis and various filarial diseases in field conditions. Cybulski recently won a Global Health Equity Scholars Fellowship (NIH-funded) for field testing this device.

The magnitude of the malaria problem in Uganda, which has one of the highest rates of infected mosquitoes in the world, became crystal clear during their trip.

“There was one hut where we trapped 400 mosquitoes in one night,” said Prakash. “And some public health centers that we visited had almost 100 malaria cases per day, with mothers of large families bringing in at least one child a week for testing.”

He added, “Being in the field gives meaning to working in global health. It teaches you empathy, a driving force so strong that transforms ideas into actions.”

Prakash’s lab is also exploring how to develop “human capital” in these resource-constrained settings, a strategy that would generate more jobs and build the infrastructure to provide these services locally. “We are looking at various ways to bring appropriate tools and training to these young college graduates who don’t have much to do,” he said.

Previously: Is the worm turning? Early stages of schistosomiasis bladder infection charted, Compound clogs Plasmodium’s in-house garbage disposal, Using cell phone data to track and fight malaria and Image of the Week: Malaria developing
Photo by Manu Prakash

Health Disparities, History, Medicine and Society, Public Health, Rural Health, Stanford News

Broken promises: The state of health care on Native American reservations

Broken promises: The state of health care on Native American reservations

RosebudI traveled to Haiti a month after the 2010 earthquake to report on what was happening there for Stanford Medicine magazine. So when I went to the Rosebud Indian Reservation in South Dakota this year with a group of Stanford students, I was incredulous to learn that the average life expectancy in this community was one year lower than Haiti’s – 46 versus 47 – and a full 33 years shorter than the average American.

Statistically speaking, the poor health of Native Americans living the Great Plains of the United States rivals many developing countries. I had no idea. Diabetes, alcoholism, and depression rates are frighteningly high. Suicide rates are 10 times the national average.

My goal in writing my in-depth story, which appears in the current issue of Stanford Medicine and was just recommended as a Longreads pick, was to try to understand how this could possibly be true, and to lend some perspective as to what could be done to change it. What I found was a toxic mix of causative factors: isolation, poverty, poor nutrition, poor education – each of which has its roots in history. What became strikingly clear during my visit to the federally funded Rosebud Indian Health Service Hospital on the reservation was that the United States government has never kept its promises, made in multiple treaties, to provide health care to Native Americans in exchange for land.

From my piece:

One afternoon during a visit to the hospital, I walk from the ER to a separate wing to find the CEO, [Sophie Two Hawk, MD, who also happens to be the first Native American to graduate from the University of South Dakota’s medical school]. Her door’s ajar, and she waves me in. She’s dressed in the military-style uniform of the U.S. Public Health Service Commissioned Corps, her long, gray hair pulled back in a braid that drops down her back. She’s doing paperwork — denying a pile of requests from her physicians for additional care for their patients. The requests are appropriate, she says, but the hospital just doesn’t have the money to pay for the care. “If someone shows up with a torn ACL, we can’t afford to fix it,” she says. “He will walk with a limp.” Two Hawk, like many others, links the poor health statistics of Native Americans not only to the lack of adequate (federal) funding but to the community’s tragic history. The hopelessness, the despair — it’s rooted in history.

The story delves into some of that history, including the forced relocation of Native American children to faraway boarding schools, another particularly ugly chapter in history that I knew nothing about. This forced relocation led to “cultural distortion, physical, emotional and sexual abuse, and the ripple effect of loss of parenting skills and communal grief,” a government study states. Hope on the second poorest county in the country – neighboring Pine Ridge Indian Reservation comes in first place – is a struggle to find. But it’s there, particularly in the strong bonds of the community itself:

Leaving Two Hawk, I head to the office next door where another Native American hospital employee, psychologist Rebecca Foster, PhD, works. When I knock on her office door, she’s taking a break to cradle her week-old grandson. Foster and her husband, Dan, also Native and a psychologist at the hospital, have 14 children — seven of those adopted from relatives on the reservation who were unable to care for them. All seven of those children are special needs, like the baby’s father, who was born with fetal alcohol syndrome… ” I see a lot of kids who are depressed, who talk about suicide,” she says, then pauses to look into the eyes of her grand baby. “And yet, kids are still resilient. They still have a desire to have a good life, to be happy, to accomplish things. No matter where you come from, you can never completely destroy that. There are very few kids here who don’t have a dream. What I tell young people is that there is a difference between having to stay here because you are trapped and choosing to be here because you have something to give. One’s a prison, the other is a home.”

Previously: Finding hope on the Rosebud Indian Reservation, Getting back to the basics: A student’s experience working with the Indian Health Service, Lessons from a reservation: Clinic provides insight on women’s health issues, Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a  reservation: Visit to emergency department shows patient care challenges
Illustration by Jeffrey Decoster

Men's Health, Public Health, Research, Rural Health, Stanford News

A guide to coping with a common male birth defect

A guide to coping with a common male birth defect

One of the most common birth defects in boys occurs when the urethral tube fails to completely close, leaving the urethral opening somewhere along the underside of the penis, rather than the tip. Approximately one in 200 males is born with the condition, but the cause is usually unknown. It’s been suggested that exposure to pesticides might be the culprit in some cases, but no definitive studies have been done.

A paper from Stanford researchers, which came out today in the journal Pediatrics, presents results of analyses they conducted of several hundred pesticides commonly used in commercial applications. They found weak links with 15 of the chemicals, but emphasize that further studies need to be done before anyone can say there’s a link between any of the chemicals and the condition, called hypospadias. You can read more of the details in our press release.

Causation aside, parents of a baby boy born with the condition have to make decisions about how to treat the condition.

“Any birth defect is concerning to parents, and a defect in the genital structure often causes special concern,” William Kennedy, MD, associate professor of urology at Stanford and associate chief of pediatric urology at Lucile Packard Children’s Hospital, told me.

Kennedy has been counseling parents and performing corrective surgeries for years and has seen the difficulty parents often have in dealing with the condition.

“Parents are often reluctant to talk to anyone — even medical professionals — about the baby’s condition,” Kennedy added. “Fortunately, most corrective surgeries have positive outcomes.”

Kennedy says a lot of parents first turn to the Internet for information and, as we all know, sometimes what we find there can be misleading. That prompted Kennedy and Suzan Carmichael, PhD, associate professor of pediatrics and lead author of the Pediatrics study, to join with Matt Dorow, who has a son born with the condition, to write a book on
the subject for parents.

“Hypospadias – A Guide to Treatment,” is a slender volume of just over 100 pages, containing information and guidance on every aspect of hypospadias. The recently published book presents information in a clear, organized fashion and includes short pieces written by a man born with the condition and Dorow. If you have a boy born with hypospadias, or know someone who does, it could be immensely helpful.

Cardiovascular Medicine, Global Health, Nutrition, Research, Rural Health, Stanford News

Could a palm oil tax lower the death rate from cardiovascular disease in India?

Could a palm oil tax lower the death rate from cardiovascular disease in India?

palmoilHow could you encourage widespread adoption of a healthier eating habit? Not so much in the form of Justice Antonin Scalia’s broccoli comment, but something less controversial and more like a tax on, say, Pop-Tarts so that they’d be the same price as something healthier, like broccoli. And then it’s still your call which – if either – to choose to eat for dinner.

A recent study in the British Medical Journal tested a simulated 20 percent tax on saturated-fat-laden palm oil designed to reduce its consumption – and adverse health effects – in India. (Earlier this year, John Farquhar, MD, professor of medicine and health research policy, emeritus named palm oil among his top foods to avoid.) Authored by scientists from Stanford School of Medicine, Stanford Woods Institute for the Environment and collaborators in London, Oxford and Delhi, the study used an economic-epidemiologic model to predict whether increasing the price of palm oil would have an effect on the death rate from hyperlipidemia-induced cardiovascular disease in the years 2014-2023. It also considered a palm oil tax’s possible implications for food security – a measure of confidence about the availability of food and lack of fear of starvation.

As discussed in the paper, the researchers chose to study India because the country “is not only expected to face the greatest burden of cardiovascular disease mortality among low and middle income countries but is also considered a policy leader in the prevention of chronic disease among these countries.”

Looking at household expenditure data in subpopulations of Indian residents age 20-79, the researchers forecasted a 1.3 percent reduction in cardiovascular deaths over the next 10 years in people who were to stop using palm oil and not substitute another oil for it, and an additional benefit to those who introduced heart-healthier oils and the benefits of polyunsaturated fats to their diet.

The study’s findings predicted more benefit to males and urban-dwelling people than females and rural residents, owing to differences in consumption and cardiovascular risk. Researchers determined the palm oil tax would lead to a dietary reduction of about 13 calories a day, and an increase of food insecurity of about 0.59 percent, over the 10-year period.

I asked study author and Stanford internist Sanjay Basu, MD, PhD, to comment on the significance of these findings. He said, “the 1.3 percent reduction in cardiovascular deaths is huge because India has such a large number of these deaths.” Still, he said, “I think we’re cautious about recommending such a tax because of the potential for food insecurity among the rural groups.”

Asked whether the mathematical model he and his team developed could be used for other risk factors and health solutions within the Indian subpopulations studied, Basu replied that yes, “we’re looking at taxes on sugar sweetened beverages and large-scale subsidies for fruits and vegetables.” As for the study’s possible implications for the United States, he said, “palm oil is of limited consumption in the United States, but this is analogous to the sugar taxes in the U.S. where there’s a commonly-consumed good, primarily affecting obesity and type 2 diabetes among low-income groups.”

Previously: Can food stamps help lighten America’s obesity epidemic?, Stanford preventive-medicine expert: Lay off the meat, get out the sneaks and New evidence for a direct sugar-to-diabetes link
Photo by One Village Initiative

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