Living in a Post-SARS World: What happens when another outbreak occurs?

September 27, 2010

In this day and age of global travel, you can get anywhere in the world during the incubation period of a new pathogen.  In the case of SARS, it took 61 days for a global pandemic.

Timothy Brewer of McGill University in Canada, speaking on the panel: “One Health: Detection and Control of Emerging and Endemic  Zoonotic Pathogens” noted that in the Guandong Province in China, people were walking around with masks, hospitals were shut down, and people were buying white vinegar to disinfect their homes long before most of the world knew what was happening.  He said the outbreak became widely known in November 2002, but it wasn’t until March 2003 that the Chinese government acknowledged it.

In 2005, WHO passed the Revised International Health Regulations, which requires mandatory reporting of outbreaks on international concern. The regulations went into effect June 15, 2007, and although there is no police force backing the regulations, Brewer said it adds more pressure to countries to come forward.

So has outbreak recognition improved over time?

In an analysis of the 398 reported outbreaks by WHO between 1996-2009, Brewer said there has been a slow improvement in outbreak discovery and reporting.

“SARS was the real impetus for outbreak discovery,” he said.

Panelist Jonna Mazet of University of California, Davis, an expert on surveillance, said researchers now have a cell phone network in place in many communities with an application to notify people when people see a sick animal.

But the gaps in zoonotic surveillance are still pretty big.

“Detecting a new respiratory pathogen is tricky unless you get lucky,” Brewer said.  Many of the new pathogens like H1N1 look like other  infections, so unless a pathogen creates unusual symptoms, he said it will be hard to detect especially with a lack of lab capacity.

“Even in 2010, you cannot access the WHO database unless you are with the Ministry of Health,” he said.

Panelist Hector Garcia with the Universidad Peruana Cayetano Heredia Institute of Neurological Sciences in Lima and an expert on cysticercosis (a disease from pigs) and Mazet of University of California, Davis,  said capacity building is a huge need.

Garcia said capacity building needs to happen with organizations and among collaborations. And Mazet said there is a huge need to fix the brain drain and to create a proactive approach. Her experience has been that when hunters in the Congo died of hemorraghic fever and the lab determined the pathogen wasn’t ebola, no one was interested in doing more investigation.

All three of these panelists also discussed the political pressure to keep outbreaks quiet because of the enormous economic consequences. 

For example, Garcia said during a continent-wide cholera outbreak in Peru in 1991 when many people got sick after eating fish, the health minister announced it was unsafe to eat ceviche but Peruvian President Fujimori, fearing a huge impact to the seafood industry, went to the media and said it was OK to eat ceviche.

Prepared by Bobbi Nodell,  Communications Specialist, University of Washington

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Engineering, Innovative Technologies and Global Health

September 22, 2010

The four panelists for the “Engineering, Innovative Technologies, and Global Health” session looked at ways that bioengineering is driving advances in global health.

 Joseph Hughes of Georgia Tech said that more 1.5 million children die each year because of preventable water- and sanitation-related diseases, but solving this problem isn’t easy. Water sanitation requires many things, including infrastructure, capital, and regulation. While there is no “silver bullet” technology yet for the developing world, there are promising developments, Hughes said.  Water can now be decontaminated by using UV rays from the sun to kill germs; Hughes is also looking at ways to sanitize water in bottles using visible light, which is a more abundant light source.

Catherine Klapperich of Boston University demonstrated a prototype of a small, portable tool that could be used to test a patient for HIV on the spot, or at “point-of-care.”  The tool, which is about the size of a student microscope, doesn’t require a power supply. The sample pops out of the tool so it can be processed and then shipped and stored. 

University of Washington professor Paul Yager showed slides of a point-of-care diagnostic tool prototype developed as part of the Gates Foundation-funded Grand Challenges in Global Health initiative. The tool, called DxBox, can detect six different pathogens and is about the size of a Netbook. “We want to be able to backpack it into a small village somewhere,” said Yager. DxBox is being developed by Seattle-area company Micronics. Yager also talked about what his lab envisions as the next step in point-of-care diagnostics – using a cell phone to run the diagnostic code or sending the data elsewhere for analysis.

The fourth speaker, panel moderator Sakti Srivastava of Stanford , described how students in the Biodesign program at Stanford prioritize clinical needs and then seek to address them through prototypes . Students in the program recently helped develop the Stanford-Jaipur Knee, a prosthetic limb now in trial in India.  Billed as the $20 knee, it was recognized by Time magazine as one of the best inventions of 2009.

The panel made numerous joking references throughout the session to the “valley of death.” This was described as the long, difficult passage between an idea or even the prototype and the product  actually being made and put to use. Does that mean that the need should always be identified first, someone in the audience asked? One of the panelists said there was no perfect answer. It’s important to have a need in mind, but you don’t want to suppress the innovation that comes out of brainstorming either.

Prepared by Mary Janisch


Chronic Diseases, Innovations in Health Systems and Data for Decision Making

September 22, 2010

The participants in this session all reinforced the need for using innovative approaches to address global health issues. In describing the problem of rising cancer incidence in developing countries, Sofia Merajver quoted the gospel of Matthew, “The harvest is plentiful, but the workers are few.” She pointed out that the vast burden of cancer deaths is borne by low and middle-income countries, which have the fewest resources to deal with cancer and other chronic diseases. Recognizing that strategies for addressing cancer deaths in high income countries are not appropriate for low income countries, her team developed local cancer registries, which allowed them to better understand the types of breast cancer affecting women in North Africa and the Middle East. This in turn led to dramatic reductions in stage 4 breast cancer.  

In a similar way, Pamela Andreatta and colleagues were able to use cell phone technology to show that use of bimanual uterine compression can reduce deaths from post-partum hemorrhage. Her team trained illiterate traditional birth attendants in rural Ghana to collect data and report it via SMS messaging. A spinoff of this research was the growing sense of empowerment of the traditional birth attendants.

Woutrina Miller provided another example of ways in which technology can be borrowed from one arena and used to meet global health challenges. She described an innovative and cost-effective way of detecting water-borne pathogens which uses the principles of hemodialysis technology to concentrate pathogens from large water sources. 

Two of the panelists reported on efforts to address chronic diseases in Brazil. Beatriz Carlini spoke about a study on the impact of telephone counseling for those wishing to quit smoking in Brazil, and James Macinko presented some work showing that Brazil’s roll-out of a strong, universal primary health system was associated with a dramatic reduction in hospitalization rates.

Finally, Erika Arteaga, from the People’s Health Movement, gave some provocative comments on how policy decisions based on the principle of economic growth can actually lead to worsening health, and gave the example of the 3-fold increase in cancer incidence among indigenous people impacted by the Texaco Oil Spill in the Amazon. She alluded to the need for stronger advocacy for the rights of vulnerable populations, and promoted a political ecology framework for looking at global health issues.

Prepared by David Roesel


A System Approach to Prevention and Control of Diabetes, Cardiovascular Disease

September 21, 2010

Diabetes is one of the top ten non-communicable diseases worldwide with an increased risk of death.  Current treatment systems support curative medicine but they fail to include lifestyle interventions.

To reduce the risk of death in developing countries, interventional programs must be seen as a top priority in disease management. The qualities of systems using interventional programs include data measurement; decision-making, low cost options and scalability. 

By adding prevention strategies such as blood glucose screenings, symptoms of metabolic syndrome can be diagnosed.  Early treatment of metabolic syndrome reduces the risk of diabetes and other co-morbidities associated with non-communicable diseases.  

Lifestyle interventions such as screenings by local lifestyle coach’s support healthy living, are cost effective and sustainable.  Great work in being done but more evidence is needed from developing countries about the benefits and feasibility of these programs. Universities can support the development of studies that provide additional information needed to support future investments in system infrastructure and program growth.

Prepared by Anita Beninger


David Fleming: Global Health: A Two-way Street

September 19, 2010

David Fleming

As budget constraints tighten and we think about how to invest our education dollars at universities, tax payers have a right to expect a return on that investment.  When it comes to global health studies at universities, that return is not always obvious.  As I talk to people across King County and the country, I find that they tend to think of “global health” as something that benefits people overseas.  Yet, we increasingly find that global health is a two-way street.  What we learn and the strategies we use in global health can also greatly improve health in our own country.

Reality check: Although the United States has the world’s best medical system, we do not live as long or as well as Bosnians or Jordanians.  The U.S. is not even one of the top 25 countries with respect to indicators of health.  Why?  Because although we have poured money into our clinical health care system, we have neglected community health.  As a consequence, communities across America have health indicators on a par with those in developing countries.

What global health strategies might also work at home to improve health?  One example is community health workers–people from the community who are trained to deliver frontline health information to their neighbors.  It’s low cost and highly effective, particularly for reaching communities that have been marginalized on the basis of culture or language, and whose members may have difficulty understanding or accessing health care professionals.

Global health also teaches us that technology can leapfrog over barriers in delivery.  For example, across much of the developing world, cell phone technology is filling in for a lack of physical infrastructure—like roads and health clinics.  We could make some of the same leaps: video phones can be used to watch people take their tuberculosis medicine rather than having to send an expensive healthcare worker to the patient’s house.  Or we can use cell phones to deliver messages in an emergency in languages that are understandable to non-English speakers. 

Additionally, we should borrow a page from global health in our approach to linking health and economic development.  We know that poor health is strongly linked to poverty. Globally, micro-credit loans are being used to improve family income and health.  Why not do the same here?  For example, microloans could even pay for citizenship applications—which cost $700.  The benefit: citizenship is linked to higher incomes and higher incomes are linked to better health.  But many who are qualified and would like to become U.S. citizens cannot afford the application fee.  And all loans need not be “micro”.  Larger low interest loans could enable corner groceries in poor neighborhoods to invest in the equipment for stocking healthy, nutritious fresh fruits and vegetables. 

Let’s use the conference of the Consortium of Universities for Global Health to build out such ideas and to establish the collaborations that can make them happen.  Global health and local health is a two-way street.  The job in front of us is to make it well traveled in both directions.

David Fleming, M.D.
Director and Health Officer for Seattle and King County Public Health


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