“Maybe you are too heavy for the roads here” — postcard from Uganda

[This post sent in by Hema Kondur, a UNC sophomore who is majoring in chemistry]

“Maybe you are too heavy for the roads here.”  The friends I made in Uganda always did have a way with words.

Sure, that’s a possibility.  Or maybe my Chacos knew I was an imposter and not worthy of wearing them.  Either way, during my 7-week internship in a community-based health organization in Uganda, I completely wiped out two days in a row. Slipped and fell, just walking on the dirt roads.

Kondur (wearing her Chacos) grinding coffee at a coffee farm outside Mbale, Uganda

Since I was working at a health clinic, I figured after my second fall that it was time to pay a visit.

I knew I’d have to wait in the clinic for a while, so I asked my Ugandan friend Winnie if she could scrounge up some extra Neosporin for me. Then she decided she wanted to take a look at the scrapes. As I pulled back the Band-Aids, she asked me where I had found them. I told her that I brought them from home. As she was cleaning up my leg, she told me that they don’t have adhesive bandages at the clinic.  They use white tape.

My mind shot back to a few weeks earlier when I was sitting in the office of my pediatrician (lame, I know) updating my vaccinations so I could travel internationally. After I was done, the nurse let me choose between about 7 different types of children’s bandages, ranging from Hello Kitty to Spider-Man.  Eventually I chose a Crayola crayon to cover the tiny dot on my arm.

Now I was putting plain white tape over a pretty nasty scrape. It’s not as if one did a better job than the other of protecting my wound. It’s just that one is more aesthetically pleasing and a lot more expensive.

This got me thinking about how many amazing things this health center—Kyetume Community Based Health Care Programme—was doing with limited resources.  Like tests for infectious diseases with a 10-year-old microscope, for example.  The microscope doesn’t have to be sleek and shiny to work.  In the U.S., it’s hard to remember how much is possible without gobs of technological gizmos.

But places like Kyetume CBHCP are showing what’s possible. I’m grateful I had the chance to experience those possibilities last summer with AGRADU:  Advocates for Grassroots Development in Uganda.  Ironically, I guess, I spent most of my time there updating and restructuring the website (hello, technology!) that  my classmate Saumya started (http://www.kyetumecbhcp.org/).

As for my leg, it’s fine. Just a couple of light scars.  The Ugandan roads are going to have to try a lot harder to keep me down!

- Hema

In memoriam: Mary Rose Tully, co-founder of Carolina Global Breastfeeding Institute

Mary Rose Tully

Mary Rose Tully, our friend, colleague, and comrade-in-arms in defense of mothers and babies everywhere, passed away at 3:30 AM, January 20, 2010 on her 42nd wedding anniversary after five months of nearly constant suffering with pancreatic cancer, surrounded by her husband Doug, son Chris and his wife Tania, her mother Rose Weber, and many of her siblings. Mary Rose received her MPH from our department, was one of the very first lactation consultants certified in the U.S. She served as Director of Lactation Services at UNC Hospitals, Adjunct Associate Professor, Department of Maternal and Child Health, and co-founder of the Carolina Global Breastfeeding Institute, Gillings School of Global Public Health. . . .

(Read the rest of this post on the CGBI blog, Mother/Child Dyad.)

UNC earns a new distinction

Humanized "BLT" mouse

UNC researchers’  BLT mouse (described in this post) has been named “rodent of the week,” according to the L.A. Times blog Booster Shots.

For the first time, one step ahead of HIV

[Cross-posted on the UNC Health Care blog]

“We live now in a vicarious age, but we don’t live our lives through other people. Instead, we live our own lives vicariously through what our technology creates. The technologies that are now at our fingertips promise a reality as efficient and logical as they are.”

I wish I’d written those sentences. It’s not a new concept, but boy they sure sing. Charles P. Pierce wrote them. He was lamenting social isolation. Vicarious technology could be someone playing Farmville on their iPod in a dark room they don’t leave for days.

But in a different context it illustrates advances in science, including one created by J. Victor Garcia-Martinez, Paul Denton and other researchers in a lab at UT Southwestern a few years ago.

Garcia, a native Mexican with piquant passion for his work, and Denton, an easy-going native Texan who hasn’t escaped his accent, are now at UNC’s Center for AIDS Research with many of their UTSW lab colleagues. But before I tell you what the advance was, let me tell you the result of its most recent application.

HIV, the virus that causes AIDS, was prevented, locked out, turned away at the gates, with “pre-exposure prophylaxis” of antiretroviral medications. In the 1990s, ARTs turned HIV from a death sentence into a chronic disease, but data to support using them in healthy people are sparse. It was tested successfully in pregnant women to prevent transmission of HIV to their babies, but mother-to-child transmission makes up only about 1% of HIV cases. Meanwhile, cases of HIV are increasing in the U.S. and around the world.

Garcia and Denton tested PrEP against the most common routes of transmission; rectal and IV injection. PrEP worked in every case of rectal transmission and in 90% of IV tests.

How? Vicariously. Through “humanized” mice. Again, this isn’t a new concept, but their mouse model for human cells is the only one that works. They create mice with human bone marrow, liver and thymus – the immune system.

Researchers use a number of non-human, animal models, but these humanized mice are the closest thing science has to people. Profiles of CD cells in mouse and human blood are almost identical. In their PrEP study, they placed human virus cells into human tissue. (In human trials the drugs have to be given to healthy people, and people are much less reliable to study than animal models.)

“For the first time, we’re one step ahead of the virus,” says Garcia, a distinguished statesman for his science. “This is beyond a mission for us.”

Certainly, there are limitations to vicarious studies. Nobody’s using the “c” word. Yet. It’s doubtful that doctors will start using PrEP tomorrow. Science protocol has to be observed – large (and lengthy) human trials, etc., etc. But read the study. It was published yesterday in PLoS One. It adds further credence to using ART as prevention, and further hope that the disease can be stopped.

What Denton and Garcia do, it’s not Farmville. It’s better.

– Clinton Colmenares

In the news: WRAL, HealthDay, WCHL, la Repubblica, GQ (2008)

When it comes to maternal death, the United States is falling behind

[Post sent in by UNC junior Saumya Ayyagari]

According to a 2007 World Health Organization report, at least 40 other nations have lower maternal mortality rates than the United States. That year an estimated 15.1 maternal deaths occurred per 100,000 live births, which is up from 7.5 per 100,000 in 1982.

This ratio should be decreasing, not increasing. The Healthy People 2010 goal is a maximum of 3.3 maternal deaths per 100,000 births, which countries like Ireland have already accomplished.

Over half the reported maternal deaths in the U.S. could have been prevented by early diagnosis and treatment, according the CDC.

In addition, cesarean births have a maternal mortality rate four times that of vaginal births. According to a study by the National Center for Health Statistics in 2007, 31.8% of births in the United States were by cesarean section.

Another part of the part the problem is underreporting of maternal deaths. In 1998, the CDC estimated that the U.S. maternal death rate was 1.3 to 3 times than reported. This could be because reporting of maternal death is based on an honor system.

The fact that autopsies are performed on fewer than 5% of women of childbearing age who die in hospitals and that the U.S. does not define a woman’s death a year after pregnancy as a maternal death is are also factors contributing to underreporting.

The UK has the most complete model for reporting and analyzing reasons why women die of childbirth. More information about this model can be found at www.cemach.org.uk.

If we want to save our mothers we must improve diagnosis and treatment of factors that cause maternal death. We must decrease our cesarean rate. We must accurately report maternal deaths, including those of women who have died up to one year after their pregnancy.

It has been shown that the risk of having a cesarean is reduced when the primary care provider is a midwife. UNC Health Care provides mothers with the option of choosing a midwife. See www.uncmidwives.org for more information.

A doula present during the birth process also reduces the risk of having a cesarean. UNC BirthPartners is UNC Health Care’s volunteer doula organization. If you would like to learn more about becoming a doula, please contact Teresa Howard at birthpartners@gmail.com.

Midwife and women’s health advocate Ina May Gaskin started the Safe Motherhood Quilt Project to raise awareness of the maternal death rate and underreporting. The quilt also serves as a memorial for women who have died of pregnancy since 1982.

If you know of a woman who has died due to pregnancy-related complications and you would like to contribute to the project by creating a square, donating, or through some other method please visit the project’s website.  (Most of the statistics I used in this post are from that website).

I do hope that this post spurs discussion so that childbirth and motherhood in the United States can be made safer.

– Saumya

White House tackles issue of women and HIV

Ada Adimora, MD, MPH

Our own Ada Adimora, professor of medicine and public health, was recently named to The Root 100 list of top African-American leaders. As a clear leader in the field of HIV research, Adimora was invited to the White House earlier this month for a joint meeting of the Office of National AIDS Policy meeting and the Council on Women and Girls.

Read the White House blog post here.

Could the Grinch benefit from medication?

Courtesy of our friends at the UNC Health Care news office, a couple of holiday themed videos for your viewing pleasure.

And whatever holiday you celebrate (or don’t) at this time of year, be safe and healthy!

and

Global Health and Human Rights

Meier adopts Hanoi's typical mode of transportation

Earlier this fall, UNC Assistant Professor of Global Health Policy Ben Meier traveled to Hanoi, Vietnam for the International Conference on Realising the Rights to Health and Development for All.  Nearly 300 international delegates from government, NGOs, intergovernmental organizations and academia took part in the conference.

IGHID was instrumental in recruiting Meier to the faculty at UNC, and we are thrilled that he was able to represent UNC, one of only four U.S. universities to attend.

Conference organizers say that despite steady increases in global health funding since the 1990s, problems are outpacing solutions by a large margin, and the conference examined threats to global health in the context of human rights.

We all know that conferences can be hit or miss when it comes to generating ideas and producing tangible outcomes, but Meier returned from this conference energized and optimistic.  “Best conference ever,” he told me, for actually discussing real issues.  Meier attributes part of the meeting’s success to the broad representation at the meeting.  Thanks to USAID providing funding for travel, a number of developing countries who normally don’t participate in these kinds of meetings were able to send representatives.  Attendance at the meeting was further aided by the fact that it was held in Vietnam, which has minimal visa restrictions.

Conference attendees attended sessions from sunrise to sunset, and the conversations continued over dinner.  By the end of the meeting, agendas were set for future realization of the right to health within in the context of economic development.

Meier presented a paper titled “Human Rights for Global Health Governance: The World Health Organization, the Human Right to Health, and the Failure to Achieve Health for All.”

A day in the life of a Malawian girl: a doctor’s perspective

[This post was submitted by UNC professor Ian B. K. Martin, MD. Martin is director of Global Emergency Medicine at UNC and recently returned from Malawi, where he was visiting UNC Project-Malawi and other organizations in Lilongwe.]

Ian Martin, MD

Saturday, November 28, 2009 — Picture it:  It’s 95°F and muggy in a small pavilion constructed of cement.  This is the Under 5 (U5) clinic at Kamuzu Central Hospital in Lilongwe, Malawi..  This enclosure is packed with children escorted by various adults.  Some are on queue to see the “P” clinical officer; s/he is ready to see the kids triaged as priority patients.  Others are in line to see the “Q” clinical officer who evaluates these patients prioritized at this lowest level.  But at one end of the structure is a walled-off area.  The door to this small room reads “Emergency.”  Inside are four beds for the sickest kids who require immediate attention.  This is where my journey with 7-year-old “Joyce” begins.

Joyce was brought in by two women—I’m still not sure how exactly they are related to her, if at all.  There she lay, listless, barely conscious, and struggling to breath.  On prying her eyelids open, I could see the yellow tint of her sclerae.  The accompanying adults added little more insight.  When asked about Joyce’s status, the guardian responded that she is HIV negative.

I was in the U5 clinic to visit with Dr. Jeff Robison.  He is an American pediatrician working with the Baylor HIV Initiative here in Lilongwe, Malawi.  Jeff plans a career in pediatric emergency medicine and as such has a tremendous interest in the acute care of children.  I was spending the day with him to see how he has affected the delivery of acute care to children.  But as the need arose, I jumped into action to lend a helping hand caring for patients.

The team, including a clinical officer, a nurse and another pediatrician from the UK, struggled to get IV access.  The British pediatrician and I finally secured two IV lines—one in the arm and the other in the neck.  Joyce’s pulses were fast and thready at times and she was clearly in shock.  What is from malaria or bacteria?  The blood smear didn’t reveal any parasites, but it could still certainly be malaria.  Fortunately, at this U5 clinic at Kamuzu Central Hospital, we could get a malaria smear, glucose and hemoglobin measurements, as well as a pulse oximetry reading right away.  Joyce’s glucose was so low that the machine read only “low.”  Her hemoglobin concentration was amazingly only about 2 grams (far below the normal range).  And her pulse oximetry read only 77% on room air with a heart rate of about 150 beats/minutes—both signs of a girl in great distress.  We needed to take action, or Joyce was going to die right in front of us!

Thankfully, Dr. Robison and his team have truly changed how acute care is delivered in this U5 clinic.  Those of us from the developed world may take this for granted, but any who have spent time in the developing world, particularly sub-Saharan Africa, know that quality emergent care is not commonplace.  At least at this hospital, a kid would usually wait in a long queue to be seen by a clinical officer (who is neither a nurse nor a physician).  In Joyce’s case, the clinical officer likely would have identified her as very ill and just directed her to the wards to be admitted—no further evaluation and no life-saving interventions!  But luckily for this little girl (and seemingly many others), things have changed at Kamuzu Central Hospital.

Clearly Joyce needed blood, and it was ordered from the laboratory.  In the meantime, we rapidly infuse lots of saline—bolus after bolus.  She doesn’t improve.  We infuse dextrose, but still, Joyce’s condition worsens.  She is given oxygen and broad spectrum antibiotics, yet her pulse weakens.  “Where’s the blood?” Dr. Robison asks and asks again.  Inside, I was thinking that if this girl didn’t get blood yesterday she’s as good as dead.  To make matters worse, Joyce has another seizure (two or three in total).  Just as hope seem to fade away completely, along comes Dr. Robison with the blood.  He had taken it upon himself to go fetch it from the laboratory while the team and I continued to care for our critical patient.

The nurse hung the blood—two units in all.  The clinical officer now infused quinine for the suspected malarial infection.  Joyce’s pulse improved with the blood.  She was responding, ever so slightly, to our critical interventions.  But her breathing became more labored, and she remained barely responsive.

In richer parts of the world, Joyce surely would have been intubated at this point, but that’s because there would have been a bounty of ventilators and good intensive care unit (ICU) support.  But here in Lilongwe, where could this critically ill child go?

I followed Dr. Robison to Kamuzu’s very small and modest ICU, where he pled the case for admitting Joyce to the unit.  You have to understand that this ICU only has four, maybe five beds—and more importantly—only four ventilators.  Resources in this environment have to be rationed very carefully.  Fortunately, one ventilator (the one used for kids) had just become available.  The ICU team was fearful, however, that the man who had just been extubated would not “fly” and would need the ventilator again.  One of the ICU team said, “Bring her by on a trolley on your way to the ward.”  We said OK.

We ran back to the U5 clinic where Joyce was still fighting.  We packaged her up for transport to the ward—and hopefully ICU.  Dr. Robison, a volunteer nurse from Spain and I pushed the trolley as fast as we could to the ICU.  I was literally holding the infusing blood above my head while helping to push the patient.  On arrival to the ICU, the intensivists came to evaluate Joyce.  They were clearly concerned about her condition and quickly assumed care.  First order of business:  intubation!

I visited Joyce in the ICU later that same day and again a day later.  She looks better and is breathing much easier.  I found out that contrary to what her guardians told us, she is HIV positive, which I suspected given the very fine texture of her hair.  I used to see this a lot in AIDS patients during my training in Baltimore some years ago.  The intensivists agreed with our assessment (septic shock of some sort) and were continuing to support her.  All we can do now is hope.

Update 12/18/09:  Unfortunately, Dr. Martin has just learned that Joyce died.

Science, not science fiction: two flu drugs studied at UNC

[Originally posted on the UNC Health Care blog and penned by Clinton Colmenares]

When Scott Pelley of “60 Minutes” asked HHS Secretary Katheleen Sebelius about political punditry critical of the public health response to novel H1N1, she pointedly said, “I tend to like to get my health advice from doctors and scientists.”

She’ll be getting some of her advice about treating flu from UNC. Charlie van der Horst and Christopher Hurt, from our much heralded Center for Infectious Diseases, are each leading the first studies of medications for IV treatment of influenza.

ID at UNC is known around the globe for groundbreaking work in HIV/AIDS and other scourges. They’ve identified who’s most at risk for HIV and potential ways to prevent infection. But this is the first inpatient flu study.

“We’ve never had IV drugs (for flu) before. Ever,” says van der Horst, who ran his first clinical trial in 1983 at UNC. “Each year in the U.S. 35,000 people die from flu … We’ve had nothing to offer these people,” van der Horst says. “We’ve routinely had patients die.”

Novel H1N1 put a scare in the medical community because, Hurt and van der Horst say, it resembled “Spanish” flu that killed tens of millions of people around the world from 1918 to 1920. Both bugs started in spring and made a come-back in the fall. If you get the flu now, you can bet it’s H1N1, van der Horst says.

Late-20th century medicine gave us the anti-flu drugs Tamiflu, Relenza and peramivir. Tamiflu is taken orally; Relenza is aerosolized. They prevent the flu or shorten its duration. So it made sense to provide them in IV form, which provides a more accurate, assurable dosage that goes directly to the bloodstream in people who are hospitalized and beyond the help of chicken soup.

Hurt is studying peramivir, a medication that had not been tested until recently. It’s only available in IV form, and the criteria for receiving the drug in the study are pretty tight; prior treatment with Tamiflu eliminates a lot of people.

But viruses mutate for a living, and novel H1N1 has beefed up its resume by showing some resistance to peramivir’s close kin, Tamiflu, in an isolated instance. One of the usual seasonal flu viruses from last year had widespread resistance to Tamiflu. Both medications operate by blocking the same protein to keep the virus from spreading.

So far, novel H1N1 hasn’t shown widespread resistance to zanamivir. And to get into that trial a patient has to be sick enough to be hospitalized for five days and, basically, have the flu. It’s open to pregnant women, people on ventilators, people who have received other flu meds, etc.

As for the protection against pundits, some are more innoculated than others. Van der Horst waves them off. “Vaccine and medication development in the U.S. is based on pure science, not science fiction,” he says.