Three in the World

1. The Cholera Crusade

Sending medical expertise around the world - on a CD, no less
By Jacqueline Mitchell

Right now as you read this, someone is suffering from cholera. The fast-acting diarrheal disease is sweeping through refugee camps in Congo, where a quarter of a million people have been displaced by civil war. In Iraq, which did not see outbreaks for 50 years, health officials have confirmed more than 300 cases across nine provinces. "Cholera is one indicator of the collapse of a civilization," says Eric J. Nelson, MD/Ph.D10.

Nelson is on something of a crusade to educate relief workers and public health officials about how to stop a cholera outbreak in its tracks. Together with his colleagues, including Danielle Kauk, '07, a second-year resident in Tufts' family medicine program, Nelson developed the Cholera Outbreak Training and Shigellosis (COTS) program, a CD-ROM that's part textbook, part instruction manual, about the prevention, diagnosis and treatment of diarrheal outbreaks.

As a Ph.D. student in the lab of Andrew Camilli, professor of molecular biology and microbiology, Nelson focused on cholera's transmission and pathogenicity, the mechanisms by which the bacterium causes illness. When he was awarded a Fogarty International Center/Ellison Medical Foundation research fellowship - which pairs U.S. health science students with research partners in developing nations - Nelson knew there was only one place he wanted to go.

Bangladesh, a nation of 1.5 million people wedged between India and Burma, sees two cholera outbreaks each year and has become a sort of global ground zero for cholera occurrence. "Cholera outbreaks are so well managed there, people are almost complacent about it," Nelson says. But, he notes, this kind of expertise is lacking in Africa and other places where cholera occurs.

In 2005 Nelson and Kauk traveled to the International Center for Diarrheal Diseases Research in Bangladesh, an organization that is the world's leading authority on handling cholera outbreaks.Working with Bangladeshi experts and David Sack, professor of international health at Johns Hopkins Bloomberg School of Public Health, Nelson began to put the COTS protocol together on a CD as a quick, easy way to export Bangladesh' s clinical expertise in handling cholera outbreaks to places like Africa and the Middle East.

Caused by the bacterium Vibrio cholerae, cholera is most often transmitted through contaminated water and food, so outbreaks occur where people lack access to clean water and modern sanitation.Untreated, the sudden, acute diarrhea that cholera brings on can kill an otherwise healthy adult in just a day. But with treatment, less than one percent of people who contract the disease will die.

Much of the three-part COTS CD-ROM offers strategies for organizing patients, staff and supplies. The knowledge base section is a virtual textbook, reviewing the basic science and clinical treatment of cholera and other diarrheal diseases, including shigellosis, a food-borne illness usually caused by an organism found in water polluted with human feces. The virtual hospital portion of the CD describes the most efficient layout for an emergency treatment center, including staffing requirements for each station. Nelson envisions a relief worker reviewing the CD on a plane headed to the scene of an outbreak. "I want to get people on the ground teaching this material within an hour or two," he says.

Supported by a grant from the U.S. Agency for International Development, (USAID), the collaboration was something of a family affair. Kauk researched and wrote most of the text. Robert de Leeuw, a colleague in Bangladesh, handled programming and photography. Kauk's sister, a professional actress, provided the voiceovers. Nelson wrote and performed the CD's soundtrack.

The team's three-year effort has been well received by peers. They've presented COTS at two National Institutes of Health conferences and have fielded inquiries from the World Health Organization and Doctors without Borders. After the thousands of hours the team has spent on the project, Nelson and his colleagues are anxious to get the COTS program into the right hands. Soon they hope to see the program translated into other languages, including French and Arabic. TM

2. Dialysis in Cameroon

Wayne Trebbin brings first-class renal care to a land where witchcraft rules
By Bruce Morgan

On his first trip to africa, the American physician had just landed and was engaged in friendly conversation with his hosts in a parking lot when the airport disappeared from view. The blackout was complete. A few people laughed uncomfortably, and then a nearby voice offered, in a lilting, accented voice, "Welcome to Cameroon, doctah." A moment later, the airport returned as the electricity came back on line.

The adventure was just beginning. Salem, Massachusetts, may have been an unlikely starting point for a medical rescue mission - or, contrarily, if you think like Wayne Trebbin, '72, it was as good a place as any. It was there at Salem Hospital that he first heard about the problem that would later absorb him. Trebbin, trained as a nephrologist, was talking to one of his residents who happened to be Cameroonian. Chronic renal failure in my home country, the young man told him quietly, "is a death sentence." Trebbin began to wonder what he might do about improving people's lives 7,000 miles away.

Over the past several years, under the auspices of a nonprofit he formed called WORTH (World Organization of Renal Therapies), Trebbin has opened a small dialysis unit at the Central Hospital in Cameroon's capital, Yaounde', that has brought sophisticated Western-quality levels of renal care to the country for the first time.He has managed to overcome a bevy of local challenges - social, cultural, environmental - and has actually bettered U.S. survival rates for end-stage renal disease in the process.

"In sub-Saharan Africa, doing high-tech medicine is extremely difficult," Trebbin points out. Dialysis requires, at a minimum, reliable power supplies and ample clean water to run the machinery, and these basics remain luxuries in a place like Cameroon, a country of 16 million people the size of California. The per-capita annual income is a little more than $2,000, and life itself is a chancy thing. Life expectancy for Cameroonian men and women averages about 53 years.

How many people in Cameroon need dialysis? Right now, no one can possibly know, says Trebbin. Adequate medical records are non-existent in most of the country. Most people rely on tribal authorities for diagnosis and treatment of physical ills. If a man is sick with uremia, for example, a symptom indicating that he needs dialysis, "he'll go to the local healer and be treated for witchcraft," Trebbin suggests. "How can you determine accurate pathology in that context?"

The American doctor is not being dismissive of tribal ways in telling the story - he's merely stating a fact of life. In fact, Trebbin has been adopted as an honored member of a local tribe and takes pride in his inclusion. "I'm a Royal Court member of the Bali tribe," he says. "Now, when I say 'tribe,' I'm not talking about grass huts," he adds. "Picture something more like an impoverished city with 80,000 residents."

For now, Trebbin's presence in Cameroon is a drop in the ocean of need.Using second-hand donated American equipment, and supported by donations from back home, he has one dialysis unit up and running, with 16 patients in the care of 10 on-site nurses.He is in the process, with the financial support of NBA All-Star Dikembe Mutombo, of opening a second dialysis unit in the Democratic Republic of Congo, where the basketball player was born, and likely launching more initiatives as well. Trebbin's purpose is twofold. He hopes, first, to save some African lives. Beyond that, he wants to set an example for his fellow physicians of the sort of mission they themselves might take on. Ideally, he says, he would like to see these doctors "do something and do it relentlessly."

"Cameroon, in many ways, is symbolic of Africa," Trebbin wrote recently in the American Journal of Kidney Disease. "It is poor. It is struggling. And it has great promise! We are succeeding in introducing and maintaining, at a high level, a form of technology few would have believed possible to implement in the developing world. We have shown it can be done."

For more about WORTH, go to worldorganizationofrenaltherapies.org
Bruce Morgan is editor of the Tufts Medicine Magazine

3. Traffic Jam

A recent grad examines child pedestrian injuries in Peru
By Jacqueline Mitchell

When Joe Donroe found himself heading to Peru to begin a public health research project a few years ago, he thought he would study one of the infectious diseases that ravage poor people around the world. But on the bustling, overcrowded streets of Lima, he discovered another public health problem: the high rate of pedestrian traffic injuries, especially those involving children.

"Injury prevention is an important issue in poor countries, but it is often overlooked in the age of HIV, TB and malaria," says Donroe, A98, M.D./M.P.H.07. "Traffic injuries are projected to be one of the biggest causes of death in developing nations, and children suffer the most."

Donroe, a former captain of the Tufts basketball team who went on to earn a dual M.D./M.P.H. degree from Tufts Medical School, was already familiar with Peru. In 2005 he founded LimaKids, a nonprofit that enables orphaned, homeless and abused children to experience some of the joys of childhood on the soccer field. So when he was named a recipient of a Fogarty International Center/Ellison Medical Foundation research fellowship, there was little question about the direction he would head.

Working with Robert H. Gilman, professor of international health at Johns Hopkins Bloomberg School of Public Health, Donroe and his colleagues took stock of the traffic conditions in Lima and analyzed what environmental and behavioral factors lead to pedestrian accidents. Public health researchers have extensively analyzed these topics in wealthy nations, but Donroe was interested in the "locally relevant modifiable risk factors" specific to Lima.

"I wanted to know the specific risk factors that might lead a child to get hit in Lima and how they might be different for a child in the U.S.," says Donroe. "The cultures are different; we might expect kids to behave differently and for traffic patterns to differ."

Knocking on doors in San Juan de Miraflores, a poor section of Lima, Donroe and his team collected information about 100 child pedestrian injuries dating back to 2000. They gathered data about the accidents - what time of day, where the child was headed - as well as demographic information about affected families, such as income, number of children in the family and parents' level of education.

Donroe also considered the scene of the accidents, assessing factors at 40 accident sites, such as traffic volume and speed, the presence and use of crosswalks and the presence of street vendors. As in the United States, Donroe found that high traffic volume and speed are major risk factors in Lima. Donroe cites the pervasive motorcycle taxis on Lima's already-chaotic roadways. "There seems to be a lack of regulation.You see a lot of underage drivers operating overcrowded motor taxis," he says. "Residents comment on how they zip up and down streets. There is definitely room for legal enforcement."

While Lima's lack of painted lane demarcations, traffic lights and crosswalks contribute significantly to injuries, Donroe also identified some risk factors unique to the city. For example, Lima's high number of street vendors turned out to be a significant risk factor. They create hazardous conditions by blocking streets, diverting traffic, concealing oncoming vehicles from view and distracting pedestrians and drivers.And while poorly educated mothers are one important risk factor in the developed world, there seems to be no relationship between maternal education and pedestrian traffic injuries in Lima.

Donroe's research was, in part, inspired by the work of Doug Brugge, associate professor of public health and family medicine, who examined pedestrian traffic injuries in Boston's Chinatown. Donroe had taken Brugge's course in community collaborative research before leaving for Peru, and Brugge served as a faculty advisor for Donroe's study.

Though Donroe is currently a resident in medicine and pediatrics at Yale, he hopes to return to Peru to follow up on the study, published September 10 in PLos ONE, the online journal of the Public Library of Science. "The hope is the research translates into intervention," he says. "The next steps would be to do the experiments with our findings and see if it can reduce traffic injuries. I hope that would generate the political will to make some changes." TM