Author: plosmedstudent

Do all roads lead to ROME (Research Oriented Medical Education) in India?

Research is a massively neglected part of undergraduate medical training in India. Students join undergraduate medical courses straight after high school, but the emphasis on scientific inquiry in the secondary and higher secondary levels at school is restricted. This, together with a curriculum that does not encourage research during medical studies, goes a long way to ensuring that medical students have minimal exposure to research.

Classically, the developing world has applied the medical knowledge generated in the developed world to solve their needs. But as we progress into an era of evidence based medicine, the need for thinking global and acting local is getting more intense. We need Indian medical practitioners to generate research data specific to India. But with an undergraduate education system that barely touches on research, the average Indian Medical Graduate lacks  the tools s/he needs to provide the best service to society and to Medicine. If India is to become a major player in the medical/healthcare fields in the near future, then a medical education system which incorporates the best of both the clinical and research worlds needs to be devised and implemented at the earliest possible opportunity.

A survey by the Indian Council of Medical Research (ICMR) revealed that about 20% of medical colleges did not publish a single original research paper in the period between 1990 and 1994 . A recent survey by Elsevier based on bibliometric analyses revealed that while India is in the global top ten for research article output, ‘health sciences/medicine’ still featured in the ‘not so strong’ category. Although the nation produces more than 30,000 doctors annually, the research output is insignificant. However, this cannot be blamed on a lack of interest of medical students in research. The Summer Research Training Scholarship offered by the ICMR (ICMR-STS) has gained great popularity amongst the students, as seen by the rise in recipients from 496 in 2005 to 802 in 2011.

What can be done to promote a Research Oriented Medical Education in India?

1. Provide a formal introduction to research methods as part of the medical curriculum, including critical appraisal of evidence.
2. Establish an MBBS/PhD or MD/PhD Course. Initiating such a program would produce more physicians committed to research and produce role models that we, as medical students, could emulate.
3. Support INFORMER: the Forum for Medical Students’ Research, India (INFORMER) brings all students interested in medical research together. Its annual flagship conference, MEDICON, is organized by medical students for medical students. INFORMER needs institutional support, from the Medical Council of India and the State Medical Councils to extend its support to more medical students. In this regard, it is worthy to mention the efforts of the Moving Academy of Medicine and Biomedicine, which has started regional conferences for undergraduate medical students to present their research and attend research orientation workshops as well. (5)
4. Strengthen Infrastructure and Research in Medical Colleges:
Trained mentors, teachers, research infrastructure, adequate laboratory support are lacking in all but the best of institutions.
5. Student Publications:
There are few student journals in India. The launch of the Student IJMR is a laudable step forwards. Student-led efforts in editing and running journals focused towards students’ research need to be encouraged in medical schools.
6. Rewarding Research Involvement:
Until and unless medical research brings some benefits to the students, there is little chance that it shall be viewed as anything else but a distraction.

The revolution to involve more medical students in research so as to improve the quality and quantity of biomedical research in India has started. It now needs institutional support and impetus to go forward. And the first step in that direction is to expose medical students to research as early as possible. The Medical Council of India has advocated the introduction of electives in various topics including research methodology in its proposed Vision 2015. And though these reforms may take some time to be brought in, one has to remember that ROME was not built in a day.

Guest post by Pranab Chatterjee, MBBS, Medical College Kolkata, Kolkata, India & Tamoghna Biswas, 8th Semester(Final Year) MBBS, Medical College Kolkata, Kolkata, India (tamoghnab@gmail.com)

Competing interests: Pranab Chatterjee was associated with INFORMER. Both the authors(PC and TB) were reviewers at Student BMJ and the Lancet Student (not presently reviewing). Both PC and TB have been recipients of some/all of the research fellowships mentioned in the text. Both PC and TB are country representatives of HIFA 2015, and have been staunch supporters of the open-access movement. TB was selected a student ambassador of Elsevier India.

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Tackling the Global Epidemic of Non-Communicable Diseases

Guest student blog by Fiona Rae, third year medical student at the University of Edinburgh [fionaelizabethrae@gmail.com].

In September 2011 the issue of non-communicable diseases (NCDs) will be brought to the attention of a UN General Assembly at a High Level Meeting in New York. In April 2011, key stake-holders are gathering for a preparatory WHO led-forum on NCDs in Moscow. However, in March 2011 on a particularly blustery day in Edinburgh, students, activists, academics and policy-makers gathered to offer their own contribution towards ‘tackling the global epidemic of non-communicable disease’ by participating in a conference organised by Edinburgh University’s Global Health Academy. Representing the student-led campaign Universities Allied for Essential Medicines (UAEM), I entered the discussion, hoping to inspire and expecting to be enlightened.
I was not disappointed. However, I imagine that some of the audience was when it was revealed that keynote speaker Dr Ala Alwan of the WHO was unavoidably held up in Geneva and so would be presenting electronically rather than in person. Nevertheless, Dr Alwan’s presentation was still vibrant. NCDs cause 35 million deaths every year, accounting for about 60% of the global disease burden. 80% of this burden is borne by Low and Middle-Income Countries (LAMICs). In fact 9/10 deaths before age 60 from NCDs occur in LAMICs. But, in the next 10 years NCD deaths in Africa are projected to increase by 27%. Such an emphatic overview further opened my eyes to the reality that in terms of fighting the Global Burden of Disease, we are already losing the battle. Even more worrying is the dangerous lack of awareness of this threat of NCDs to global health. Just one week before this conference I sat with a hundred other third year medics in a lecture on cardiovascular disease and was ‘taught’ by a specialist pathologist that atherosclerosis is a disease of affluence and ‘not something that you find in the developing world.’ However, I now know that an estimated 80% of deaths due to cardiovascular disease currently occur in LAMICs!

It is easy to feel disempowered by such widespread misconceptions, but the rest of the morning’s talks were uplifting. Playwright Mr Murray Watts, took a philosophical perspective on tackling NCDS and iterated that ‘despair is not the opposite of hope. . .cynicism is’. Students are frequently harangued for being too idealistic. However, Watts emphasised that being unchangingly pessimistic is not a mark of wisdom. Mary Cuthbert, head of the Scottish Government Tobacco Control Policy, certainly brought this message home when discussing the process of achieving Scotland’s Public Smoking Ban. Cuthbert described how 20 years ago, the idea of a smoking ban was deemed highly unrealistic, 10 years ago was thought to be ‘political suicide’ and now 5 years on since successful implementation of the ban there has been a 15% drop in hospital admissions for asthma in children and a 17% fall in heart attacks.

However, my optimism did not survive the conference’s panel discussion. A specialist psychiatric registrar in the audience asked the panel where mental health disorders fitted into the upcoming NCD conferences. The answer? They don’t. The panel responded that the current UN outlook is that not everything can be included, and the focus is going to be on the four diseases causing the greatest mortality: cardiovascular disease, cancer, diabetes, and respiratory disorders. It pained me to see lessons from the communicable diseases being ignored. For years we have been focused on the ‘Big Three Killers’, HIV, malaria and TB, whilst the Neglected Tropical Diseases remain critically underfunded, because these have the misfortunate of destroying lives, but not always ending them. It seems that the international community is incredibly narrow-minded in its approach to tackling the global burden of disease, despite the WHO’s famously broad definition of health.

The afternoon of the conference was a ‘speed-dating’ series of 5 minute presentations from grass-roots organisations. Representing UAEM, an international student-led campaign, I outlined our solutions to improving access to NCD therapies. First up was our mission to ensure that future NCD medicines developed in universities will be affordable and available in the developing world. This we hope to achieve through equitable licensing strategies between universities and the pharmaceutical industry. Second, our intention to raise awareness of the importance of rational procurement of NCD medication by empowering students to take action on this issue, for example through our past work in expanding the WHO’s Essential medicines List (EML) to incorporate NCD therapies (1). I also emphasised our intention in 2012 to campaign for the addition of mental-health drugs to the EML. Perhaps this generation of ‘idealistic students’ can hope for a future where we recognise the importance of holistic healthcare.

For more information on UAEM please visit www.facebook.com/uaemuk or www.uaem.org or email Fiona Rae at fionaelizabethrae@gmail.com.

Fiona Rae

Fiona Rae is a third year medical student at the University of Edinburgh who graduated from Bristol University last year with a BSc in International Health. She has been a member of UAEM for 3 years and has a special interest in intellectual property rights, the pharmaceutical industry and new models of incentivising health technology research.
(1) Kishore, S, P. Herbstman B, J. (2009) ‘Adding a Medicine to the WHO Model List of Essential Medicines’, Clinical Pharmacology and Therapeutics, 85(3): 237-239

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Patent pool party highlights lack of access to HIV drugs

Guest student blog by Harriet Gliddon, third year Biochemistry undergraduate, Imperial College London [harrietgliddon@googlemail.com]

Student campaigners promoting access to affordable HIV treatment held a National Day of Action on 30/03/11. In the small hours of a grey, chilly day in March fifty students from all over the UK gathered at the Restless Development offices in Westminster as part of a National Day of Action co-ordinated by the Student Stop AIDS Campaign.

The atmosphere was thick with excitement and anticipation, as beach balls and rubber rings were inflated and bikinis fitted. Why? For a pool party, of course. But this was no ordinary pool party; it was a patent pool party. After setting up outside the Johnson & Johnson UK headquarters (and lengthy negotiations with security), the pool party got started, with the Beach Boys and S Club 7 getting us in the mood for some pool party fun.

Along with partners from the US, we are currently calling on Johnson & Johnson to enter into negotiations with the UNITAID Medicines Patent Pool (MPP), so that HIV drugs like Darunavir (currently patented by Tibotec/Johnson & Johnson) can be made accessible to the people who need them.

10 million people worldwide are still without access to HIV medication. Paediatric formulations are in huge need of serious research, and the lack of affordability of existing drugs, particularly fixed-dose combinations, is crippling their supply to HIV patients in developing countries.

One solution to this is for those who hold patents to voluntarily sign them over to the MPP, which would then allow both researchers and generic producers access to the drug. This would mean that as well as companies being able to manufacture it for a fraction of the price, further research could be carried out on the product to make it child-friendly or appropriate for use in resource-limited and/or tropical climates. Meanwhile, the patent holders would receive fair loyalties in exchange. So instead of one company having a monopoly, multiple manufacturers would be able to produce a given drug, which would lead to competitive pricing and a huge fall in drug prices.

The importance of the MPP cannot be underestimated. However, in order for it to establish itself as a viable solution to the access to HIV medicines crisis it is essential that industry members agree to license their patents to the MPP. In December 2010, we urged GlaxoSmithKline/Viiv Healthcare to enter into talks with the MPP. While it is encouraging that Gilead Sciences, Sequoia Pharmaceuticals, Viiv Healthcare and the US National Institutes of Health are all currently in negotiations, other members of the pharmaceutical industry, including Abbot, Merck, Bristol-Myers Squibb and Johnson & Johnson/Tibotec, have so far declined invitations to enter into any such negotiations with the MPP.

It wasn’t all fun and games though. Diarmaid McDonald, the coordinator of the Stop AIDS Campaign, was permitted to enter the building (after some mild persuading of security). He managed to organise a meeting with representatives from Johnson & Johnson to discuss negotiating with the MPP. This was fantastic news and spurred us on to continue the rest of the day with as much energy and enthusiasm as we showed at the patent pool party!

Back in London, we were joined by another fifty or so students who had travelled from further afield. In the pouring rain, we staged a beautifully acted patent pool role-play on Oxford Street, with pills being prevented from joining the patent pool by pharmaceutical representatives.

During the afternoon, we turned our attention to certain provisions being laid down during the negotiations of the EU-India Free Trade Agreement. India is currently an incredibly important source of affordable HIV drugs for patients in developing countries. However, there are fears that India will give in to pressure from the European Commission and strengthen its patent laws, meaning that the production of affordable HIV antiretrovirals is under threat. Of particular concern is data exclusivity, which governs access to clinical trial data. If this was to be enforced, generic producers would no longer have access to clinical trial data and so would be forced to choose between waiting for another ten years or so, or running the clinical trials themselves. Clinical trials are notoriously expensive, and repeating them is deemed unethical because it would require a control group to be subjected to less effective drugs than are currently available.

There have been indications that pressure has come from the UK to enforce ‘TRIPS Plus’ (Trade-Related Aspects of Intellectual Property Rights) measures like data exclusivity. Whether this is to appease the pharmaceutical industry is a matter of debate, but it is essential that politicians are made aware of the consequences of these clauses. For this reason, many of us involved in the National Day of Action arranged to meet with our MPs and inform them of these critical negotiations. Most have responded positively and have agreed to take the matter further. We also campaigned outside the Department for Business, Innovation and Skills and managed to arrange a meeting with the Business Secretary, Vince Cable, to urge him to ensure that data exclusivity is not included in the free trade agreement.

Despite achieving our lofty goals for the day, what really made it such a success was the bringing together of so many passionate, ambitious and open-minded students. This seems to happen far too rarely these days, and it is very easy to forget just how inspirational our own peers can be.

The Student Stop AIDS Campaign (SSAC) aims to stop the HIV/AIDS pandemic through promoting universal access to evidence-based prevention, ensuring long term and sustainable treatment and care whilst providing education to reduce stigma and discrimination. For more information, visit http://www.stopaidssocieties.org.uk/ or email lotti@restlessdevelopment.org.

Universities Allied for Essential Medicines (UAEM) promotes access to essential medicines in developing countries, research into neglected diseases and the empowerment of students worldwide. We are particularly interested in the way universities license health-related products to industry. For more information, visit www.facebook.com/uaemuk or www.uaem.org.

Harriet Gliddon

Harriet Gliddon is a third year Biochemistry undergraduate at Imperial College London, where she will be completing a PhD funded by the Medical Research Council in the next four years. Her research will focus on the molecular biology of infectious diseases, but she is also particularly interested in the translational aspects of medical research and access to medicines.

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Addressing the Needs of Cancer Survivors: An Emerging Global Challenge

Guest student blog by Matthew J. To, BMSc candidate,  Schulich School of Medicine and Dentistry, The University of Western Ontario (email mto3@uwo.ca)

This past summer, I worked as a research student at a new cancer survivorship research centre, one of the first of its kind in Canada [1]. It was through working at the centre that I came to realize the enormous challenge that the global community is faced with in addressing the needs of cancer survivors. In this piece, I hope to share some of the things I learned through my work experience.

Despite the huge amount of cancer research that is being conducted worldwide, it is clear that this disease or rather, this set of diseases, will be sticking around for a while [2]. With the ever increasing number of individuals who are diagnosed, the emerging field of cancer survivorship plays an important role in highlighting and addressing the needs of patients from the time of diagnosis to after treatment. There are over twenty-eight million cancer survivors worldwide [3]. Traditionally, a cancer survivor is someone who has been diagnosed with cancer, but this definition has been updated to include family members, friends, and caregivers of the affected individual [4]. Cancer survivorship as a field deals with a whole range of issues including but not limited to cancer-related physical and psychological issues, lifestyle after treatment such as the return-to-work transition as well as follow-up care and prevention of secondary malignancies [4].

In the past, it was not particularly clear whose responsibility it was to address issues like cancer-related fatigue after treatment. If the patient had already received the proper treatment, were they expected to approach their family physician or their oncologist? For more sensitive topics like psychosexual issues prevalent in genitourinary cancers, patients and physicians alike may have been uncomfortable in addressing the topic. However, this appears to be changing. For example, family physicians want to be more involved in managing care for patients affected by cancer and oncologists have been involved in the delivery of follow-up models which include screening for recurrence and promoting healthy lifestyles [5, 6]. Also, many non-profit organizations such as the National Coalition for Cancer Survivorship have worked tirelessly to raise awareness about the issues faced by cancer survivors and advocate for high-quality care [7].

Delivering quality survivorship care is often complicated by the fact that each type of cancer has its own unique set of subtleties that need to be addressed. For example, testicular cancer primarily affects young men between the ages of 15 to 35 and high cure rates of the disease have led to a huge increase in the number testicular cancer survivors [8, 9]. Some issues that these survivors are faced with are infertility and sexual dysfunction [10]. Managing survivorship care for this younger population of survivors would be markedly different from a disease like lung cancer which generally affects an older population. Moreover, factors such as employment status, food availability, and emphasis on spirituality differ between populations within each country and between countries. This means that countries will have to develop survivorship strategies that uniquely address the needs of their respective populations [6]. Furthermore, the aging of the oncology workforce and the increasing number of survivors worldwide presents an additional challenge [11].

Undoubtedly, individuals diagnosed with cancer will need much more than the latest surgical intervention to live healthy and happy lives. Cancer survivorship as a field seeks to address the needs of survivors with a holistic and increasingly community-engaged approach. As the global population of survivors steadily increases, more partnerships between health care professionals, research groups, and community organizations are needed to bring cancer survivorship forward in tackling the unique challenges faced by those impacted by cancer.

References

1. ELLICSR (2010) Available: http://ellicsr.ca. Accessed: 24 February 2011.

2. Downar J (2010) Cancer: it’s time to change the sign. CMAJ 182: 1588.

3. American Cancer Society (2008) Lance Armstrong Announces Global Cancer Summit. Available: http://www.cancer.org. Accessed 24 February 2011.

4. National Cancer Institute (2006) About Cancer Survivorship Research: Survivorship Definitions. Available: http://cancercontrol.cancer.gov/ocs/definitions.html. Accessed: 21 February 2011.

5. Grunfeld E (2005) Cancer survivorship: a challenge for primary care physicians. British Journal of General Practice 55: 741-742.

6. Robinson E (2010) Expert Editorial: The Global Puzzle of Survivorship: Assessing Current Standards, Gaps, Best Practices. Available: http://www.asco.org/ASCOv2/Meetings/Gastrointestinal+Cancers+Symposium/2011+Gastrointestinal+Cancers+Symposium+Daily+News/Features/Expert+Editorial:+The+Global+Puzzle+of+Survivorship:+Assessing+Current+Standards,+Gaps,+Best+Practices. Accessed: 24 February 2011.

7. National Coalition for Cancer Survivorship (2010). Available: http://www.canceradvocacy.org. Accessed: 21 February 2011.

8. Feldman DR, Bosl GJ, Sheinfeld J, Motzer RJ (2008) Medical Treatment of Advanced Testicular Cancer. JAMA 299: 672-684.

9. Gospodarowicz M (2008) Testicular cancer patients: considerations in long-term follow-up. Hematol Oncol Clin North Am 22: 245-255.

10. Arai Y, Kawakita M, Okada Y, Yoshida O (1997) Sexuality and fertility in long-term survivors of testicular cancer. Journal of Clinical Oncology 15: 1444-1448.

11. Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M (2007). Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 3:79-86.

Competing interests: Matthew To states that he worked as a paid research student at ELLICSR (Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research).

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Are White Coats Turncoats?

Guest student blog by William W. Motley, Neurogenetics Branch, NINDS, NIH, Bethesda, MD, USA (wmotley@gmail.com)

I was recently admitted to medical school and am excited to start my training to be a physician. Soon I will symbolically celebrate the beginning of my medical education at a white coat ceremony.

I am looking forward to joining a profession that constantly strives to innovate in its effort to improve outcomes. But the white coat uniform is a tradition that has persisted for too long and undermines our commitment to improvement. White coats introduce another vector for pathogens and reinforce hierarchy in medicine—to the detriment of the objectives of physicians.

Doctors’ coat cuffs harbor virulent bacteria1, 2. Often worn outside the hospital on coffee breaks, white coats are not treated as an aseptic barrier as they are in laboratories. White coats provide a vehicle for pathogens within the hospital and between the bedside and the curbside. British health officials have responded by issuing plans to eliminate white coats and encourage physicians to roll sleeves up to the elbows3. Hospitals in the US should follow suit.

When presented with short coats, medical students are effectively asked to submit to a dress code that establishes a hierarchy amongst healthcare providers. Medical researchers have conducted studies and shown that breaking down the hierarchical structure through team training exercises and simple checklists reduces surgical error4, 5. Rigid ranks inherently silence the concerns of those lower on the totem pole and result in missed opportunities to identify errors. Stopping use of white coats can help teach future physicians a valuable lesson in humility. By eliminating attire as a marker of hierarchical importance in the quest to improve care, we will encourage students to realize that doctors, nurses, technicians, and even students play a role in recognizing and stopping medical mistakes.

I realize that gaining the trust of a patient is an important part of effective doctoring and that this uniform helps instill confidence. A baby-faced 27-year-old, I would probably benefit from such a strong symbol of authority. But I hope that my communication skills (learned in medical school and before) and knowledge will be more effective tools than an infrequently laundered coat.

I think that more medical schools should start welcoming students with a stethoscope ceremony. White coats are superfluous uniforms; stethoscopes are important diagnostic tools. Stethoscopes also symbolize an even better way to gain the trust of a patient: by listening to them, and by listening to the evidence.

1. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ. Dec 21-28 1991;303(6817):1602-1604.

2. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers’ white coats. Am J Infect Control. Mar 2009;37(2):101-105.

3. The traditional white coat: goodbye, or au revoir? Lancet. Sep 29 2007;370(9593):1102.

4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. Jan 29 2009;360(5):491-499.

5. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. Oct 20 2010;304(15):1693-1700.

William W. Motley has submitted his PhD thesis in a combined program between the National Institutes of Health and the University of Oxford. This fall he will start his MD training at the University of Pennsylvania.

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Making anti-malarials from yeast: Jay Keasling and synthetic biology

Guest blog by  Shah R. Ali, an MD candidate at Stanford Medical School.

Malaria  is getting a cutting-edge, first world scientific treatment at the hands of synthetic biologist Jay Keasling.

The most effective antimalarial currently in use is artemisinin, which is effective against the Plasmodium falciparum species (the most lethal malaria-causing species), including multidrug-resistant forms. However, most of the available artemisinin is extracted from the Artemisia annua plant, and supplies depend on the yield and cultivation-related factors. Chemical synthetic options are being explored, but their potential costs are not lower than for extraction of the active ingredient from plants. Dr. Keasling’s synthetic biology approach to re-engineer yeast to synthesize a key artemisinin precursor is estimated to reduce the cost of artemisinin-based combination therapies by 30-60%.

Dr. Keasling recently spoke at Stanford Medical School as part of the “Access and Delivery of Essential Medicines” lecture series about the story of artemisinin. At the beginning of his talk, he surprised audience members by talking about computer parts. He used this example to make his point that “we often take for granted the standardization that is so important for engineering disciplines.” Standardization of various biological components is one of the major goals of synthetic biology. After providing the background of the field, he said, “we thought…we could engineer a chemical factory inside a microbe to produce [artemisinin].”

The premise is deceptively simple: since we know the metabolic pathway to synthesize the drug in A. annua, we should be able to put it into another easily-cultured organism to churn out the compound at high quantities. Dr. Keasling did just this: his team tested some steps in E. coli then moved onto S. cerevisiae, into which they engineered 1) a mevalonate pathway engineered to increase yield of farnesyl pyrophosphate, 2) the amorphadiene synthase gene, and 3) a novel cytochrome P450 monooxygenase. The modified yeast metabolizes simple sugars to artemisinic acid, a nontoxic precursor to artemisinin. This genetically engineered yeast strain could prove a boon for malaria patients worldwide. The work was funded by the Bill and Melinda Gates Foundation, which gave Dr. Keasling (UC-Berkeley), Amyris Biotechnologies, and the Institute for OneWorld Health $43 million for this project.

Amyris Biotechnologies optimized culturing conditions and the chemical process for scale-up, and Sanofi-Aventis has partnered with these groups and obtained a license to produce the drug on a large scale and sell it cheaper than the farmed artemisinin. Furthermore, Sanofi currently produces several antimalarial compounds and has distribution networks in the developing world, and their partnership with the Keasling team should enable access to the infected individuals who need the drug.  The Institute for OneWorld Health will support global access to the drug through public policy. The synthetic version of the drug is projected to cost a fraction of its current retail value, and thereby make it more affordable in resource-poor settings.

I think the reason that yeast-derived artemisinin has captured the attention of the media is that its story is compelling: a world-class researcher used cutting-edge science to produce a drug for the developing world, while collaborating with a start-up (Amyris), a non-profit drug-development company (Institute for OneWorld Health), and a for-profit pharmaceutical company (Sanofi-Aventis), and using the equipment and manpower of one of the premier research universities in the world (UC-Berkeley) and funds from the BMGF. This unique collaboration is all the more exciting given that the project actually worked in the laboratory, and many organizations and groups of people optimistically look forward to the translation of this benchtop discovery to the bedsides of infected individuals in the developing world. It remains to be seen whether such a scenario is, like a good experiment, replicable, but I hope that similar attempts will be made in the future that follow this paradigm. After all, Dr. Keasling did stress the importance of standardization.

Access and Delivery of Essential Medicines is a Stanford elective that aims to increase attention to diseases particularly concerning to the developing world at the medical school. The majority of talks, including Dr. Keasling’s, are recorded and made available to the public at www.adem.stanford.edu/talks.

Category: Neglected Diseases, PLoS Medicine's Daily Click, Students | Tagged , | 1 Comment

The role of medical students in limiting the spread of antimicrobial resistance

Guest blog by Adam Castaño, Sujal Parikh and Eunice Yu, medical students at the University of Michigan Medical School, Ann Arbor, Michigan, USA ( These authors contributed equally to this post). Contact Adam Castano on acastano@umich.edu.

Nowhere in the world is free from the spread of drug-resistant bacteria, parasites and viruses.  The World Health Organization (WHO) Global Alliance for Patient Safety has recognized the dual problems posed by the increasing incidence of drug-resistant bacteria and the decline in antibiotic innovation.  For the past two years, a working group of policy makers, scientists, epidemiologists, and economists have assembled at several international meetings to outline an international strategy to address antimicrobial resistance (1). Policy recommendations, to be launched in 2010, will establish new roles for governments, public health departments, industry, and physicians as primary stakeholders in AMR prevention and alleviation.  Physicians prescribe antimicrobials, contribute to the spread of pathogens (particularly hospital-acquired infections), educate patients about appropriate use of antimicrobials, perform research, and set research agendas.  Medical students are being trained in an era where the toll of antimicrobial resistant infections is evident on a daily basis.  As future physicians, they have the potential to help to address this problem.  Here, we describe new leadership roles for medical students within their medical schools, hospitals, communities, states, and countries to alleviate the problem of AMR.

The role of medical students in medical schools

Medical schools, in particular the preclinical years, offer time for extracurricular activities that could be devoted to student forums dedicated to educating peers and discussing antimicrobial resistance with faculty members from a wide variety of disciplines.  Medical students can form a student group, such as a chapter within their medical school of Antibiotic Defense , an organization of doctors, scientists, and professionals dedicated to conserving the availability and efficacy of antibiotics.  Initial meetings dedicated to discussing fact sheets and publications from experts and opinion leaders would build the knowledge base needed to understand core issues in the field.  Initiatives at the World Health Organization (2), ReAct: Action Antibiotic Resistance,(3) the Alliance for the Prudent Use of Antimicrobials,(4) and the Global Health Education Consortium (GHEC) contain useful information.  Antibiotic Defense, in conjunction with GHEC, has published an open-access online module that medical students can utilize to educate themselves about the global nature of antimicrobial resistance (5).

Once students have attained a baseline understanding of the field at the local, community, national and international level, they can help educate fellow students in health professional schools in their region.  GHEC accepts modules written by medical students designed to educate peers about issues pertaining to global health.  Medical students can also work with faculty in their medical school to identify and fix gaps in their curriculum.  Medical students should be informed of relevant international, national, and local policies affecting antimicrobial resistance, in addition to epidemiology, pathophysiology, and treatment.  It should be emphasized to medical students that they play a role in containing AMR (figure).

The role of medical students in hospitals

Medical students in hospitals – as healthcare providers and as inadvertent contributors to the spread of pathogens – play an important role in the containment of AMR.  Hospital-specific resistance trends and drug sensitivities for specific organisms can be learned from antimicrobial stewardship committee lectures and in-house publications.  Familiarity with such resources can inform accurate antimicrobial choices.  Equally important are drug resistance and sensitivity data for individual patients with culture-positive infections.  Medical students can find this data by calling the microbiology lab or contacting outside hospitals for transferred patients.  This up-to-date culture information can influence medical decision-making and ensure rational antimicrobial use.  Finally, medical students can contribute to patient safety guidelines and quality improvement efforts in addition to role-modeling infection control techniques for their patients, residents, and attendings (senior physicians).

The role of medical students in the community

In addition to promoting change in their schools and hospitals, medical students can play a key role as educators and advocates in their local communities.  The first step to fulfilling these functions is learning local patterns of AMR using resources outlined above.    Students can then educate their community by writing opinion pieces and informational articles that discuss the growing problem of antimicrobial resistance and highlight its local manifestations.  Articles specifically outlining steps for community members to limit the spread of resistance will be most applicable to community audiences.  For example, methods highlighted for a community should relate to its unique circumstances in addition to reiterating known containment methods, such as not sharing antibiotics or thoroughly cleaning shared items like gym equipment (6).[v] Students can also determine the extent to which local public health and sanitation regulations limit the spread of antimicrobial resistance and lobby policymakers to change those statutes to protect public health.

As students engage in these processes, they will undoubtedly encounter topics where no reliable information is available.  In these cases, joining a team that researches the biological, clinical, epidemiological, social, or economic aspects of antimicrobial resistance can generate the knowledge required to engage the activities outlined throughout this article.

The role of medical students in their state and country

Medical students can also influence discourse and policy at the provincial, state and national level.  For example, In the United States, state health departments and the National Institutes of Health (NIH) offer opportunities for medical students to work to address the problem of AMR.  Internships at state health departments could be arranged in order to learn epidemiology and public health initiatives involved in AMR surveillance and containment.  At the national level, the NIH offers prestigious year-long fellowships in basic, clinical, and translational research.  Such a program can be pursued to study the latest issues and solutions in AMR (7). Medical students interested in the politics and policies related to AMR can pursue similar internships in the office of a United States Congressperson.  In addition, the collective voice of medical students can be harnessed through organizations such as the American Medical Student Association (AMSA) or American Medical Association (AMA) in support of efforts to strengthen research and development in this sector.  Similar efforts can be pursued in other countries by working with state and provincial health departments, national medical organizations, and the International Federation of Medical Student Associations.  The World Health Organization offers additional opportunities for medical student contributions both at its Switzerland headquarters and at regional offices in the United States, Denmark, the Philippines, India, the Congo, and Egypt.

A fundamental shift is needed in our attitudes to antimicrobials.  What if antimicrobial effectiveness – not just antimicrobials themselves – was viewed as a global public good, much like clean water and forests?  Antimicrobial effectiveness is a depletable resource, accessible to all but limited in quantity.  Every time someone uses an antimicrobial, the effectiveness of that drug is slightly “used up” or “lost.”[vii] This continual depletion of antimicrobial effectiveness diminishes our ability to combat life-threatening infections and practice modern medicine.  The spread of resistance by antimicrobial overuse is therefore similar to the problems we face with regard to other resources, such as carbon emission, overfishing, and the exhaustion of oil reserves.   If we view antimicrobials as a global public good, a powerful agent whose effectiveness belongs not to an individual person or institution, but to society as a whole, then innovative efforts and policies become applicable.  These realities must of course be balanced with the benefit of antibiotic use to the individual patient.

Competing interests statement: The authors are members of Antibiotic Defense, an organization founded by medical students at the University of Michigan that aims to preserve antibiotic effectiveness.


Figure : The role of medical students in limiting the spread of antimicrobial resistance

Figure : The role of medical students in limiting the spread of antimicrobial resistance

 


[1] World Health Organization, Third Global Patient Safety Challenge, Tackling Antimicrobial Resistance (2008).  Available: http://www.who.int/patientsafety/events/09/12-130309_amr_minutes.pdf.  Accessed : 28 October 2009.

 

[2] Cure With Care: Understanding Antibiotic Resistance.  ReAct: Action on Antibiotic Resistance:  Available: http://soapimg.icecube.snowfall.se/stopresistance/cure%20with%20care[1].pdf.  Accessed: 28 October 2009.

[3] Alliance for the Prudent Use of Antibiotics.  Research and Surveillance Initiatives: Available: http://www.tufts.edu/med/apua/Research/research.html .  Accessed 28 October 2009.

[4] Castaño A, Kober M, Jain A, Prensner JR, Haack S, Parikh S (2008)  “Antibiotic Resistance: Challenges and Solutions.” Global Health Education Consortium.  Available: www.globalhealthedu.org.  Accessed: 28 October 2009.

[5] Centers for Disease Control, Interagency Task Force on Antimicrobial Resistance and a Public Health Action Plan to Combat Antimicrobial Resistance. National Center for Preparedness, Detection, and Control of Infectious Diseases/Division of Healthcare Quality Promotion (2006) Available: http://www.cdc.gov/drugresistance/actionplan/index.htm.  Accessed 28 October 2009.

[6] Howard Hughes Medical Institute, Research Scholars Program. National Institutes of Health. Available: http://www.hhmi.org/cloister/.  Accessed 28 October 2009.

[7] Laxminarayan, R and Brown GM (2000) Economics of Antibiotic Resistance: A Theory of Optimal Use. Resources for the Future.  Discussion Paper 00-36.  Available: http://www.rff.org/rff/Documents/RFF-DP-00-36.pdf.  Accessed 28 October 2009.

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Uniting Tanzanian Medical Students to Reverse the Brain Drain

Guest blog by Evance L Mmbando, 3rd year medical student, Weill-Bugando University College of Health Sciences, Tanzania

According to the World Health Report 2006, the population of Sub-Saharan Africa totals over 660 million people with a ratio of fewer than 13 physicians per 100,000 people. The continent bears 24% of the global burden of disease but has only 3% of the health care workforce and 1% of the world’s financial resources.

Sub-Saharan Africa needs about 700,000 physicians to meet the Millennium Development Goals, the international framework to halve poverty by 2015. The UN Economic Commission for Africa has sounded the alarm on the mass exodus, the so-called “brain drain”, estimating that some 20,000 African professionals leave the continent each year.

African institutions invest heavily in the training of health professionals, and their loss has far-reaching effects. Tired of sitting idly as our country, Tanzania, watches its physicians leave, we medical students organized a movement to highlight the brain drain to our local communities and, critically, develop prescriptive policy recommendations to our national governance.

Our medical college, the Weill-Bugando University College of Health and Sciences  and the country-wide Tanzania Medical Students Association partnered to seed this movement, highlighted by a conference in July of 2008. We wrote a proposal for such a movement, raised funds locally and sponsored influential thought leaders from across public and private sectors to attend our conference. Participants included students, faculty, deans and ministry of health representatives. Notably, the location of this conference, Weill Bugando, is a successful example of the twinning process, by which universities in the global North (in this case, Weill Cornell) partner with African universities (in this case, Bugando Medical College) in the realm of education.

Drivers and Impact of the Brain Drain in Tanzania

From our shared experience, there are four essential components to the brain drain that we described at the conference which compel us to consider leaving.

  • The first, and perhaps most widely cited, is the prospect of higher quality of life in developed countries.
  • The second is the lack of funds for research and innovation in Tanzania. It is difficult, if not impossible, to find research positions at our medical colleges. And if found, the resources to carry on long-term research programs are lacking.
  • Third, inadequate stocks of medicine, supplies and equipment demoralize our efforts to deliver required services. It is difficult to avoid feeling frustrated when the quality of care is substandard.
  • Finally, the academic climate in our country is not a healthy one – intellectual freedom is stifled, not nurtured, and it is difficult to operationalize one’s ideas into new programs.

Naturally, there are also parallel “pull” forces at play which further incentivize health professionals leaving our country: better wages, working conditions, career options, access to sizeable research funds and a higher quality medical service environment.

The impact of the brain drain is seen everywhere, in both developed and African countries. In the United States, for example, an estimated total of 130,000 foreign medical graduates (FMG) have saved the US more than $26 billion in training costs. The WHO estimates that every time Malawi educates a doctor who practices in Britain, Britain saves $184,000.

Most health professionals in “source countries” (those countries from which there is a brain drain) are trained at the public’s expense. When these professionals leave, the vacancies are often filled by imported expatriates who are highly paid.

Losing highly trained professionals through brain drain also contributes to contracting the economy: you cannot pay income taxes if you are not here anymore. Development contracts in both health and non-health sectors. For example, even though there is a government sponsored clinic within 5 miles of any village in Tanzania, there is often no one present to staff it.

Intriguingly, an internal brain drain is now in full effect, the phenomenon in which professionals are steered toward private, high-end, urban settings rather than resource-poor, rural ones. In the coastal regions like Arusha, Tanzania, there is one doctor for every 40,000 people compared to one doctor for every 300,000 in Mwanza, the home city of our medical college.

I asked 30 medical students at my medical school (15 male, 15 female) their opinion on brain drain and possible interventions by government towards thwarting the problem:

  • Twenty seven said that working conditions for doctors are  inadequate.
  • Twenty five said that the government’s response to the brain drain problem has been poor to average.
  • However, despite the dissatisfaction with the status quo, only 7 of the students actively plan to emigrate (in order to seek a better standard of living as well as reputable training and career opportunities).
  • Interestingly, when given a choice of three possible solutions to brain drain, 24 students chose an increase in salary incentives as the most important solution (over increase in medical facilities or openness in intellectual freedom).
  • The much-quoted notion that medical students are all on public subsidies, and therefore are doubly hurting the government if they leave, may be over-estimated. Over half the students in this survey were borrowing money to pay for their education.

Next Steps

To help organize around next steps, stakeholders at our conference laid out the following proposed recommendations for our national government and other sub-Saharan African countries. We acknowledge that it is not a perfect list, but this is our collective voice:

  • The governments in Sub Saharan Africa should take deliberate actions to provide equally competitive salaries and wages for health professionals in an effort to offer a more attractive quality of life.
  • There should be adequate work incentives for rural practice.  Health workers who practice in rural communities should be reimbursed at the same pay as those in the cities in order to retain them and attract more health workers.
  • The governments should put emphasis on training students on research methodology and deliberately allocate funds specific for researchers who train and mentor medical students.

The first priority of health budgets should focus on improving health facilities and services. We have decided to take deliberate actions towards the problemsby introducing and forming a new organization named “Medical Students for Neglected Tropical Diseases Organization.” This organization will work to provide public health education to rural communities as well as opportunities for students to do hands-on research, to evaluate the burden of neglected tropical diseases locally,  and to get involved in eradicating neglected tropical diseases (such as lymphatic filariasis and onchocerciasis).

I call upon medical professionals and students globally to recognize the ongoing brain drain from Africa. Help us ensure safe, reliable and high quality medical services.

Acknowledgements:

I thank the major participants of the conference, Prof. William Mahalu Dr.Gozibert Mutahyabarwa , Dr Safari M. Kinung’hi S, Dr. Kamugisha Erasmus Dr.Magambo Kinanga, Dr.Barnabas , Dr. Sweya M. K  M , Dr.Stella Mongela,  Ms. Zanaida Marwa and fellow students Mr.Charles Mguta, Mr. Magambo Fabian, Ms Adela Luhigo and Mr.Kamuli Simon. I thank Sandeep Kishore and Marilyn Michelow for editorial assistance.

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The dawning era of personalized medicine exposes a gap in medical education

Guest blog by Keyan Salari, PhD Candidate at Department of Genetics, Stanford University School of Medicine and MD Candidate at Stanford Medical School

“It’s far more important to know what person the disease has than what disease the person has.”

- Hippocrates

The importance of personalized medicine has long been understood in the medical profession. Physicians routinely take into account a patient’s environmental, behavioral, and genetic factors of disease and drug response in their clinical practice, but until recently the granularity at which genetic risk has typically been assessed has been the family history and ethnicity. However, in the near future high-throughput genotyping and DNA sequencing technologies may dramatically change the way physicians assess genetic risk, and give personalized medicine a new meaning.

In an article published this month in Nature Biotechnology, Stanford engineering professor Stephen R. Quake described the decoding of his own genome for less than $50,000 using a machine built by a company he founded, Helicos Biosciences. Dr. Quake noted that steadily declining costs of DNA sequencing “will democratize access to the fruits of the genome revolution” by enabling many labs and hospitals to decode whole human genomes. Similarly, in June of this year, genomics technology company Illumina announced the launch of a $48,000 genome sequencing service at the Consumer Genetics Conference in Boston. However, unlike most consumer genomics companies, Illumina’s service will require a physician’s prescription. While the price tag is still out of reach for most consumers or healthcare payers, the cost of DNA sequencing is falling faster than that of computing power. This means that the much-discussed goal of the $1,000 genome could be attained within two or three years. Provided the cheaper and better technologies translate to new clinically relevant findings, physicians may soon see a new array of gene-based tests, or perhaps even whole genome sequencing, become reimbursable clinical tests.

Today, companies like 23andMe, among others, are offering direct-to-consumer testing for common genetic variants. The advent of consumer genomics will certainly increase the demand for genomics-savvy physicians. But more importantly, clinicians stand to greatly benefit from the incorporation of genomics and pharmacogenomics into their own clinical practice. Already, studies showing how specific genetic variants can alter a patient’s response to drugs have led the US Food and Drug Administration to change the label of warfarin and clopidogrel (Plavix). The labels now suggest that a patient’s genetic variants should be taken into account when dosing the drugs for optimal safety and efficacy. While the potential for genomics to influence clinical practice is huge, the benefits will only be realized if physicians are poised to take advantage of them. To that end, medical education needs to be revamped.

For three years, I have served as a teaching assistant for the human genetics course required of all first-year students at Stanford Medical School. Birthplace to the DNA microarray, among other genomic technologies, I imagined Stanford would be an ideal place for medical students to learn about such paradigm-shifting technologies and their impact on clinical medicine. But despite their juxtaposition just two floors below the Department of Genetics, medical students have been lectured on basic principles of genetics with little mention of advances made over the past two decades. Hearing similar anecdotes from colleagues at several other US medical schools led me to the medical education literature, where I learned that this gap in medical education is widespread and must be addressed.

Several organizations have begun to develop learning objectives and competencies in genetics for all health professionals, as highlighted in the article I just wrote for PLoS Medicine. I argue further that physicians should have several additional competencies to fully realize the potential of genetic information in advancing personalized medicine. To in part address this need, I have been working with several faculty members across the School of Medicine to design and implement a new course for medical students on personalized medicine. The course will focus on recent advances in genomics and pharmacogenomics, and how to incorporate genetics into clinical practice. We hope the course, among the first of its kind in US medical schools, will encourage other medical schools around the world to follow suit and help close this gap in medical education.

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