Body of Work: Global is Local

Why should we think about health on a global scale? What diseases are of most global concern? Why are many global health solutions developed in the form of technology? Director of Baylor Global Health Dr. Sharmila Anandasabapathy explains.

Sharmila Anandasabapathy, M.D., is a professor of medicine in gastroenterology and director of Baylor Global Health at Baylor College of Medicine. She is also a member of the Dan L Duncan Comprehensive Cancer Center. An advanced gastrointestinal endoscopist by training, Dr. Anandasabapathy’s research focuses on developing new technologies for the diagnosis of early gastrointestinal cancer.

Learn more about Baylor Global Health.

See below for more of Dr. Anandasabapathy’s research:

• Colon cancer in Africa: Primetime for screening?
• Use of Augmented Reality and Virtual Reality Technologies in Endoscopic Training
• Quantitative analysis of in vivo high-resolution microendoscopic images for the detection of neoplastic colorectal polyps

[Music]

Erin: Welcome to Body of Work, an exploration of health topics in the news and important issues facing science, with experts from Baylor College of Medicine. I'm Erin Blair, and my guest today is the director of Baylor Global Health Dr. Sharmila Anandasabapathy.

So what diseases are of the most global concern?

Dr. Anandasabapathy: So, the diseases that are of the most concern worldwide, right now, are what we call non-communicable diseases. So cardiovascular disease, heart disease, stroke, cancer, followed closely by neurodegenerative diseases. These are Alzheimer's, and other related dementias, diabetes. This doesn't mean that infectious diseases, or the communicable diseases, are not important. We still have tuberculosis, aids, and malaria, particularly in low-income countries, but they're rapidly being overtaken worldwide by these non-communicable diseases and diseases of our lifestyle, basically in the aging population. Now, unfortunately, countries within sub-Saharan Africa see a dual burden of disease, so they're still seeing high rates of HIV, and malaria, and of course we know there's an Ebola epidemic recently, but the leading cause of death worldwide over the next two decades will actually be cancer, and stage by stage mortality rates are higher in low-income countries, so this is really the big disease to be concerned about globally.

Erin: Why should we think about health on a global scale?

Dr. Anandasabapathy: So, today, we are truly one world, and I don't mean this as a platitude. It's not kumbaya, you know around the campfire, but literally from a healthcare perspective, we are one world, and this is directly a result of industrialization and globalization. We are deeply interconnected worldwide, so think of it food, especially with fast food going into these remote regions, is on a global scale. The internet, which has an effect on lifestyle and habits worldwide, and of course air travel right. The net result is that diseases that affect us, affect others, particularly our lifestyle-related diseases, diabetes, heart disease, lung cancer, and diseases that affect others affect us, and we often are surprised by this, but if you recall the 2014 Ebola epidemic came to Dallas. So, I think we should be concerned about other parts of the world, and we should be interested in diseases of other areas.

Erin: Can we use global health strategies to overcome some of America's homegrown challenges?

Dr. Anandasabapathy: Oh, absolutely, and we found that this happens often unexpectedly. I love to tell my students, you know, that necessity is the mother of invention right, and what this means is that when you have a lot, there's less need to be creative when you have little or nothing you are forced to innovate. So this is why many low-income countries are leapfrogging ahead in health care innovation, both in terms of technologies, physical technologies, such as mobile technologies both for diagnosis, and providing care, and their approaches. So they don't rely on traditional models, where a patient comes in to a hospital to see a doctor, but they're looking at more innovative methods of delivery into the community, often leveraging software for remote consultation, or even apps, where patients and families can directly manage their care and of course the big driver and this is cost. It almost always is right; in the US, we spend about $9,000 a year per person or more on health care. In sub-Saharan Africa, this is closer to $200 per patient. Austerity forces transformative approaches, and I'm not saying it's good to be under-resourced, rather that we could all be more cost-conscious and creative.

Erin: Why do you think so many global health solutions are developed in the form of technology?

Dr. Anandasabapathy: Well, if we've learned anything this past century, you never bet against technology right, but I do believe that this is both need and market-driven. We have an aging population, an increased onset of chronic disease, as we talked about, and we're lucky actually that there's a lot of ingenious tools and technologies that are emerging, often at a lower price point. I do think the challenge never really is technology. Technology advances, technology is continually innovated; it's often the implementation. So how do you get doctors, nurses, healthcare workers, the medical establishment to accept new tools and approaches and then utilize them safely, consistently, effectively? They're often, you know, several P's, if we use the letter P in terms of thinking about technology innovation, one is the person, you know who is using the technology, the provider, we need to think about who that is. Is it a community health worker, is it a nurse, is it a physician, so we have to target the technology to that person. And then who is the technology being used for in the patient, what is the language the literacy level, their cultural understanding, and or bias their acceptance of the technology, and then of course the place, where is it being used, and what are the challenges, their power supply, water, infrastructure. These are all things that lead to either the success or failure of a technology

Erin: What are some of the new innovations coming out of Baylor Global Health?

Dr. Anandasabapathy: So you must have heard about the smart pod?

Erin: Oh, yes.

Dr. Anandasabapathy: Everyone's talking about the smartphone. Well the smart pod is a great example of a technology that was developed for West Africa during the 2014 Ebola epidemic, but then as we learned, has tremendous applications in the US as well, and the smart pot itself is an 8 by 20 shipping container that expands within about five minutes, with four people, into a four hundred square-foot clinic. And we have deployed a clinic to Monrovia Liberia, where it's being used in Ebola patients and subsequently, we built two laboratories a biosafety level two lab, and a biosafety level three lab, as well as a pharmacy and those, are in the field in West Africa as well, and this was a really interesting challenge in term of understanding the landscape in West Africa. For one, we started out with a standard steel shipping container, and then we realized that the roads there couldn't handle the weight of the steel, and because bleach was being used for Eboli, would corrode. So we had to switch to an aluminum structure that was lighter weight. In addition, we thought we were helping the healthcare workers by providing air conditioning and all of these you know kind of first world advantages, and then we turned out the patients didn't like that, so he had to redesign it, so the doors were apart to allow cross ventilation. The idea of privacy in that culture; not only was it less of an issue; the patients wanted to be able to see their family members. So we had to think about where we were replacing windows to allow visual access at least. And lastly, we had to provide support for the doctors, nurses, and healthcare workers that were using the unit's by providing software and apps using figures and graphics, rather than language for guiding them on the procedures. And so this was a really important case example for us on developing a technology for one part of the world. It worked in Africa, which was great, and in when hurricane Harvey hit Houston, we realized that there may be a need for these types of technologies in the United States. So now we're looking at applying that model for healthcare here in Houston, which is really exciting.

Erin: What about telemedicine? I would think that would be a useful application in a remote location?

Dr. Anandasabapathy: So, one of the greatest advantages of being in Houston, I think, is being close to the Johnson Space Center in NASA, and they actually helped us, their engineers helped us with the volumetric modeling for our units that went to Africa. We took a cue from them in terms of remote medical management to support healthcare workers in the field. So we've been looking both at what we call tell a guidance, using augmented reality to guide a physician or healthcare worker through a procedure, or a laboratory procedure, in a hands-free fashion. So you can see the guidance on the augmented reality glasses, and then perform the procedure hands-free, and then we are also working with them on the development of apps for assistance in the field in real-time and training. And some of these can either be used on a cell phone or using virtual reality glasses if you need a more immersive experience.

Erin: It seems like NASA would have a lot of commonality with a lot of the problems that you see in under-resourced parts of the world.

Dr. Anandasabapathy: Well, they have to work in the most austere inhospitable under-resourced environment known to mankind, right? So ya know it's been a unique opportunity to have them close by

Erin: How does computer-assisted diagnosis work?

Dr. Anandasabapathy: So, this gets to the concept of autonomous medicine. When we have to practice medicine in an area that has no support, so either the remotest part of Africa or you know for NASA, Mars right. So we've used this actually for gastrointestinal cancer screening. I'm a gastroenterologist, and if you think about how cancer screening is done in the United States, it'll give you a sense of all of the things that can go wrong when you do this in a more austere environment. So what do I do when I look for esophageal cancer in a patient? I have to insert a scope in a patient that's asleep. I have to image the esophagus, and I've had to have you know over a decade of clinical training to learn what abnormal looks like. When I see tissue that is abnormal, I have to take a biopsy, and my technician needs to know how to assist with it and remove that biopsy. That biopsy has to get processed in a laboratory, sent to a pathologist, the pathologist has to provide a diagnosis, get back to the doctor, the doctor has to get back to the patient with a diagnosis, and the patient has to come back and if it requires treatment. So let's change that paradigm, let's talk about a portable tablet-based endoscope that perhaps, provides the diagnosis. Well, what if your scope was attached to a tablet computer, and the scope was portable and battery-operated, perhaps smaller, perhaps it could be inserted easily by a non-gastroenterologist. Perhaps even a non-physician in a patient that didn't need to be asleep, and what if the scope was powered by and connected to a tablet computer, or even a cell phone, and that tablet computer or cell phone could not only obtain the images but store the images and analyze the images, using software algorithms, effectively a computer-assisted diagnosis. And then what if you didn't need to take that piece of tissue because the computer was providing you the diagnosis, so you could basically obtain, in real-time, in the field, an optical biopsy and then treat the patient immediately if they needed it, or tell them that they were cancer-free at the time. So what have we done by changing this paradigm? We've reduced the cost, we've increased the impact, we potentially improved outcomes from loss of follow-up, and this can really provide a transformative effect on medical care. In the areas of the world that we worked in which include Africa northern China South and Central America, we've found that over 25% of patients who we do endoscopy on, once they go home often to remote or rural areas, they don't return for follow-up and this is a huge problem with cancer care, because if you find something and you can't treat it, you can imagine the devastating effect of this. So currently we've been doing clinical trials in the areas that I've mentioned working with Dr. Rebecca Richards-Kortum and her engineers at Rice, and we've enrolled over 1,000 patients worldwide looking at this tablet-based a portable endoscopic approach.

Erin: Have you been involved with maternal and child health initiatives as well?

Dr. Anandasabapathy: Yeah, this is something that's really important to us because one of the leading causes of mortality and women worldwide, particularly in low-income countries is childbirth, and it really shouldn't be a cause of death in this day. And so we're looking actually at the approach we mentioned which addresses both the infrastructure by provision of our off-grid pods for labor, and delivery, and the performance of C-section. Then also providing training via apps virtual reality and augmented reality guidance to nurse midwives and physicians in the field.

Erin: How do physicians and their health care workers in the field respond to a sort of a virtual reality training session?

Dr. Anandasabapathy: That's a great question. You would think they would be deeply skeptical, some are, but I find the skeptics are actually more in the United States. What we've actually found, and we've actually done some studies looking at acceptance of these types of technologies, what we found is really surprising. In areas of the world, such as sub-Saharan Africa and most recently we're working in Liberia where our pods are. We found that the healthcare workers were very responsive to anything that used cell phones. Our augmented reality, with the use of cell phones, and it's simply because cell phones are so pervasive and people are fairly comfortable with mobile technologies, and when you have nothing else, it can be a lifeline for many people. So we were actually surprised on how accepting the providers are in those settings.

Erin: Well, and as you say the technology is just leapfrogged there, you didn't go through the period of landlines. They just went directly to the cell phones.

Dr. Anandasabapathy: That's exactly right.

Erin: When we think of global health, we think of lack of basic resources like electricity, Wi-Fi, and water, how do you mitigate those issues when developing technologies?

Dr. Anandasabapathy: Yeah, so I mentioned that I often think about the letter P, and when we talk about the success of a technology, and so that really gets to the issue of P for place right. So think about the environment you're working in. If there's no power grid, you need to think about solar or hybrid generators, battery backup, and if there's no water supply, you have to think about using the existing water that you have, if it's from river, lake, or a stream, or rainwater, and using filtration systems. And we can't do all of this at Baylor global, so it brings us to another P which is partnerships. So we partner with others in this space, and there are a lot of groups that are coming up with really innovative batteries, which can increase capacity for storage of electricity, and also innovative water filtration systems, so that you can have an autonomous water supply in these settings.

Erin: In medical technology development, what separates a cool idea from an innovation that is sustainable and effective?

Dr. Anandasabapathy: So, what separates a cool idea from an innovation that's sustainable and effective is really how it's implemented and scaled right. So cool ideas abound, but sometimes that cool idea may not be acceptable in that culture. It may not work in that environment, and it may not have a plan for scale-up and dissemination, which includes financing, delivery mechanism, supply chain, and lastly, education is so critical. If we can't train health care workers on how to use the technology safely, effectively, then your technology is not useful. And Baylor in medical school and I believe this is where we can make the biggest difference, in terms of educating the healthcare workforce globally, and you partner that capability with engineers with business schools, who can assist with financing and delivery mechanisms, and I think it's a very powerful combination and so the most impactful approach is not incremental, it's transformative. It understands the people in the setting where it's being used, whether it's the provider or the patient. It understands the environment and the limitation, and it has the ability to be spread, get used around the world scaled up and able to access different areas.

Erin: I understand that it's a common practice for hospitals to donate their slightly older technology to the developing world are there any issues with that?

Dr. Anandasabapathy: I think this is one of the biggest issues that exists in global health. Donations abound, and I think it's wonderful that people are generous, but when we think specifically about donations of equipment or technology, we really have to make sure they're appropriate for that environment and one of the things that has always saddened me, when we work in many of these settings, are these equipment graveyards. Where you'll see a three Tesla MRI scanner, that was donated by a government that is basically sitting in the basement of a hospital, or outside in a courtyard broken and not functioning. And this is because either the power requirements were not appropriate for that area. There was nobody there to repair it, or it required so much support and maintenance that that was not feasible in that setting. So I think we need to think very hard about what types of technologies that we're putting in an area who the user is and what the capability is for both for maintenance, and then repair.

Erin: What's next for global health?

Dr. Anandasabapathy: That's my favorite question. So after Hurricane Harvey, we realized as a program, that global can be local, and there may be need for some of these approaches in the United States, especially after catastrophic natural disasters, such as the hurricane. And then you remember Star Trek right, space the final frontier. So the next few decades, I believe that global health will be galactic health. The next place we will be screening or treating cancer may be outside of Earth's orbit, and I, for one, would love to perform the next portable tablet endoscopy on Mars.

Erin: That would be cool.

[Music]

Erin: Thank you for tuning into Body of Work, by Baylor College of Medicine. If you enjoyed this episode, be sure to subscribe and be on the lookout for our next episode where we'll talk with Dr. Malcolm Brenner about immunotherapy and using your body's own immune system to fight cancer.

If you like the show, please give us a five-star review and tell your friends to listen. We're available on Spotify, Apple podcast, and Stitcher, as well as at BCM dot edu slash podcast. There you can find the episode notes, including information about the experts featured on the show. A quick note about the medical advice and opinions stated in this podcast, each individual's health profile is unique, so please see a health care professional about any questions you may have. Until next time, take care.