On Drug Resistance

As the distribution of medications worldwide advances, individuals gain access to improved treatment options. Among the medications most frequently distributed are antibiotics. Though expanded access to medicines is “clearly desirable,” it can also create “challenges in preserving the efficacy of these drugs.” A recent report from the Center for Global Development (CGD) indicates that antibiotic distribution programs put in place by the World Health Organization, government agencies, and other groups may be contributing to the increased incidence of drug-resistant bacteria. According to Nancy Birdsall, the president of the CGD, “Drug resistance is a serious problem that doesn’t get serious attention.”

Antibiotics and antimicrobial agents are the most effective means of combating infectious disease. However, as a class of drugs, antibiotics are unique in that once an antibiotic is utilized, the bacteria it is intended to fight begin to develop a resistance and the effectiveness of the medication is diminished. According to British researchers who analyzed 24 previous studies, the excessive prescription and use of antibiotics for coughs and flu-like illnesses leads to antibiotic resistance. Studies indicate that the overuse of medications, inconsistent drug quality, and other factors hasten the adaptation of resistance to given antibiotic and antimicrobial agents.

This increased resistance to commonly used antibiotics can result in “superbugs,” such as methicillin-resistant Staphylococcus aureas (MRSA), which is the cause of more than 50 percent of staph infections in US hospitals. Additionally, in the developing world, drug-resistant strains of malaria, tuberculosis, HIV/AIDS, and other diseases are the cause of death for millions of children each year. According to Céire Costello Research Associate at the University of Bristol, “there are some concerns that some common infections are becoming increasingly difficult to treat.” This is seen with increasing frequency in many remote and medically underserved areas of the world where medication dispersal programs are especially prevalent. Reports indicate that 60 to 80 percent of dysentery cases among children in Latin America are “resistant to the drugs recommended to treat it.”

By retaining the medications available now and developing new drugs, experts hope to be able to continue combat bacterial infections effectively. Because of the lengthy development and testing process associated with creating new medications for mass consumption, it is critical to ensure that drug resistance is minimized as much as possible. By urging providers to keep track of which antibiotics they prescribe and how frequently, it may by possible to help slow the rate of drug resistance. It is also essential for clinicians and individuals worldwide, particularly in the developing world, to be aware of the importance of not over prescribing or over using antibiotics.

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Using SMS for Healthcare

Over 4.1 billion cell phones are in use globally, and they are quickly becoming a part of the “digital life” for many.Reports indicate that individuals worldwide now use Internet-based and mobile technologies to find health-related information more frequently than ever before. Although cell phones are more common than computers in some areas of sub-Saharan Africa, it is important to note that they are frequently low-cost models with less features as opposed to high-tech smartphones, so mobile web-based information and applications may not be available.



As a means of delivering health-related information in remote areas, many clinics and organizations have begun to utilize short message service (SMS) technology. SMS or “texting” is a mature technology that is supported worldwide on all cellular network operators, through which messages of up to 160 characters can be delivered to a user’s cell phone. In regions where “personal computer technology” may not be available, it is possible to better ensure the delivery of health-related information through the use of basic cell phones and SMS technology. Over the past few years, SMS-based systems have been put in place throughout the developing world to combat diseases like malaria, provide medical and health information, and support rescue and relief efforts following natural disasters.

In regions where malaria is prevalent, SMS systems, such as the “SMS for Life” program currently in use in Africa, have been implemented to deliver information about the availability of treatment and medications. This program allows the inventory of anti-malarial medications at healthcare facilities throughout Africa, particularly in remote areas, to be tracked by clinics and aid organizations to improve distribution rates. Similar programs which allow physicians to monitor their patients at a distance have been put into practice for other diseases, including a program to ensure the provision of quality care to patients with HIV/AIDS in Kenya. This type of patient-monitoring SMS program has also been instituted to allow healthcare workers in Rwanda to monitor pregnant patients remotely, provide basic health and well-being information to patients throughout Africa, and provide clinic location information to patients in India.

SMS systems have also been established following natural disasters, such as the earthquake that struck Haiti on January 12, 2010. A number of relief organizations set up SMS shortcodes, which assisted individuals searching for friends and family members. Shortcodes are set numbers – usually only five digits long - used to quickly and easily gather messages for delivery. Additionally, SMS messaging and shortcodes allowed for a simplified donation process to a number of aid organizations providing assistance in Haiti.

Although mobile applications, smartphones, and other cutting edge technologies have provided enormous advancements in healthcare, high-tech solutions are not always appropriate for worldwide use. In settings where reliable Internet connectivity may not be available and where basic cell phones are the norm, SMS-based systems allow for the distribution of health-related information to a wider audience.

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HIV/AIDS Worldwide

Worldwide, an estimated 33.4 million people are currently living with HIV, and a recent WHO report indicates that 68 percent of these individuals live in sub-Saharan Africa. Though HIV is prevalent in the developing world, infection rates in the United States continue to be a major health concern. Reports indicate that at the end of 2006, an estimated 1.1 million people were living with HIV in the U.S. and these figures have continued to grow. Though education, testing, and treatment efforts have increased worldwide, ensuring that all individuals with HIV are aware of their status and have access to life-saving medications, remains an enormous challenge.

The human immunodeficiency virus (HIV) was first recognized in 1981. The virus destroys specific cells that are imperative to the functioning of an individual’s immune system known as CD4+ T cells. An individual’s HIV status can be determined by administering an antibody test, which detects the substances that the body produces in response to HIV infection. If an individual with HIV does not receive treatment, their condition will progress to the point at which they will be diagnosed as having acquired immune deficiency syndrome (AIDS). A healthy individual has a CD4 count of more than 500 cells per cubic millimeter (mm3) of blood, but when an individual’s CD4 count is below 200 mm3, they are diagnosed as having AIDS.

Though anyone can contract HIV, there are certain behaviors known to increase the risk, including promiscuous and/or unprotected sexual contact, using intravenous drugs, homosexual intercourse, and sexual intercourse with individuals who have been incarcerated. According to Carla Bruni-Sarkozy, wife of the President of France and Global Fund’s Ambassador for Protecting Women and Children Against AIDS, children born to mothers with HIV are also at an increased risk, and over 400,000 babies are born with HIV each year. New study findings also suggest that the risk of female-to-male transmission of HIV doubles during pregnancy, but the reason for this increase has not yet been identified. Individuals with HIV can suppress the virus and stop its progression through the use of antiretroviral therapy (ART), which consists of the use of at least three antiretroviral (ARV) medications. Reports indicate that the United States now supports more than 2.5 million individuals receiving ART, the WHO estimates that at least 9.7 million people, primarily in low- and middle-income nations, are in need of these lifesaving medications.

In the hopes of identifying more effective treatment options, research is ongoing to explore how HIV infection progresses in the body. Though it is no longer used following the eradication of smallpox, experts have found that the smallpox vaccine may interfere with how HIV replicates. Additionally, tests have been conducted using experimental vaginal gels containing antiretroviral elements, and they have been seen to reduce transmission of a virus closely related to HIV in monkeys. Researchers have also identified a bacterium found in the human throat which secretes a toxin that has been found to enable antibodies to destroy viral particles in the blood.

Though promising, it remains to be seen if this research will yield any substantial advancement towards finding a cure for HIV. Until a cure is found, expanding existing treatment options and ensuring the provision of testing and education programs are essential to shunting the spread of the virus.

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Innovative Appropriate Technologies

Some high-tech healthcare devices can be created inexpensively and may be beneficial worldwide. Devices which utilize local resources, often referred to as Appropriate Technologies, are especially valuable as they often make use of the skills of local craftsmen and rely on readily available materials. According to Danielle Zurovcik, student researcher at MIT, these devices have the potential to greatly improve care in clinics that “don’t have power, don’t have a lot of supplies.”

Using automobile parts, including headlights, an HVAC, and tires, which are common in even remote regions of the world, researchers have created an incubator in the hopes of decreasing infant mortality rates. By using car parts, researchers were able to create a device that could be fabricated and repaired by auto mechanics and others with limited or no training building or repairing medical equipment. In addition, the prototype incubator uses electricity, but also has a motorcycle battery to provide power if it is not available.

Low-cost diagnostic and treatment devices have also been developed to allow for access to these services in areas where they might otherwise be limited. Undergraduate students at Rice University have developed a centrifuge that can be constructed using a salad spinner and other common plastic items. Like conventional centrifuges, it is able to separate blood samples in only 10 minutes. These samples can then be used to test for anemia, as well as tuberculosis, malaria, and HIV/AIDS. Another simple device was created by students at MIT to help speed the healing process of wounds. The small molded plastic pump can be used to apply suction to a wound, helping to keep the draw away bacteria and wound clean, as well as allowing it to heal more quickly.

Medical devices and aids for individuals with disabilities have also been conceived for use in areas with limited resources. In many areas, low vision is a tremendous problem, affecting literacy and employment rates. In spite of the great need, eyeglasses and the personnel needed to properly fit them, are frequently not available. To address this need, Oxford University professor Josh Silver devised a solution: eyeglasses with fluid filled sacs inside the lenses, whereby the amount of fluid can be adjusted by the user to change the power of the lens. Simple, low-cost devices have also been created to allow individuals with disabilities to communicate with care givers. The Communication Board was developed by the Center for International Rehabilitation’s (CIR) Yeongchi Wu, MD in the early 1980s using only a sheet of paper and pen. The simple and low-cost device can also be used in nursing homes or intensive care units.

Innovative Appropriate Technologies which utilize local resources can help improve the quality and availability of healthcare worldwide. There is often a stigma attached to lower-cost and lower-tech devices, as more expensive can be perceived as better, however their use in the developed and developing world may prove beneficial in reducing overall healthcare costs.

Vote for the Communication Board on Instructables – May 23-30, 2010

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On Malaria Worldwide

Nearly half the world’s population – roughly 3.3 billion people – are at risk of contracting malaria. Though individuals in Latin America, the Middle East, and Europe are among those most often affected by the disease, the Centers for Disease Control and Prevention reports that 98 percent of global malaria deaths occur in 35 countries - 30 of them in sub-Saharan Africa and five in Asia. Every year there are nearly 250 million cases and an average of one million deaths due to malaria. Reports show that in 2008, an estimated 863,000 people died from malaria infection, indicating some improvement in diagnosis and treatment outcomes. Transmission is possible to any individual, however some groups are at an increased risk. These include young children who have not yet developed full immunity, pregnant women whose immunity has been decreased by pregnancy, international travelers who lack immunity, and individuals with HIV/AIDS or others with compromised immune systems.

Malaria is a preventable and curable acute febrile illness caused by the bite of Anopheles mosquitoes which have been infected with Plasmodium parasites. The long lifespan of the Anopheles species found in Africa contributes to the disease’s prevalence in the region, and experts note that more than 85 percent of the world’s malaria deaths occur in Africa. Symptoms are usually seen seven days after the infective mosquito bite, and include fever, headache, chills, and vomiting. If diagnosed quickly, malaria can be treated using artemisinin-based combination therapy (ACT), however if treatment is not initiated, malaria can progress and lead to severe anemia, respiratory distress, or death.

In countries where malaria is endemic, access to diagnostic tools and medications may be limited. Less than 15 percent of these individuals are able to begin treatment within 24 hours of the onset of fever, which is when treatment must be started. Malaria diagnosis relies on either microscopy or rapid test procedures to allow healthcare providers to quickly determine if patients have the disease and require treatment. The Malaria Product Testing Evaluation Programme recently completed an assessment of 29 rapid diagnostic tests and found that 16 of them met the minimum performance criteria set by the WHO. According to Robert Newman, the director of the WHO’s Global Malaria Programme, using rapid tests allows healthcare providers to “test people who cannot access diagnosis based on microscopy in remote, rural areas where the majority of malaria occurs” and thus improves treatment outcomes.

In addition to improved testing, global efforts are underway to control malaria by eliminating the mosquitoes that transmit the disease. During the past decade, the distribution of treated bed nets has increased rapidly in 11 African nations, helping to reduce infection rates. Reports indicate that in 2008, 31 percent of African homes had insecticide-treated nets (ITNs), compared with 17 percent in 2006. Through the use of ITNs, as well as spraying of homes with insecticide chemicals, 10 African nations reduced the number of cases of malaria by at least 50 percent between 2000 and 2008.

Though there is no vaccine for malaria, more effective prevention measures, diagnostic tests, and medications can help to improve treatment outcomes for those affected. Government agencies, including the World Bank, and other groups, such as Roll Back Malaria global partnership, have made efforts to increase global awareness about malaria. By utilizing social media and online tools it has been possible to improve the effectiveness of outreach and fundraising for efforts which may help to eradicate malaria worldwide.

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Find out about iCons in Medicine’s efforts to collect donations of mobility aids for Haiti

On Obesity Worldwide

The prevalence of obesity continues to increase worldwide. Reports indicate that in 2005, 1.6 billion individuals over the age of 15 were overweight, and at least 400 million were obese. Projected figures indicate that this will continue to increase, and that by 2015, 2.3 billion adults will be overweight, and more than 700 million will be obese. Though data from the Centers for Disease Control and Prevention (CDC) indicate that obesity rates among Americans have peaked, World Health Organization (WHO) statistics point to increasing obesity rates in both the developed and developing world.

Abnormal or excessive accumulation of body fat often indicates that an individual is “overweight” or “obese.” The body mass index (BMI) - the weight of an individual in kilograms divided by the square of their height in meters – provides a crude measure to determine into which category an individual falls. According to the WHO, a person with a BMI between 25 and 30 is generally considered overweight, and over 30 is generally defined as obese. Overweight and/or obese individuals are more susceptible to many serious health complications. Excess body weight has been shown to increase the risk of ischemic stroke by 22 percent in overweight individuals, and 64 percent in obese individuals. The Mayo Clinic reports that obesity can cause a number of additional health complications, including high blood pressure, heart disease, osteoarthritis, and type 2 diabetes. Reports also indicate that “in the U.S…. [an estimated] seven types of cancer…are weight related [and] just under 20 percent could be prevented through people being a healthy weight.”

Obesity is commonly thought of as a condition of the developed world. However, a 2007 surveyThe WHO notes that the “increased consumption of more energy-dense nutrient-poor foods…[and] reduced physical activity” have led to increased obesity rates worldwide. According to experts, people around the globe are being introduced to more “Western” lifestyles which often include an influx in the supply of unhealthy choices, reduction in exercise, and higher-stress occupations.

While this shift affects individuals worldwide, they are somewhat magnified in the United States where in the past 30 years, the number of obese adults has doubled, reaching nearly 34 percent, and the number of obese children has tripled to 17 percent. A study from the University of Michigan Health System shows that more Americans are becoming overweight or obese at a younger age and carrying the extra weight for longer than previous generations. According to research from Oxford University, the life expectancy of moderately obese individuals is reduced by about three years, and severely obese individuals’ life expectancy is reduced by 10 years. While obesity can be attributed to poor dietary selections or a lack of physical activity, research from the University of Texas Medical Branch at Galveston shows that a tendency towards obesity can be detected in infants as young as 6 months of age, and many of these infants are likely to continue to carry extra weight as they mature. To identify a means of overcoming obesity, researchers have continued to try to locate a genetic cause and help to improve treatment options. Findings from a indicate that the Chinese studyfat mass and obesity-associated gene (FTO) may be strongly linked to the predisposition for some individuals to gain weight more rapidly than others.

While there may be both genetic and behavioral causes for obesity, it can be prevented. Recent studies indicate that in teenagers who carry the FTO gene, physical activity can help to mitigate its effects. By gaining an understanding of the causes of obesity and preventative measures that can be taken, it may be possible to reduce its likelihood and detrimental effects.

Find out more about a recent study on medical care for obese patients

Check out the iCons in Medicine blog on Obesity and Nutrition or Join in on the iCons in Medicine Forums to discuss this and other public health topics found that the South Pacific island of Nauru was the nation with the highest percentage of overweight people – 94.5 percent of its population. Other small nations including the Federated States of Micronesia, Cook Islands, Niue, and Tonga were noted among the nations with over 90 percent of the population overweight or obese.

Tuberculosis Worldwide

Tuberculosis kills more than 1.7 million people around the world each year, and this figure is growing as over-crowded conditions in poverty stricken areas can elevate transmission rates. The World Health Organization’s (WHO) recently published report, entitled “Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response” outlines the prevalence of the disease and its potential global impact. In it, data from 114 countries around the world are examined to determine the extent of this “serious threat to global health.”



Mycobacterium tuberculosis, the organism that causes tuberculosis (TB), is an airborne bacteria exclusive to humans and can be transmitted through close personal contact, particularly coughing. According to the United States Centers for Disease Control and Prevention (CDC), the bacteria usually affect the lungs of an individual, but can also impact the kidneys, spine and brain. Nikoloz Sadradze, International Committee of the Red Cross (ICRC) medical delegate, explains that more than two billion people – approximately one in three – carry the microbes that cause TB, but only one in ten will actually experience symptoms. Effective treatment of TB depends on daily doses of courses of medication lasting six to eight months. Tuberculosis infection is defined as multidrug-resistant (MDR-TB) if it cannot be eradicated by the antibiotics commonly used to treat tuberculosis: isoniazid and rifampicin. It is classed as extensively drug-resistant (XDR-TB) if it is also resistant to fluoroquinolone antibiotics and the injectable drugs amikacin, kanamycin, and capreomycin. If an individual contracts a MDR-TB or XDR-TB strain, a combination of oral medications, injections, and other treatment may be required for 24 to 36 months or longer. Costs associated with treating MDR-TB are, on average, 10 times more than “standard” TB. The WHO reports that 60 percent of individuals who contract of TB have been cured.

The WHO also reports that drug-resistant forms of TB killed approximately 150,000 people in 2008, and that 50 percent of all cases of MDR and XDR-TB occurred in India and China. Further, 57 countries have had at least one case of XDR-TB since September 2009, according the WHO report. Programs to combat the spread of tuberculosis have been established by the WHO in 30 countries around the world, primarily those that are impacted most by the disease. Reports from the CDC indicate that reported TB cases in the United States are at an all time low, but that there were a total of 108 reported cases of MDR-TB in the U.S. in 2008. According to the WHO there were approximately 440,000 reported cases of MDR-TB worldwide in 2008. Many cases of MDR and XDR-TB are due to individuals lacking access to necessary medical attention and drug treatments. In addition to a lack of available treatment, reports indicate that only an estimated seven percent of patients with MDR-TB are diagnosed.

In regions where access to medical care and treatment may be limited, telemedicine can be used to improve the rate of diagnosis and treatment outcomes. Programs like iCons in Medicine allow healthcare providers in remote and medically underserved areas to connect with physicians who can provide knowledge and guidance for recognizing and treating tuberculosis.