Stoves and disease

A blessing of modern life that feels decidedly mixed is the need to accept that seemingly pleasant old-fashioned ways are untenable and even dangerous.  Tiresome safety-conscious reformers have long had a way of pointing out that, say, the elegant horse and carriage brings with it piles of horse shit; the classic car's glossy dashboards are blindingly so; and the delicious all-American meal of burger, fries, and pop has abhorrent ingredients. You'd almost rather not know, but there it is.

So, too, I'm sorry to say, must go the open fire, with its beauty, its simplicity, its utility, its potent symbolism, and its many chemicals and particulates that lead to childhood pneumonia and a host of other diseases, both respiratory and otherwise.* I'm stretching the analogy, of course: a fire for s'mores is worlds apart from a fire for flatbreads.

Built fires are, in fact, a scourge. People suffer and die prematurely, as do forests and ecosystems and the climate, when fire is used for everyday cooking and warmth. In a recent New Yorker article (available by subscription only, alas) "Hearth Surgery," Burkhard Bilger describes it thus: "Clean air...contains less than fifteen micrograms of fine particles per cubic metre. Five times that amount will set off a smoke alarm. Three hundred times as much--roughly what an open fire produces--will slowly kill you. Wood smoke, as sweet as it smells, is a caustic swirl of chemical agents, including benzene, butadiene, styrene, formaldehyde, dioxin, and methylene chloride....Indoor smoke kills a million and a half people annually." Not to mention heats the atmosphere with terrible efficacy.

Seems like a low-hanging fruit, no? Get people cheap, powerful, clean stoves; prevent suffering, deforestation, and global warming. But it turns out that designing and introducing good cookstoves present knotty engineering and cultural problems. As Bilger explains, it's hard to come up with a stove that's simultaneously efficient, cheap, clean, durable, and easy to use. And many people accustomed to their usual way of cooking aren't eager to change. (As the New York Times put it in a recent article, can you imagine asking a traditional Italian cook to make risotto in a microwave?)

But stove development is hot. It has attracted organizations and passionate hobbyists who like the technical challenge and the idea of saving lives and the planet. To learn more, check out the blog Improved Biomass Stoves for discussions of stoves and stovers (as developers of stoves often call themselves). BioEnergy Lists and Rocket Stoves are resource sites for stove developers. The journal Indoor Air reports on these issues (free access to developing-world institutions). Then, too, there are GTZ; Stove Camp; ETHOS; Darfur Cookstoves; and the Ashden Awards, among many other sites. Lists of relevant links much more comprehensive than mine can be found here and here.

Let's hope that good stoves spread everywhere and make open fires a matter of misguided nostalgia.


*Carbon monoxide poisoning, pneumonia, lung cancer, bronchitis, chronic obstructive pulmonary disease, heart disease, high blood pressure, low birth weight, cataracts...

UpToDate's grant program: free software and information.

Information wants to be free, or so say the hackers. And while good medical information has long been expensive, some of it will soon become free for some of those least able to afford it.

On December 4th I mentioned that UpToDate, the eponymous medical-article service, has rolled out a grant program. Today I talked to Drs. Ellie Baron and Denise Basow--respectively, UpTo Date's Deputy Editor for Infectious Diseases and Editor-in-Chief--about the service's plan to give away free subscriptions to its giant article database for low-resource practices.

"We've been providing donated subscriptions for several years," said Dr. Baron, who told me that they get about 20 requests a year, many of them from UpToDate authors who are doing medical work abroad. "What's changed is that recently the application process has become more formalized." To wit, they've formed a partnership with a group called the Global Health Delivery Project (GHD), which was started by low-resource godfather Paul Farmer and colleagues. If you run a medical organization in a low-resource setting and can't afford the pricy subscription to UpToDate, you can fill out an application, whereupon GHD doctors will decide whom to grant subscriptions to. This is the first year of the program and Dr. Baron wasn't able to say how many subscriptions they plan to give. It may depend in part on the number of applications they get. One hopes there will be a lot more than 20.

On the other hand, since most of UpToDate's articles are written by and for physicians in high-resource settings, it's worth asking what good they are to our low-resource colleagues. Does it help to read about the latest chemo recommendations for breast cancer when all your hospital has to offer is a surgeon? To UpToDate's tremendous credit, they are studying this. Low-resource sites affiliated with Partners In Health (also a Farmer organization) are using UpToDate and recording which articles and what kinds of information seem to be most useful. Their ultimate goal, said Dr. Basow, is to publish this information. For the moment, Dr. Baron told me, though people may not have access to the most costly resources mentioned in an article, they can adapt what they do have to the article's recommendations (which, in my experience, often offer multiple suggestions ranging from the simple to the complex). And I would submit that all health-care workers are entitled to the best information, period. If they don't have the ideal chemo cocktail, at least they will know something about how to use it if their clinic does gain capacity in the future. Which it would seem more likely to do if its leadership has a clear idea of what the clinic needs.

Also to be applauded is the fact that UpToDate is developing more content geared toward low-resource practitioners. Baron told me that the company is gradually adding authors and articles to the existing database, and once they have enough, they plan to make it a dedicated section within their contents. With the subscriptions and the articles, she said, "We're trying to get at [low-resource medicine] from more than one angle." Bravo, UpToDate.

Animals as diagnosticians and treatment aids

Ants' interest in urine can be used to see whether the urine contains sugar, a marker of diabetes. (If the physician prefers, he can taste it himself.) The use of ants for urinalysis comes up in tropical medicine and historical references, but there appear to be zero articles in PubMed about it. So I remain in the dark as to which species of ant should be used, how long they should be given to show an interest in the urine, or whether more ants mean more sugar is present. Ants have also been studied in arthritis, though it's not clear from the abstracts I can find whether the ants are eaten, encouraged to sting the sufferer, or what. (Interestingly, a friend who has studied traditional medicine in Morocco tells me that bee stings are used to treat arthritic joints. Perhaps Order Hymenoptera contains an antiinflammatory agent.)

Maggots can clean the dead tissue from wounds. So-called larval therapy is used in the U.K. Here's a free fulltext review. (Dermestid beetles can clean carcasses for museum display, too. The idea is that many tiny sets of jaws can scrape off flesh better than human hands can.)

Leeches secrete a blood thinner that can keep wounds from becoming engorged, which is useful when attaching severed body parts and in other such plastic surgery needs. There are a number of articles about this in PubMed, many of which are free. These creatures have been used to treat priapism as well, though this is poorly documented in the medical literature (there's a 1960 Russian-language article about the topic, but no reviews more recent than that to my knowledge).

Also of interest:

* Zootherapeutics (the use of animals in medical treatments) in Brazil and India.

* An insect formulary of sorts, drawing upon Indian folk remedies. I don't know whether studies have been done, and if so how rigorous they've been, but as long as information about such things continues to be published in periodicals like International Chickpea and Pigeonpea Newsletter, low-resource practitioners are not going to have access to it.

* Some articles from Chinese journals are cited here regarding ants and their uses in China. Again, these are buried in journals that aren't easy to find online.

Many of these remedies remain completely unstudied by science. There are probably a lot of safe and effective medicinal uses of insects, but until they're subjected to scientific scrutiny we may never take full advantage of them in either low- or high-resource medicine.

Books, journals, and UpToDate for less than retail

Until recently, most physicians consulted the kind of medical journals that stand bound in hundred-year chunks on the towering metal shelves of medical libraries. Those journals not only make for meaty browsing, with their retro advertisements and dated syntax, but also hold a wealth of valuable medical information, much of which remains unarchived on electronic media. Still, going to such shelves to look up a journal article is like knitting your own socks: it would be nice, but nobody has time. We find journal articles online instead.

Most of the journals I've needed to consult in my medical career are available online by subscription. Already pricy as physical copies, the journals can be grievously expensive in their electronic forms, even with tiered pricing. In some cases, caregivers in poor countries get a price break. The New England Journal of Medicine, for example, allows free access to URLs from 119 low-income countries.

The WHO has seen to it that many such journals are accessible to low-resource clinicians who have the bandwidth. HINARI is a WHO project to allow some institutions* in developing countries to read medical journals in the medical literature either for free or for $1000/year, depending on level of poverty of their countries. It was started in 2001 with six publishers: Blackwell, Elsevier Science, Harcourt Worldwide STM Group, Springer Verlag (Bertelsmann), John Wiley, and Wolters Kluwer International Health & Science. The site comes in seven languages, and the journals in 22. So far there are 6,458 journals thus accessible.

Despite Wolters' involvement with HINARI, one resource I haven't found on either HINARI or Free Medical Journals is UpToDate, Wolters' immense evidence-based and physician-authored article service that is the first place many American doctors turn with questions on the job. It has plenty of international subscribers, but they are charged full price. I filled out their subscription form as a theoretical internal medicine physician from the United States. The cheapest option is one for trainees at $195 a year, plus $15 for shipping and handling. A standalone subscription is $1,495. I also filled it out as the same physician from Botswana--same prices, except higher S&H.

That looks to be changing, though. Though their home page and subscription form don't signal this, UpToDate recently rolled out a donations program that allows institutions in poor areas of the US and poor countries to apply for "a limited number" of free subscriptions. It's administered through the Global Health Delivery Project, a brainchild of Paul Farmer, Jim Kim, and Michael Porter (if you don't know who these guys are, read this first). Institutions can apply to a January or May 2010 deadline for the first round of grants. It's not clear how many grants will be awarded or how applicants are judged, although an UpToDate spokeswoman has promised (12/3) to get back to me on this. In any case, it would seem to be a welcome development for low-resource medicine.

* A small-town clinic doesn't quality under its rules, which state that access "applies only to bona fide academic and research institutions."

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Other links to free medical information online:

* The WHO Formulary (pdf).
* Pubmed.gov allows the searcher to specify that searches return only free fulltext hits.

* HighWire's list of free full-text journals, some offering only older content for free.

* Excellent list of online resources compiled by a nursing informatics specialist. The most helpful links are toward the end of the page.

* FreeBooks4Doctors and FreeMedicalJournals' eponymous offerings are apparently accessed by thousands of readers around the world, though some of its journals are only free after a one-year paid subscription. This and the preceding site are maintained by the efforts of a man named Bernd Sebastian Kamps, who also offers a prize to the best medical textbook created to be freely available online. Good idea--there is nothing like a contest to maximally leverage effort.