Fwd: Bridges to Nepal

[Seth Sicroff]

---------- Forwarded message ----------
From: Pepper Etters <pepper...@hotmail.com>
Date: Sat, May 9, 2009 at 3:27 PM
Subject: RE: Bridges to Nepal
To: Seth Sicroff <sic...@gmail.com>

Rolwaling has fewer than lower villages, and with the clinic in place there is a better chance that they are being treated on a case by case basis (I know for a fact that several of the children have been treated over the course of the last year). 

When I brought up the NTDs, I was thinking more broadly... the places that will benefit most are those en route to bedding and probably below lukla. 

Nepal has roundworm, hookworm, whip worm, tapeworm (not one of the top 7, but big in Nepal), elephantiasis, trachoma and leshmaniasis (another non-big 7 NTD).  The idea of the "rapid impact package" is that it is a series of 4 drugs that treat the big 7 and then some...  there is a chance that given the lack of onchariasis and the snail one (cant think of it right now) we could cut back to 3 or fewer drugs, but I would have to look into it. 

Honestly, I think that this is probably a better project to attack independently rather than used to "pay off" research subjects. 

If you do decide to incorporate it in one way or another, I think it will be very important to include a small info session on drugs in general to make an attempt to preempt any negative results such as expectation of meds from trekkers, a misunderstanding of the function/value of meds, etc. 

As for developing a parallel concept... it would be more just specifying those NTDs on their lists that are most prevalent (and treatable) in the region and adding other common high impact diseases.  I think this is already the direction you are taking with the COPD thing (esp if you include other pulmonary diseases).  Other big ones would be TB (expensive and super intensive to even try to approach... beyond educations, its better left to the bigger organizations like PIH, or dedicated TB programs).  Other than that, were talking more simple things... GI infections, UTIs, skin infections, injuries, headaches, arthritis, etc...  many of which dont really need to be treated (and shouldn't necessarily without a medical professional on a semi-regular basis).  The last thing that we should be doing is handing out antibiotics like we might with antiparasitics... thats just asking for trouble!  Really, beyond the simplicity of the NTD rapid impact package, the biggest steps are and COPD/pulmonary mitigation projects, the standard drinking water/sanitation improvements, and immunization programs, both which are all important, but more involved. 

I have attached an article that discusses the burden of the NTDs a bit more...  the slant is more toward incorporation within HIV/AIDS, TB or other current programs... but I think you can get a bit more relevant info out of it with that aside. 

On another note, I have discussed with the Mountain Fund the possibility of them initiating a Trek4Good program to Rolwaling.  I haven't heard much about it in awhile, but if they decide to do so, they may be in good shape to take on many of these ideas, or at least supplement any efforts you make. 

Pepper

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Date: Sat, 9 May 2009 13:20:09 -0400

Subject: Re: Bridges to Nepal
From: sic...@gmail.com
To: pepper...@hotmail.com
CC: natalie....@ucdenver.edu; jtu...@sunny-net.ne.jp; elizabet...@mac.com; pac...@aol.com

Does Rolwaling actually have those NTDs? I know at least some of them occur in Kathmandu (e.g. elephantiasis). Maybe we should develop a parallel concept for hill diseases (NHD).
Seth

On Sat, May 9, 2009 at 11:43 AM, Pepper Etters <pepper...@hotmail.com> wrote:

Good point.  Even despite the patience you mentioned with the interviews we conducted, our last visit reminded us that they do have lives and priorities of their own.  There were several individuals with multiple ailments that still did not find the time to come into the clinic until we practically dragged them in on the last day that we were there.  It is easy for us to assume that what we are there doing fills some big void in their lives, but that doesn't necessarily mean they are ready to drop their other responsibilities to conform to our schedules. 

Obviously, the trick will be to figure out a way that you can gather the most information in the least invasive way...  I would imagine that most people will be willing to participate, but will not necessarily make the effort to involve themselves.  Short home visits at times in which they are not otherwise busy seem to yield the best results.  Some explanation as to how participating will actually help (ie in the case of bedding - helping direct the type of care and treatments that are avaliable) will make them all the more receptive. 

There is also the double edged sword of offering something in return for participation. No one wants to set up a precedent, but then is it right to expect their participation in a project that may not have an obvious direct benefit to the participants?  One thought would be to bring in a course of NTD treatments which some organizations are suggesting rural areas recieve at least once a year.  At the cost of pills in Nepal, it could only amount to a dollar or so per treatment.  I dont have time to get into the details now, but you can check out this site to get an idea what I am talking about (Started by one of my profesors here): http://www.globalnetwork.org/.  But then, is it ethical to withold such treatments if they dont want to participate?  Probobly not!  I think I am venturing into a whole other area here... better just leave it at that.


Pepper

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Date: Sat, 9 May 2009 11:14:16 -0400

Subject: Re: Bridges to Nepal
From: sic...@gmail.com

To: pepper...@hotmail.com
CC: natalie....@ucdenver.edu; jtu...@sunny-net.ne.jp; elizabet...@mac.com; pac...@aol.com

Thanks, Pepper. I agree that it will be useful to see how the Kathmandu Rolwalingpas are doing, pulmonarily. There is an additional constraint to consider, and I believe Jan has raised it previously, which is how much prodding and poking the Sherpas can stand. I know you found the Valley people rather patient in response to your demographic and genealogical questioning, but still I'm glad that you have established some kind of track record for at least producing positive change (the clinic) as a result of all our hovering and even home invasions. In any case, we're going to have to think about how to streamline the data-gathering process.

Another potential medical issue might be the impact of inbreeding. Jan can probably help on the risk factors associated with traditionally acceptable degrees of consanquinity.

Seth

On Sat, May 9, 2009 at 10:49 AM, Pepper Etters <pepper...@hotmail.com> wrote:

Seth/Natalie-

Glad to hear this project is going forward, now more than ever I wish that we had the time and resources to gather more concrete data when we were in Bedding last.   I agree that there a number of variables that could be addressed, and you have brought up several which I had not really considered before. 

One which it does not look like you have yet discussed is the difference in roof construction.  The old style of wooden shingles (or slate or thatch in certain villages) was much more effective at allowing smoke to leave the homes.  With the increased use of tin roofs there is a much greater accumulation of smoke within the homes.  It would be interesting to see if this has yet had any affect on the rate of pulmonary problems. 

Something else to consider - given the large number of people who have left the mountains to live in Kathmandu, it woudl be interesting to compare them against those who remain in the mountains.  Are they better off with cleaner home environements but increased outdoor polution, or vise versa?

Other than that, I think that both sex and age would be important to account for.  It is true that the women spend more time in closer proximity to the fires, but given that many of the homes get completely filled with smoke, I would still expect there to be a significant risk for the male population.  In terms of age, it would be great to determine how early there are measurable impacts upon the youth.  Unfortunately, spirometry is not very effective for younger children due to compliance issues. 

Also, when looking specifically at COPD, it may also be wise to at least consider the prevalence of other respiratory diseases such as Asthma and pneumonia. 

One factor that may be difficult to account for is that the Sherpas and other Tibetan cultures have a larger lung capacity than most other populations... I don't know if or how that might skew spirometry results, but it will be important to consider ahead of time.  Peter would probably have that answer.  It wouldn't expect it to affect the shape of the curve, but could still make interpretation a bit difficult. 

As far as the elevation, I would not expect that to have as large of a direct impact on pulmonary disease but it would be especially interesting to consider.  I would beware of secondary causes however (ie home construction, access to tobacco products, prevalence of pulmonary infections, other environmental exposures, time spent in Kathmandu, proximity to automobile traffic, etc). 

Ultimately, I agree with Seth that gathering baseline data may be the most beneficial aspect of the project.  As building materials continue to change, new technologies are implemented (cleaner stoves, chimneys, etc) and so on, it will be nice to be able to compare future data against that which you collect to see if there are any trends associated with specific changes.  However, I also think that it is always important to look at how a project can a have an immediate benefit.  If no one ever decides to compare your data against theirs in the future, ideally your project would still accomplish something.  For that reason, I think that the more things that you can look at to account for any trends the better.  It will put you in a better position to make suggestions for specific public health programs to be implemented.  On that note, if you have to consider certain aspects to ignore in order to simplify the project, I would recommend focusing on the variables that can more easily be changed (ie behaviors, construction materials, etc) over more fixed problems (air quality, climate change, altitude, etc). 

Sorry if this is a bit disjointed, hopefully it will help as you consider how to proceed with the project! 

Pepper Etters

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Date: Wed, 6 May 2009 15:26:57 -0400
Subject: Re: Bridges to Nepal
From: sic...@gmail.com
To: Natalie....@ucdenver.edu
CC: Kevin....@cortland.edu; ted...@cortland.edu; pac...@aol.com; pepper...@hotmail.com

Natalie -

Kevin told me you had spoken -- he was quite impressed!

If you see Peter, give him my regards. I don't remember if I wrote anything about his work at Pheriche. He struck me as something of a saint. Spent several years in truly Spartan conditions, and, although he was supposed to be there just in case mountaineers or other tourists had problems, he knocked himself out for the locals. I recall him taking off towards dusk to go to another village where somebody was dying -- nothing he could do, just be there. So I was very pleased when I heard that he had gotten attached to an American scientific expedition to Everest and managed to squeeze in a summit. I think it must have been one of the tougher expeditions... they were up for a long time, and I think the pre-assigned summit teams must have failed. But that's so long ago, I think I may have hallucinated the whole thing. Anyway, the guy is a real hero.

Yes, I have done some GIS -- mostly baby programs like MapInfo. I did take a course in ArcInfo, but that's like taking one semester of Chinese -- you don't get very far. I also took a course in critique of GIS programs -- we were looking at Medfly and I also studied a project in Nepal. I could find out who did that work and see if he's around, but that was in the early 90s, and I'm sure lots of people are pretty competent at GIS.

I do think a GIS study would be useful, but there are an awful lot of variables. Elevation is probably not as significant as proximity to the trekking trail (correlating with overtime cooking for guests), fuel mix (wood, kerosene, dung, electricity), availability of extra cash for cigarettes, availability of antibiotics to treat bronchitis, and so on. Some of the factor have contradictory impacts: extra money may mean more cooking, more cigarettes, but also better insulation, better meds, and so on.

Another problem might be the small size of the population. You might want to just collect baseline data on one variable, such as FEV1 or oxygen saturation.  But I'm sure Peter would have ideas about that.

Kathmandu itself has problems that probably distinguish it from the general elevational trends. The inversion system (the old lake bed is forms a bowl similar to LA) traps pollutants and allergens. So I would expect some complications in the analysis. Peter recommended my contacting somebody in Kathmandu -- I can't remember if I did or not. Have to check. There is also an excellent Western-run clinic -- CIWEC. So we should take the time to find out what data is really out there, and what is worth studying.  One level of analysis that would make sense is gender (the women spend a lot more time around the stove than men), and it would also be useful politically to see how the kids are doing. Personally, I would not go into this hoping to confirm a particular hypothesis. I would rather think of this as an attempt to gather baseline data about a problem that requires time-series study; if a hypothesis jumps out of the data, so much the better.

I'll think about this some more and get back to you later. I want to try to contact my old buddy Al Pach -- an anthropologist/epidemiologist whom I've been trying to rope into this project. Also Pepper Etters, who ran a health expedition to Rolwaling, may have some ideas.

Seth

On Wed, May 6, 2009 at 1:47 PM, Lencioni, Natalie M <Natalie....@ucdenver.edu> wrote:

Seth,

Hello again!  Here are some updates regarding the potential to conduct the COPD study in Nepal-

 

1. I spoke to SUNY-Cortland.  They do have quite an exciting program.  Kevin and I spoke for an hour and a half and I foresee myself getting involved in sport management possibly later on...they are doing some great things for their students- including the Canadian broadcast company, that's revolutionary technology.  Right now, I am more focused on identifying health outcomes than the management program.  I'd like to register under the open enrollment program.

 

2. I spoke with my advisor today.  As of next week, I will have completed the Certificate program and off for a year before I apply for the succession of the MPH.  There is a class offered this summer that is for individual investigators- it's epidemiological field methods.  I am emailing the professor (currently out of town) to see if I could enroll.  After I hear back from the prof I will contact Peter and run ideas by him, possibly meet, he has a clinic here in Denver.  Otherwise, I wouldn't mind a weekend summer trip to Telluride :)

 

3. There are training courses on proper use of a spirometer at National Jewish. http://www.nationaljewish.org/research/diagnostics/ppu/spirometry-education.aspx

 

4. I believe having a faculty advisor or mentor (in the case that Peter isn't available) would be important.  I am considering any person here who has interest in COPD research...hopefully someone at National Jewish.

 

5.  Have you ever considered any sort of GIS mapping?  There is a professor who does GIS health mapping and it is gaining a lot of attention...

 

6. I'd like to bounce some ideas off you on how to propose this research.  A prevalence study- comparative between high altitude v low altitude? Or between impacted and unimpacted?  I know you have been there several times- are villages mainly impacted at the lower elevation?- more people have access than at the higher elevations.

...I've also looked into the CAI (http://www.cleanairnet.org/caiasia/1412/propertyvalue-13720.html)  and how air quality and climate change are factors.

Basically, I'd really like to take on this project as I have access to a lot of expertise and resources here in Colorado and I could continue on in high altitude research and environmental determinants of health, ie. air quality.

 

Natalie 

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From: Seth Sicroff [sic...@gmail.com]

Sent: Thursday, April 30, 2009 4:11 PM
To: Lencioni, Natalie M

Cc: Kevin Heisey; Ted Fay; pac...@aol.com
Subject: Bridges to Nepal

Hi, again -

Actually, I have heard good things about National Jewish. If you can get someone there to collaborate, that would be outstanding. In addition -- or otherwise -- I have good relations with Peter Hacket, an Everest summiter that I met in Nepal when he was working with the Himalayan Rescue Association in Pheriche, a few miles from Everest. It was an outstanding case of sports (mountaineering/trekking) leading the way in development (providing healthcare). He is now the most important expert on high altitude medicine. We've discussed COPD and respiratory health relatively recently and he is definitely interested. I would discuss with him any research proposal you might be thinking of, and also ask him for his suggestions.

One of the things I was thinking of was organizing the Everest Classic (long trek in to Everest) as a rally to promote awareness of and raise funding for respiratory health. There isn't much research on incidence of COPD in Nepal (one small study at relatively low elevation), so you could easily justify an oximeter-based survey. Wouldn't take much equipment, and I'm sure you could produce some pretty useful data, both for diagnostic purposes and to establish baseline data in unimpacted and impacted villages. Seems like both WHO and UNESCO ought to be interested -- and if Peter Hacket says it's a good idea, his opinion would carry a lot of weight.

By the way, COPD is a huge problem in China -- I remember reading that something like 50% of the population of Beijing have chronic bronchitis....not surprising considering the pollution and the propensity for public expectoration. So the international organizations ought to be getting ready to deal with it.

I'm cc'ing my buddy Al Pach, who has lead international programs for AIDS and other diseases; we've been discussing the prospect of dragging him into a collaborative program focusing on medical anthropology.

I'll try to dig up Peter's email for you.

Seth

On Thu, Apr 30, 2009 at 5:38 PM, Lencioni, Natalie M <Natalie....@ucdenver.edu> wrote:

Seth,

 

Thank you for the quick response!  I went ahead and contacted the guys at SUNY-Cortland and we are going to have a phone conversation on Monday.

 

I am currently in the Colorado School of Public Health and have been actively trying to find ways to build off my interests which indeed match the Bridges Program.  Being a new school, the curriculum isn't developed enough to include sport and development, which I have seen first hand, to be a powerful tool.  I am getting attuned in research methods and the scientific side of public health.  Denver hosts an excellent hosptal for respiratory health- National Jewish.  I assume that if I can create a proposal alongside some of their expertise, I could in fact produce a great research project!  This opportunity has come along at an excellent time. 

 

So I will speak to SUNY on Monday as well as my advisor and see what my options are.  Thank you for the feedback, I will be in touch in the near future.

 

Natalie

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From: Seth Sicroff [sic...@gmail.com]
Sent: Thursday, April 30, 2009 9:19 AM
To: Lencioni, Natalie M
Cc: Ted Fay; Kevin Heisey
Subject: Bridges to Nepal

Dear Ms Lencioni,

Thank you for your interest in the Bridges to Nepal program.

The program is bifurcated. You can enroll in the SUNY Cortland Sport Management Program for the MS in International Sport Management. This is an accredited one-year program, which includes the 4-month Nepal option.

Or you can join the Open Enrollment program. The same core courses will be offered, but there will be more accommodation of individual interests. Academic credit is not offered, but we will assist in the formulation of proposals to individual participants' institutions so as to maximize the chances for credit and/or financial assistance. The Open Enrollment program fees are $4700, exclusive of travel to and from Nepal, insurance, and some other personal items. You can find full information about that on the Web site at www.bridgesnepal.com.
The application links are not yet finalized, but there are no extensive hurdles to jump through. We are not trying to make this a competitive process; instead, we are just trying to make sure that the program is a good fit for your needs.

My advice, since your interests seem to be a particularly good fit for the SUNY Cortland MS in ISM degree program, would be to apply to that end of the program. I don't know exactly what the costs will be, or what the financial aid opportunities might be, but I do know that the program students and faculty are exceedingly energetic, well-organized, and helpful. As a platform for launching a career, the Cortland degree and the Cortland networking options are absolutely incomparable.

Either way, we'd be delighted to have you. I am especially interested in recruiting people with an interest in public health, because that is the number one development priority in remote mountainous destinations. Clinics are very scarce and health issues are well-entrenched. Respiratory health would be very high on my agenda, as COPD is both promoted by increased tourism (through increased use of open stoves) and also potentially countered by the impact of tourism (through electrification, better housing design, increased penetration of health services, and so on).

I believe that we could design a research project around your interests that would be worthy of publication and would give a significant jump-start to your career.

Meanwhile, I am forwarding your inquiry to our Cortland collaborators.

We'll be in touch!

Sincerely,
Seth Sicroff
Director, Bridges-PRTD

On Thu, Apr 30, 2009 at 10:53 AM, Lencioni, Natalie M <Natalie....@ucdenver.edu> wrote:

Greetings Dr. Sicroff!

 

I am very interested in the sport development study program in Nepal.  I am a student of public health- with a platform in sport for development.  I am just emailing to request more information.  How much does the program cost?  Is there a formal application or just resume/cover letter/references?

Thank you and look forward to future conversations.

 

Kindly,

 

Natalie Lencioni