This past year’s deadlier-than-usual flu season cost the U.S. an estimated $15 billion in lost productivity, as millions of infected workers called out sick. And as the Zika outbreak proved in 2016, there is reason to be worried that we aren’t doing enough to prepare for whatever infectious disease comes at us next.
To that end, scientists are turning to an unlikely ally in hopes of learning how to prevent, or quash, the next global health threat: the lowly amphibian.
In the late 1990s a deadly fungal pathogen ravaged millions of amphibians around the world, leading to catastrophic losses among their populations. But researchers recently found that a few species of frogs in Central America, which were thought to be extinct, have rebounded and, in some cases, developed even stronger defenses against the infection.
The study, published last month in the journal Science, looked at how the froggy fungal disease, called chytridiomycosis, went from epidemic levels, when an infectious disease introduces itself quickly and affects large populations, to an endemic, or the point at which the disease becomes commonplace. The fungus is still around and as deadly as ever, suggesting that some frogs have evolved to create resistance to the disease.
“If you’ve ever held a frog or toad, people have that experience of it being a slimy animal. That’s because they have these secretions as a defense mechanism,” says biologist Jamie Voyles, an assistant professor at the University of Nevada, Reno, who led the multiyear study. “Amphibian skin is actually a very complex physiological organ, so in addition to water absorption, there are also these secretions that are helpful to the immune system and are really good at inhibiting pathogens.”
Perhaps the most interesting takeaway from the study, though, can be gleaned by examining what happens to populations — and the disease itself — after an epidemic, which can inform how we to respond to human-spread diseases in the future.
“Historically, we’ve viewed infectious diseases as being able to shift over time, but we haven’t fully clarified how that works,” says Voyles. “Think of the more notorious cases of influenza, or similar kinds of outbreaks, where there is a large panic and high mutation rate, and where we know that the virus is changing all the time from one strain to the next.”
An example of this disconnect between what happens during an outbreak and what happens afterward is the 2015 Ebola pandemic, which sparked widespread media hysteria and killed more than 11,000 people.
“There is a drop-off in attention paid to host populations after an outbreak,” she says. “We tend to do a lot of hand-waving when an epidemic is going on, but [we don’t much] hear about follow-up in [terms of] understanding the disease after an outbreak.”
By continuing to examine how outbreaks affect wildlife after the fact, we might be in a better position to contain epidemics among humans in the future, says Voyles.
“If we understand the mechanistic underpinnings of how outbreaks happen, then we can apply those lessons to how we respond to other emerging infectious diseases,” she says.
The threat of a devastating global pandemic is increasingly worrisome for public health experts. They point to the lack of preparedness among some nations, even as others, such as the U.S. and China, have established rapid-response teams to swiftly deal with an emergency.
Or as Jimmy Whitworth, a professor at the London School of Hygiene & Tropical Medicine put it, “We’re only as secure in the world as the weakest country.”
And as the worldwide population grows and people pack themselves into ever-denser urban areas, as well as expand to regions previously inhabited only by wildlife, the opportunity for the spread of catastrophic diseases is only increasing.
More worrisome still: As the global stakes rise, funding in the U.S. is being cut.
The Trump administration’s fiscal plan for 2018 slashes millions of dollars from the Centers for Disease Control’s budget, which has led the agency to roll back its efforts in global-disease prevention by 80 percent.
“[Outbreaks and infectious diseases] are not problems that are going away,” Voyles says. “It’s an increasingly connected world, and what that means is that we’re going to be moving more pathogens all around the globe.”
The current situation, much like amphibians themselves, is, in a word, slippery, where preparedness for pandemics is taking a backseat to other economic priorities. Our best hope, then, might just lie with the frogs and what they can teach us about winning the war on global disease.
Tag: The Centers for Disease Control and Prevention
For Refugees, American Dream Starts With Better Mental-Health Screenings
In 2010, when Wasfi Rabaa, an Iraqi native, arrived in Seattle as a humanitarian refugee, he felt “hopeless” and drained. Six years earlier, he had been tortured and maimed by kidnappers who threatened to rape his wife. He escaped to Syria, then a safe haven, where his then 11-year-old son worked in a restaurant to support the family. There, fellow exiles predicted that in America, his children would “end up as drug addicts.”
Thanks to an innovative Seattle program called Pathways to Wellness, which identifies refugees with mental health problems, Rabaa was quickly diagnosed with post-traumatic stress disorder (PTSD) and received medication and counseling. He answered a specially designed questionnaire, which takes most refugees less than 10 minutes to complete, and then was referred to a mental health center with bilingual staff. Speaking through an interpreter, Rabaa says that the intervention “brought smiles back to my family.” His son, now 20, is studying to be an engineer at a college in Washington State.
Since 1975, the United States has accepted more than 3 million refugees, and more than 58,000 in 2012 alone, according to the Office of Refugee Resettlement (ORR), a subdivision of the U.S. Department of Health and Human Services. According to a meta-analysis in the Journal of the American Medical Association, roughly 30 percent of refugees surveyed suffer from PTSD and about 30 percent battle clinical depression.
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Pathways to Wellness, a public-private partnership, is part of a grassroots trend in the last five years to address refugees’ mental health. A keystone for providers is the Domestic Medical Examination that newly arrived refugees can receive under the Federal Refugee Act of 1980. (Refugees also undergo a mandatory physical exam before they arrive in this country.) “It’s the first chance you get to explain what mental health is in the United States,” says Beth Farmer, program director of International Counseling and Community Services at Lutheran Community Services Northwest, which helped develop Pathways. “It’s the first time you get to reduce stigma.”
Funded by groups that include the Robert Wood Johnson Foundation and the Bill & Melinda Gates Foundation, Pathways to Wellness is one tool that refugee settlement organizations can use to help those who’ve fled to the U.S. for a better life. “We wanted to find refugees in distress, get them to care, and have care that works,” says Farmer, who speaks about the initiative with the palpable pride of an adoring parent. Perhaps that’s because she spent considerable time defending her program from naysayers during its design in 2008 and 2009. “People said, ‘it’ll never work. We’ve tried it before. There are too many different languages. The stigma is too high,’” she recalls. But Pathways has proved effective and popular; more than 50 refugee aid organizations across the country and as far away as Australia have signed utilization agreements to replicate the program.
But such initiatives remain the exception rather than the rule, despite plenty of evidence that mental health screenings benefit newly arrived refugees. Many resettlement experts worry that the nationwide procedures for screening refugees for mental illness are scattershot and inadequate. Lisa Raffonelli, a spokesperson for the ORR, said it recently revised guidance to states, calling for “a head-to-toe review of all systems, including a mental health screening to assess for acute psychiatric emergencies.” The agency also plans to add one staff position devoted to the “emotional wellness” of refugees. But the federal government gives states wide latitude to design initial health exams, which were historically used to detect communicable diseases such as tuberculosis rather than PTSD or depression.
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“Some states have developed highly sophisticated programs with excellent screening,” says Ann O’Fallon, former executive secretary to the Association of Refugee Health Coordinators. “Other states, with smaller numbers of arrivals or smaller budgets, have struggled to develop a quality program.”
A 2012 survey of 44 state refugee health coordinators published in the Journal of Immigrant & Refugee Studies found that 19 states failed to screen refugees for symptoms of mental illness. Of the 25 surveyed states with screening programs, most relied on informal conversations with patients rather than screening tools tailored to assess refugees. The findings “dismayed” the study’s co-author, Patricia Shannon, an assistant professor in the School of Social Work at the University of Minnesota. She believes that proactive questioning of refugees about their trauma is common sense. “People who are in need of mental health services, like torture survivors, are not going to raise their hand and say, ‘I’m the one you are looking for over here.’”
The format of the initial medical exam varies considerably, observes Paul Stein, national president of the State Coordinators of Refugee Resettlement and state refugee coordinator in Colorado. The spectrum ranges from “bare bones minimum — no mental health included, just a health screening that’s done in one visit” to multiple visits and a comprehensive emotional health checkup, Stein says. His state recently entered into a public-private partnership to open the Colorado Refugee Wellness Center in Aurora, something of a one-stop health shop where refugees can receive a range of services, including mental health screenings and treatment. “When you come in for one service, you can access other services at the same time in the same location,” Stein says. This helps avoid the care disconnects that can occur “when you are referred across town for a follow-up appointment.”
Exactly when to schedule mental health screenings spurs debate. Some newly arrived refugees may feel like they have just won the lottery, says Greg Vinson, senior research and evaluation manager at the Center for Victims of Torture in St. Paul, Minn. He pointed out that Somalis in the Dadaab refugee camps in Kenya often refer to acceptance into the U.S. refugee program as the “Golden Ticket.” Once freed from immediate danger, many refugees experience “a honeymoon period . . . but then the issues re-emerge,” he says.
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Eh Taw Dwe, an ethnic Karen from Myanmar, knows that firsthand. As the “head man” of his village, Dwe found himself as a buffer between government soldiers and Karen rebels fighting a long and brutal conflict.
In 2002, government soldiers forced Dwe to watch four of his villagers executed. “They didn’t use a gun. They used a knife,” Dwe recalls. The soldiers imprisoned him at a military base for three days. There, an officer played Russian roulette with Dwe. “He put a gun right to my forehead. He counted ‘one, two, three’ and pulled the trigger. They laughed….” After Dwe’s family paid a ransom to his kidnappers, he was able to escape, and marched with his pregnant wife and two young children through thick jungle to Thailand. Toward the end of the harrowing 13-day journey — he had packed only enough food for 10 days — Dwe’s infant daughter became seriously ill. “She was dying,” he says, his voice breaking. “She had diarrhea. She could not breathe. I hold my wife’s hand, and I prayed.”
His family survived, arriving in Minnesota in 2004. Dwe underwent a health exam, but it did not include a mental health screening. Within two months, Dwe got a job as an interpreter with St. Paul-Ramsey County Public Health. At first, he felt euphoric, “because I don’t have to worry that people were going to kill me.”
Then the flashbacks started, imprisoning Dwe again in his cell on the military base in Myanmar. “The words that they say are still in my ears,” says Dwe, who started having angry outbursts. He was eventually referred to the Center for Victims of Torture, one of 30 federally financed programs across the country that rehabilitate torture survivors and advocate on their behalf.
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The center, founded in 1985, treats survivors at their headquarters in St. Paul. If he had not received therapy and medication, Dwe, who now runs his own translation business, imagines that life would be very different: “Maybe I would be in jail,” he says.
Ann O’Fallon, the former head of state refugee coordinators, praises states like Minnesota and Colorado — “a really beautiful model,” she says — for devoting more resources to refugees, but she faults the federal government for collecting insufficient data on mental health screenings. “It needs to be beefed up,” she says. “What percentage of refugees get screened? Is there a requirement that states report in?”
Paul Stein of Colorado understands the human and financial toll caused by not taking action. The longer that barriers to employment, such as mental illness, are not addressed, he says, “the longer it takes for somebody to start building income and paying taxes.”
Several mental health providers concur that not acting to detect and treat mental illness in new refugees amounts to neglect; some untreated refugees likely suffer from psychosomatic illnesses and as a result overutilize emergency rooms. Patricia Shannon, of the University of Minnesota, concludes that, in general, “the high cost for repeat medical visits that are based on mental health distress is something that isn’t quantified.” Instead, she offers anecdotal evidence. When a wave of Somali refugees settled in the Minneapolis area starting in 2004, many newcomers with mysterious illnesses turned up in emergency rooms. But doctors “wouldn’t find anything wrong with them,” Shannon says. “On some of the charts, I had residents tell me that they would write ‘Sick Somali Syndrome.’”
Data showing a connection between chronic stress, PTSD and depression and long-term poor health is “overwhelming,” says Dr. Michael Hollifield, a psychiatrist who primarily designed the Pathways to Wellness questionnaire.
Hollifield does not consider improved mental health screenings a cure-all for the many challenges faced by refugees, but he is certain that it is the sensible place to start. When contemplating the issue, he says he often thinks about a classic television commercial for Fram oil filters, in which a mechanic rolls out from under a broken-down wreck with a gunked-up engine and delivers the company’s catchphrase: “The choice is yours. You can pay me now or you can pay me later.”
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The Farm That Could Change Autism Treatment Forever
By age 14, Billy Nacmias had become obese, obstinate and prone to such violent outbursts that he pushed a teacher down a flight of stairs and was expelled from school.
Billy has autism, but he had not always been so contentious. His behavior had grown increasingly unstable in recent years, after being physically beaten by another teacher at his Queens, N.Y., school. He began overeating and acting out. He became easily enraged and went on binges destroying his family’s home. Billy’s parents sued the city school district after their son’s maltreatment, and as part of their settlement, they were offered their choice of institutions, on the government’s dime, to help him.
Their choices were limited: Most residential treatment centers are state-run forensic psych facilities — sometimes referred to as “lock-ins,” because residents are locked inside the premises. The Nacmiases were reluctant to confine their young son to such an institution. They had one other option: a different kind of facility, called The Center for Discovery, about 100 miles away, in Monticello, N.Y. The private not-for-profit is the largest residential treatment center of its kind in New York State, reserved for the care and treatment of those with significant disabilities, complex medical conditions and autism spectrum disorders.
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The Center, located in the Catskill Mountains, feels more like a utopia than it does a last resort. On a bright morning in early fall, the campus had the air of a tony New England prep school or a mountaintop yoga retreat — not, God forbid, an institution. Spread out over three campuses and 1,500 acres of rolling hills wound with walkways and lovingly tended gardens, the facility abounds with horses, pigs, chickens and cows. The on-site cafe serves freshly baked goods made from hyperlocal organic ingredients and offers an array of nut-based milks. Students here — some 400 adults and children with significant physical or developmental disabilities — feed the farm animals as well as the rabbits, rascal ferrets, snakes and frogs that live in the Center’s “Imaginarium.” Residents also work the farm, swim in the therapeutic pool, play fantasy football in the “Learning Center,” and volunteer at the nearby fire department. In the winter, they zip special coats around their wheelchairs so they can still go outside safely.
The activities are essential to The Center’s holistic — or “offbeat,” as Patrick Dollard, The Center’s boisterous president and CEO, puts it — approach to treatment. While the medical establishment tends to adhere to a “broken brain” theory of developmental disability, which focuses primarily on neurological problems and behavior-based therapies, the Monticello center aims to treat the entire individual. The idea is that a person’s physical, emotional and psychological health, along with his or her environment, are one interconnected whole. At The Center for Discovery, buildings conform to strict eco-friendly regulations, and the residents’ diets are stripped of artificial dyes, flavorings and preservatives. Outdoor and indoor environments, including those that foster interaction with animals, are specifically designed to promote learning and calmness by decreasing children’s stress responses. Kids eat healthily, exercise and are, above all, encouraged to express themselves and to be happy.
The place is so quiet, calm and bright that it’s hard to believe it is a counterpart to the traditional psychiatric treatment center, or lock-in. That phrase carries especially dark connotations in New York State, where conditions at such facilities as the Willowbrook State School on Staten Island were so egregious — among the offenses were overcrowding, sexual abuse and unethical medical studies — that they spawned a federal investigation and civil rights legislation protecting the rights of the disabled. (The Center for Discovery took in some of Willowbrook’s residents when the notorious facility closed in 1987.)
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Billy arrived at The Center in 2012. At the time, he would eat only pizza and blocks of mozzarella cheese, and he required two full-time aides trained in special tactics to keep him from injuring himself or his helpers. In videos taken during those early days, he angrily pushes away a plate of organic fish and rice, demanding pizza again and again, pounding his hands on the table. On a walk, he attempts to grab one of the aides and shove him forcefully.
Less than a year later, videos show a boy transformed. He lost 60 pounds; he looks years younger. He came around to organic food. He lists his favorite chores out loud, with a new spark in his eye and color in his cheeks. His incessant demands for junk food have been replaced by an exuberant enumeration of his favorite activities: “Cooking, zoo jobs, feeding the rabbits and Zumba!” he says.
Billy is, by all appearances, a far healthier kid. He is one of The Center’s most recent success stories, but the path of his evolution is not uncommon. Dollard says he’s spent the last three decades witnessing similar transformations. “If you create a safe environment, good things happen. They grow. They get better. They get more confident. I’ve seen it happen,” Dollard says. “I’ll have somebody I’ve known for 20 years, and I see them and suddenly they’re better and I say, ‘Wow! I wish I could prove that!’”
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What Dollard means is that he wishes he had the hard data to show that The Center’s treatment strategies result in improvements in health: lower anxiety, a healthier immune system and less frequent bouts of rage. And for the last year and a half, The Center has been working to collect that data. With a $10 million grant from the National Science Foundation and in partnership with the MIT Media Lab, Harvard University and the Georgia Institute of Technology, The Center has been collaborating on formal research on autism treatment.
The nucleus of The Center’s research efforts resides in its Big Barn Discovery School, the first residential campus in New York State specifically designed for students with autism spectrum disorders. As its name suggests, the school is housed in and adjacent to a converted barn — once a large dairy farm that sent products to New York City — located on a chunk of land that The Center bought nearly a decade ago in neighboring Hurleyville, N.Y. The barn itself is surrounded by chicken coops built into old, multicolored gypsy wagons. Kids gather 200 eggs a day from the coops, which are then distributed to the on-site dining areas and also handed out to neighboring community members as part of The Center’s agriculture program. Within the barn are performance and event spaces, which host proms and graduations, and this spring, a production of “A Midsummer Night’s Dream.”
Down a long wing are a series of classrooms outfitted with state-of-the-art technology — cameras, computers and biometric sensors — to monitor and measure virtually everything that goes on with each student within each room. Researchers are interested in studying how children with autism interact and respond to their environment; they’re also looking for the potential triggers of kids’ agitation and dysfunctional behaviors. For example, what are the conditions — both internally and externally — before, during and after an outburst? Are they correlative or is there something more subtle at play?
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At the end of the hall in the wing is the laboratory space, where data on physiological responses are gathered. Here, technicians and doctors monitor and record in-the-moment health measures such as heart rate and electrodermal activity via wearable sensors like wristbands. Researchers also track longer-term indicators of overall health, including the time of the student’s last bowel movement, hours of nightly sleep, food and liquid intake, exercise and duration. Using these data from the classrooms and lab, the consortium of researchers are hoping to quantify exactly how children with autism are responding to The Center’s interventions.
“All of these perspectives working collectively in this space — that’s how we’re going to have potential to have a substantive impact on public health,” says Lisa A. Marsch, director of the Center for Technology and Behavioral Health at Dartmouth College.
The latest numbers suggest that the target population is growing. The Centers for Disease Control and Prevention estimates that roughly 1 in 88 American children now have an autism spectrum disorder, up from 1 in 500 in 1995. Today, at The Center for Discovery, 60 percent of the residents comprise children with autism spectrum disorders, up from 40 percent just five years ago.
Ultimately, the impact of the research being done at The Center could extend beyond autism, and there is hope that this holistic approach could be applicable to age-related illnesses like dementia as well. The end goal, however — Dollard and others’ version of utopia — is to render facilities like this one unnecessary. With the right treatment and assistance, they say, people with disabilities may be able to live full lives in their own communities. “We want to eradicate the need for residential care altogether,” explains The Center’s associate executive director, Terry Hamlin, with a smile. “So that no one is locked away.”
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Correction: February 20, 2014
This article has been amended throughout to correct several small errors of fact.