Seeing the Future of Medicine

20.02.01 Seeing the Future of Medicine

SM Sarah McConnell

AS Audio Sample

JA Dr. Jayakrishna Ambati

JH Janice Hawkins

JO Jose Oberholzer

SZ Sharon Zook

00:00:00

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SM In 1983, the theologian John Hull fully lost his sight after years of weakening vision. He kept audio diaries of his journey into darkness and became famous for his writing on blindness and disability. The New York Times even made his audio diaries into a documentary called Notes on Blindness.

AS After nearly three years of blindness, I find that the pictures in the gallery of my mind have dimmed somewhat. So I found this great distress, that I could no longer remember easily what my wife looked like. What my daughterís image had looked like.

SM Hull's experience of blindness turned him into a disability advocate. But he also suffered from his loss of saying.

AS I had a desperate feeling of being closed, having to get out. I must get out. As if I was banging my head, my whole body, against the wall of blindness. A desperate need to break through this curtain, this veil which surrounded me to come out into the world of light out there.

SM From Virginia Humanities, this is With Good Reason. I'm Sarah McConnell. Today on the show, the hunt for a cure for a common cause of blindness. Later in the show, we'll learn how nursing students are using escape rooms and high-tech simulations to construct realistic medical scenarios.

AS We have a hospital bed and there's a mannequin and he a high-fidelity mannequin. He can do almost everything but get up out of the bed and walk.

SM But first, Dr. Jayakrishna Ambati is using new research methods to try to cure a common cause of blindness called macular degeneration. His lab at the University of Virginia made a breakthrough discovery in the cause of macular degeneration and has led the way toward a possible cure. How many of us lose our sight to macular degeneration, would you say? How widespread is this ailment?

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JA You know, macular degeneration is really a silent pandemic. Around the world, there are some 200 million people who suffer from macular degeneration. Fortunately, not everybody loses dramatic amounts of vision, but when it happens it can be devastating. Macular degeneration doesn't just steal your vision. It can rob your humanity, because in the advanced stages of this condition, people lose the ability to read, to drive, to see the faces of their loved ones. It is something that fundamentally alters the very way in which people live their lives. And we want to end this scourge.

SM You're a doctor. You're an ophthalmologist. But you also have been researching what is the cause of macular degeneration and possibly what the cure might be. Is there currently a cure?

JA Well, macular degeneration comes in two varieties, there is a wet form and a dry form. So the wet form, fortunately, actually has some treatments over the last decade. Unfortunately, the far more common dry form, which accounts for 90 percent of the people with macular degeneration, still languishes without any treatment.

SM And so when a patient comes to you with a dry form, there's very little you can offer right now?

JA You know, basically the only thing you can tell them is to eat well, exercise and do all the things that are considered good for your heart.

SM What is the story of what you and your team discovered about this? What did we think previously?

JA Macular degeneration, the dry form, which is what my group focuses on, has been poorly studied for many decades. And that's the main reason we don't have a treatment or even a cure for this condition because we don't understand what drives it, what causes it. And what my lab discovered almost a decade ago is, what is the fundamental driver of this problem?

SM How did you come across that?

JA So 2006 was an exciting time. The Nobel Prize in physiology or medicine was just awarded to two brilliant scientists, Fire and Mello, who discovered something brand new called RNA interference. Basically, they discovered that our cells, our bodies had the ability to regulate, to control the RNA molecules in our cells. And this was an amazing discovery for biology. But it was even - a greater moment for pharmaceutical companies, because now they had a brand-new technology, they could employ for any number of diseases by creating new medicines, using this RNA interference. Know, the very first clinical trials that used these RNA interference drugs was for wet macular degeneration, which at that time didn't have a treatment yet.

SM And they were using it, they brought it to market?

JA Now, they tested it in clinical trials and abandoned those clinical trials because of problems. And those were the problems that we actually found in the lab, that led in part to those clinical trials being stopped.

SM What had you and your team been doing in the lab?

JA That technology was so exciting that most research labs in the country and in the world really were starting to use RNA interference for every problem that they had. And so we, too, were tremendously excited and we were using it as well. And as we use this technology, we made a very interesting, amazing, and disturbing discovery that these drugs actually had a very terrible generic side effect. All of them caused cells in various tissues to die.

SM Similar to chemotherapy for cancer patients?

JA Yeah. In a sense, because chemotherapy certainly kills cells and the advantage there, it kills cancer cells more efficiently than normal cells. But here, these aren't interference. Drugs were killing normal cells.

SM What was this devastating to the scientific community to learn this? Was this your discovery?

JA Yeah. My lab discovered that RNA interference drugs activated the immune system in a specific way to kill cells. And that was a landmark and highly unexpected discovery that was published in the journal Nature, which is the journal that publishes when new dinosaurs are discovered, or new planets are discovered. So this was around 2007, 2008, when we made these observations, when the scientists in my lab came and told me, it was really difficult. It was very unexpected.

SM You almost didn't believe.

JA I didn't believe it. I didn't believe it for months and months. And I think disbelief is the mark of a good scientific process. So I had multiple scientists in the lab test it and over and over again, we saw the same thing. And then we - we made the breakthrough in understanding how this was happening. And that really convinced us that this was a real observation. So in 2008, just a few days before our paper came out in the journal Nature, I presented this work at a scientific meeting in Miami at the Mandarin Hotel, an audience of over 4000 physicians and scientists. And as I was giving this talk, people started streaming out of the room, not because they didn't like the talk but because they were so amazed and disturbed by the findings that they probably went to discuss, I don't know, maybe with their brokers to sell their stocks. And in fact, our publication had a tremendously devastating impact on the field and on some companies in the RNA interference space. They lost huge market shares on the day that our paper came out.

SM Were billions lost ultimately?

JA Yeah, I'm sure billions were lost. But most importantly, lives were saved and vision was saved. And that's far more important, I think.

SM How so? Explain that again. What was the damage that was being done by this technique that people thought would be beneficial?

JA Because these drugs were killing cells and, in the eye, people were actually losing their vision. And that's in part why these clinical trials were stopped.

SM So what did you do after that? What then became your mission, when it came to looking at the causes and a cure for macular degeneration?

JA So out of this bad news that SI - RNA drugs, that RNA interference drugs could cause vision loss, was the simultaneous observation that what we were seeing from RNA interference was very similar to what was happening in the eyes of people with dry macular degeneration. Are there molecules that are building up in the retina, in dry macular degeneration that look like these RNA interference drugs? So we set out to search for molecules like that.

SM And eating away at the retina cells.

JA Correct. Because this detritus, this garbage that builds up over years that doesn't get cleared away can cause tremendous damage. And that's what we know now to be the case. So we were very fortunate, over many years we diligently assembled a large library of human donor eyes with and without dry macular degeneration. And we did very painstaking, rigorous studies of what was different between the diseased eyes and the normalization.

SM What was the breakthrough?

JA So the breakthrough was that we actually found for the first time what was this buildup product that was accumulating in these disease, dry macular degeneration eyes. And it turned out to be something very unusual called Alu RNAs. So Alus are part of this large part of the DNA called junk DNA. It's something like the dark matter and the dark energy in the universe. It's abundant, but we don't know what it does. So we principally disregard it. And that's what scientists had done for three decades about Alus. They were all over the place in our DNA. Nobody knew what it did, so we called it junk and we just ignored it.

SM So what you mean is the body is producing this Alus that is going unchecked and it's eating away at the retina.

AJA That's exactly right. Normally Alu is produced but chopped up by an aptly named molecule called Dicer. You can think of it like a knife that dices away your vegetables. And this dicer molecule normally, in healthy eyes, gets rid of these alus by dicing them up and preventing them from ever building up. Unfortunately, in dry macular degeneration, Dicer levels drop. So now these alleys run rampant and start building up and then they start eating away and killing the retina. So we had submitted material from all these human donor eyes with this disease for sequencing. We had no idea what we're going to find. There are tens of thousands of genes that could have come back as the answer. But surprisingly, what came back was Alu. And that was something most people, including us, knew very little about. So it was both exhilarating and puzzling at the same time, but it was such a eureka moment, for us to finally learn the identity of this culprit.

SM Do you remember when you first learned it was Alu?

JA Absolutely. It was just before six o'clock. I was waiting at the birthday party of my fellowís daughter and just before six o'clock an e-mail popped up with the sequence and it said Alu. And it was just an amazing moment. And I immediately shared it with everyone who was there. And now we had two causes for celebration at that birthday. And actually, now we had a whole new set of things to do in front of us. But at least we knew now what the culprit was and how we're going to go after it. And actually, there are now clinical trials that are going to start this year based on our finding. So hopefully they'll work, and we'll have the most important confirmation of this finding that people's vision is saved.

SM What sort of cure are we devising for these clinical trials? We're looking for what kind of drug?

JA We're looking for a drug that prevents vision from ever being lost. So, if there is any silver lining in dry macular degeneration, itís that while it affects the center of the retina ultimately and erases your vision at the outset, it doesn't. It starts just off to the side and starts moving in almost like an amoeba, it grows into the center of the retina. So we have about a couple of years from the time we discover someone has macular degeneration to prevent that movement and extension into the very center.

SM Don't you love the scientific inquiry this way? Isn't it like a treasure hunt for you?

JA It is, I like solving puzzles, solving mysteries. And that has always excited me since I was a young boy. And it's very meaningful to me that I can put my puzzle solving abilities for human good.

SM How good and how extensive is your lab? What does it take to be doing this kind of research?

JA The most important thing is passion. I try to recruit people who have that thrill of discovery, who want to be the first person on the planet to know something. And that is the most beautiful thing about research. You can actually discover something and be the only person out of seven and a half billion people on this rock to know something. And we use that to actually improve vision and increasingly, hopefully other diseases as well.

SM What do you mean other diseases as well? What else are you working on?

JA So the concept is something we call big data archeology. Basically, for decades, hundreds of millions of people have been taking thousands of drugs for a specific disease, a blood pressure drug to reduce your hypertension, or a diabetes drug to reduce your blood glucose levels. There is information in these very large, big data sets showing that perhaps people who take an anti-hypertension drug might get less Alzheimer's. Perhaps a patient taking an anti-diabetes drug gets less Parkinson's disease or macular degeneration. And now we have the ability to discover that simply by mining these very large datasets. And that's what we've started doing and we've made some fascinating discoveries already. Are you allowed to say any? Well, I think that I can tell you that we found new drugs that have potential for Alzheimerís and for diabetes.

SM Old drugs that could be repurposed for those, too?

JA That's correct. Existing FDA approved drugs that can be repurposed for these diseases of enormous magnitude.

SM Fascinating. How are you getting 40 years of hundreds of millions of people taking standard known drugs?

JA So we collaborate with groups across the country and we've assembled the largest health insurance databases that exist, that cover virtually every adult with health insurance in this country over the last three decades. And so we now have the ability to go through and mine those incredibly large databases and find out which drugs are associated with which diseases.

SM Are we spending enough on this kind of research? It's exciting and it seems like we're on the precipice of something huge for human health.

JA I don't think we as taxpayers, we as the federal government spend nearly enough. We spend less than three dollars a day for every American on eye research for something that is our most precious sense to see and experience the joy and the beauty of this planet and of this world. So I think we need to be spending a lot more on vision research. We also need to be spending a lot more on finding ways to actually use drugs that we already have for new diseases. Because after all, why not do this big data archeology if you already have drugs that are just waiting to be mined out of the earth that already exist, that potentially work.

SM Dr. Ambati, thank you for talking with me and sharing your research on With Good Reason.

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JA Thank you very much for inviting me.

00:16:58

SM Dr. Jayakrishna Ambati is a professor of ophthalmology at the University of Virginia School of Medicine. Coming up next, how creative training for new nurses can lead to healthier lives for all of us. Escape rooms are growing in popularity across the country. But when Janis Hawkins first tried this unique form of team-based entertainment, she realized it was more than just good fun. Hawkins teaches nursing at Old Dominion University.

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You have pioneered an unlikely method for teaching nursing skills. You actually put students in an escape room. What - what is an escape room? I've heard of them, but I've never done it.

JH An escape room is where a group or a team comes together and - and plays a game. They solve puzzles and work together to try to - to escape. You know what the team is set up for them to do there. So it's a lot of fun, I've done escape rooms with my family and my kids and grandkids.

SM How did you get the idea of even doing an escape room with your students? Were you an aficionado of this?

JH I had never been to an escape room before I was introduced to it. A colleague and I were at a nursing conference out in Indiana and we had a nursing student that had also gotten picked up to present her research poster there. So we wanted to reward her, of course, for that opportunity and take her out to dinner since she was the only student out there and she turned down our offer for dinner and instead wanted to go to an escape room. So we were actually really nervous about it. We had never been to one. And there's kind of this anxious moment when you think, okay, what if I'm not good at this? And particularly, what if I'm not good at this and then the student sees that we're not good at this? What if we don't escape? So we were very intimidated. We kind of made a deal with her that we would go as long as she didn't tell anyone if we didn't make it out.

SM Yeah.

JH So we did she helped us set it up. I don't think I even knew how to organize that. I didn't really know they existed at the time. This was in 20- this was 2017 when we did this and escape rooms actually - and I've read more about this now that I've become more familiar with escape rooms, there were only in 2014 there were only about 22 of them around the nation, but by 2016 or 17 when we were going there were kind of popping up everywhere. So we went downtown and our particular escape room was an art heist. And we did manage to escape with like 30 seconds to spare. So it was just under the wire. But we were back at home speaking with a couple of our other colleagues about - about some test scores for our students that had - were a little bit lower than we wanted them to be. So we know with it we needed to kind of ramp up our education on this particular topic. And it was related to safe medication, administration and patient safety, which, of course, is a big issue in nursing and one of our primary program outcomes. And as part of that conversation, it just kind of turned into why don't we do this as an escape room and they can have fun with it. It will be a novel way of learning, but we'll also practice all those skills that we need to do again before we head out to our first clinical experience.

SM Did they get a cash prize?

JH No cash prize, they did get their pictures on Facebook. So I think they thought that was a prize.

SM That's great. So where do you take your nursing students for an escape room? Give me this setup.

JH The escape room that we set up for our nursing students is actually physically in our school of nursing. Itís set up just like a hospital room. So there's a patient room. We have a hospital bed and there is a mannequin. And he's a high-fidelity mannequin that he can - he can do almost everything but get up out of the bed and walk. He laughs, he cries, he - we have a voice modulator. So we have our simulation technician, David, who can be the voice kind of on the other side of the two way mirror. So it's kind of like the Wizard of Oz. He's on the other side and he talks for the mannequin and the mannequin is in the hospital bed and he's hooked up to all of our hospital monitors so we can monitor his blood pressure, his heart rate. It's the same setup that they see every day for their clinical simulations. But the only thing that's different about it is we have set up different clues in this room that they now have to use to navigate through this simulation scenario that we've set up.

SM Give me some of the clues they have to solve and the time pressures on them.

JH So the initial clue is they have to have the password to be able to access the electronic medical record. And we really had a lot of fun with this because we got lucky when we were coming up with our storyline for the Escape Room. So we had a big event here at ODU, at our university, we had a big football game and we were playing one of our state rivals, not really our rivals, because it was Virginia Tech and of course, they're much bigger program than we are. And by some miracle, we won that game. And so we use that game as our storyline for the escape room. So our patient in this case and the bed whose name happens to be Big Blue, and he went to the game that day and of course, he didn't take all of his meds like he was supposed to, because he didn't want to have side effects to deal with that day. He don't want to miss the game. And so later that night, he ends up in the emergency room with some issues related to his blood pressure and - and heart rate and dizziness and things going on. So this is now the next morning when the students walk in the room to take care of Big Blue. So one of the very first clues is that for them to get into the electronic safety records, they need the password. So the password is the score of the game. So it's ODU 49, VT 35. And they can find that on a couple of places. It's on Big Blue's name band, so one of the steps and medication administration is to make sure that you check the name band and the patient hospital identification number. So that says hospital identification number, but then you're also supposed to engage with the patient. So even though this is a mannequin, students practice the way that they're gonna implement this in a real-world setting. So we really encourage them to interact with the mannequin the same way they would with the patient at the hospital. So in bed, Big Blue sitting there reading the newspaper related yesterday's - yesterday's game and it's got the score on. So that's the first clue. And they know - we don't really have to do a lot of coaching on this because the students know that they've got to get into the electronic records, so they know they're looking for a password.

SM All right. What are some of the other little clues they have to solve along the way?

JA Another clue that we did is we set up a Math for Meds worksheet and the first thing they have to do is actually find that worksheet. So I guess the second clue that we did was actually related to the systolic blood pressure of Big Blue. So we can update his blood pressure at any time using our technology and our computer equipment so we can do that from behind the scenes. So when the students ask for a blood pressure check, which they're supposed to do before they would administer a medication for blood pressure, we give them this up on the screen that they can read. And the top number on that is actually the number that they need to get into another lockbox. And one of the clues thatís given there is you've got to be on top of this parameter. So when they match up that number, it opens up, it's actually a book that we have that we bought on Amazon and you can buy these things on Amazon so you can set up your own escape rooms. And when you open up the book, there's a lockbox on it and you turn the dials using that systolic blood pressure as your number and it opens up. And then what we've put on the inside of that, is a piece of paper and there and a pencil and even a calculator if they need one. And so then their next clue is to solve these Math for Meds, which is a skill that they need. And then those numbers, which we've boxed out so they know which ones to use, open up another lock that gets them to their meds.

SM You're also committed to giving nursing students real life experiences in other ways. You actually train them to advocate for vaccines before Congress. What got you interested in teaching young nurses how to talk to lawmakers?

JH Well, I think my interest in the lawmaker part of it was a little help from my colleague. About two years ago, one of my colleagues, Deb Gray, was involved with U.N. Foundation Shot at Life. And she knew that I was engaged in community health and did a lot of health promotion activities. I'm also a retired Army nurse, so my travels have helped me become more aware of some of the health issues around the world. So, she introduced me to the Shot at Life campaign and invited me to come up there with her to one of the initial summits. So, I joined her on that venture and have been really very active with him for about the last three years.

SM What is the Shot at Life?

JH A Shot at Life is a grassroots campaign as part of the U.N. Foundation. So, their specific mission is to advocate for vaccination programs around the world. So, their main way of doing that is to promote awareness of the need for vaccine programs around the world. But then also to advocate with our congressional members for funding to support these vaccination programs.

SM What do you think the role of health care workers is when it comes to advocating with politicians? How important is it that we get that sort of science-based and experience-based information to our lawmakers?

JH I think nurses are natural political advocates. It's in our code of ethics that we are to be patient advocates. And I think maybe what the nursing students don't realize initially and maybe what I didn't even realize initially when I started out as a hospital nurse, is that we do know that we're supposed to advocate for our patient that's in the hospital bed. But sometimes I don't think we realize at first that we need to advocate for our entire community. And it's really part of our code of ethics as nurses and also as other health care providers to advocate for the communities that we serve.

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SM Janice Hawkins is the senior lecturer of nursing at Old Dominion University. You can learn more about the United Nations Vaccination Program that she mentioned at ShotAtLife.org. This is With Good Reason, we'll be right back.

00:28:00

SM Welcome back to With Good Reason, from Virginia Humanities. Researchers have a message for the 30 million Americans living with diabetes today.

AS Based on what we have achieved, I'm very, very confident that we will get over those last obstacles in your lifetime. There will be a cure for this.

SM Later in the show, how countries in Africa are facing down a new, health threat.

AS Diabetes is on the rise, but the treatment has still not caught up with it because all of the aid goes for things like HIV.

SM Here in the U.S., Dr. Jose Oberholzer is a researcher and surgeon at the University of Virginia Health Center. He says transplanting islet cells from a healthy pancreas into a diabetes patient can essentially cure the disease.

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SM But there are nowhere near enough to go around. Jose, most diabetes patients live their lives without ever having an organ or cellular transplant, right?

JO That's correct. So in the United States, we have currently about 13 million diabetic patients. And only very, very small number of patients will be lucky enough to get such a transplant. So the patients who have received such a transplant and are off insulin, I think I would call this a functional cure, and we have it. And we have patients that have not injected insulin for over a decade. And you have to imagine, this for patients who don't know a life without insulin. That's just a thought that saved them. And that's going to have to be like that for the rest of their lives. And so we do this procedure in local anesthesia, it's a same day procedure. They go home and then we tell them after a few days, we'll reduce the insulin, and reduce it again. And then after a few weeks, we tell them you may now stop insulin. And to them, that's something that they never thought they would live during their lifetime. So it is transformational for those patients.

SM And to achieve that, you need an organ from a deceased donor.

JO Yes, you need an organ from deceased donor. And it's - it's a number issue. So there are some around eight thousand organ donors a year for the whole country. And of those, probably only 15 hundred are suitable for this process. That, of course, will never address the need of 30 million diabetic patients

SM With a transplant, is it better to transplant the pancreas or to transplant the islet cells from the pancreas?

JO So if a patient requires another organ transplant like a kidney, then we have to open up the patient anyway to do with a kidney transplant. Then it makes sense to choose to a normal pancreas transplant. And then for somebody who only would need a pancreas transplant, so who has normal kidney function, doesn't have advanced diabetic complications yet. Of course, they will be preferable to have the cells. However, there is a limitation in the number of cells that we can give per patient. And if somebody is very heavy or uses lots of insulin, then the pancreas transplant is still superior. So the islet cell transplant is in some ways like a mini pancreas transplant and the pancreas transplant is still the gold standard. That will change the moment we have an unlimited amount of cell sources.

SM Help me understand the cell sources. These are stem cells which can come from a number of different parts of the body.

JO That's correct. So we can simply divided in those that come from embryos, and that's more controversial. Some people would not accept that for religious or ethical reasons, and then some would question it, also from a practicality point of view. And then there are the stem cells that we take from adult people that require to transform them, to changed and to turn into stem cells. And that's routinely done. And for that, we already have therapies available for eye diseases, for example. The cells are generated, created out of those adult stem cells. And that's probably the more practical approach and probably where the field will move towards.

SM And those stem cells come from where?

JO They come from anywhere in the human body. So typically, they can come from the skin, from what they call fibroblasts or cells that we have under the skin that form various tissues. And then we - we put them essentially in a petri dish and throw some magic things at it, and then the cells will go back in time in some ways, and then turn into a stem cell.

SM If we grow our own and have unlimited quantities, don't we still have the problem of the body rejecting the cells?

JO Yes. And so today we solve the problem by suppressing the immune system of patients like we would do in any organ transplant. But moving forward, we would like to avoid that. We would like to go to infants, to small children and be able to transplant and them not having to take any medications to do so. The approach that we have chosen is to protect the cells by a membrane, by essentially a capsule. And those materials have been tested now for over two decades. And they have already been in humans. But they all provoked a forum by the reaction, a scarring reaction. So we had to go back to the drawing board and work with chemical engineers and people that know how to change biomaterials and went on a long, long search. And about two or three years ago, we were finally able to have materials, biomaterials, that we can implant at the human body and don't provoke any reaction.

SM Did it turn out to be a really interesting substance, such as a certain plant or the intestine of a pig, that kind of thing? Or was it more that they engineered something we'd already been using?

JO No, they engineered something that did not exist. So a chemist was there for more than six years, just making up new molecules. And at the end, it was a molecule that you could not have anticipated to have this effect. So this was very systematic research, there was no rationale behind - it was essentially creating new molecules and testing them. And so this is now available, and so now we have to solve the cell issue once for all. And then the combination of an unlimited cell and the capsule material, this will be microcapsules, small capsules, we should be able to provide what we call a functional cure for diabetes.

SM You have a projected number of years that you can imagine, we may get there?

JO So the capsules will be available today. So we could potentially combine them with kind of cadaveric islet is something that we are in discussion. But, of course, the large-scale application depends on the source of cells. And I think for that, we probably need another three years - three to five years to get to the point where we have the right cells.

SM That's exciting.

JO Yep.

SM Did I hear you right that there were only fifteen hundred pancreases when all is said and done that are available for the millions who have diabetes?

JO That's correct. And that's very frustrating because every time I see a patient who had an islet cell transplant who has injected for years insulin. I just like feel the same hurts that we should be able to apply this to many, many more patients.

SM How many patients, let's say roughly, do you see in a year with this diabetic condition you could do something about?

JO So to give you an idea of the proportions, I mean, we did our first trial in the United States in 2003 at the Chicago Diabetes Project. We knew that we will only be able to transplant 10 patients. That's how much funding we had, and that's what the Food and Drug Administration allowed us to get started. We screened over a thousand patients to ultimately transplant 10 patients. And we did not advertise with it. And, you know, this was just hearsay. And imagine if we would advertise ñ we would not be able to answer the phones. There are so many patients out there that would need this.

SM You're still so devoted to the Chicago diabetes project that you founded 15 years ago. What inspired you to found it?

JO That's an interesting question, and I was a bit embarrassed to say share that publicly, but it was a book about the creation of the nuclear bomb and the Manhattan Project. And I'm totally not fascinated by the nuclear bomb by any means, don't take me wrong. But I was fascinated by the urgency of making a scientific, almost impossible-appearing solution. There was a huge threat from Germany, the Americans knew if we do not create this quick enough, the Germans will create it. And there was good evidence it would happen. And in some ways we have this threat from diabetes. And if we don't find a cure for this quickly, it's going to be really devastating for millions of patients. And so seeing how the American saw that really extremely difficult scientific task of this, knowing how to create a nuclear bomb and the physics had to be invented, the manufacturing had to be invented, everything had to be invented ñ it was totally new territory. And they put all these minds together and somehow figured out how to suppress the egos and work as a team. And I just thought, wow, if we could do this, have this sense of urgency and create teams like that, not for the nuclear bombs, but to cure diabetes. I thought that would be - that would be something that would change the fate of medicine and part of community. And so that's how we started it, and that's how we try to work.

SM I'm really touched by that. Now, I understand the term project to the Manhattan Project. The Chicago Diabetes Project. Wow, what a great thing. If you have a goal, you're much more likely to achieve it.

JO Yep. There is something magic about setting goals.

SM Well, I am so grateful that you were able to do this and share your excitement and your dedication to this ultimate outcome.

JO Well, thank you very much for the opportunity. And I - I just want to let diabetic patients know out there. We understand diabetes is a 24/7 disease. We understand it just never goes away. It's all the time there. You are juggling what you need to eat, how much insulin, how much exercise you will have. It - it never lets your rest. And - and I think we all in the labs and in the clinical trials and in contact with every patient, we know that. And we feel your pain. And I can assure you, there are a lot of scientists dedicating their lives to this. And I don't want to make any wrong promises, but based on what we have achieved, I'm very, very confident that we will get over those last obstacles. In your lifetime, there will be a cure for this.

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SM Jose Oberholzer is a researcher and surgeon and director of the Charles Strickler Transplant Center at the University of Virginia Health Center.

00:39:50

SM Americans have been hearing about the diabetes epidemic in the United States for decades.

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SM But diabetes is becoming rapidly more common in developing countries. And yet in many of those places, diagnosis and treatment is far behind the United States. Sharon Zook is a professor of nursing at James Madison University. She recently led a group of nursing students on a trip to Tanzania to help fight diabetes there. Sharon, thank you for taking a moment with us. What did your students make of their experience in Tanzania?

SZ They loved it. It is life changing for them. It takes a little while and they have to discuss how the culture affects them and what they think. And, of course, you can always have somebody that's homesick. But in the end, they love it.

SM Help me understand the lifestyle and the health challenges for the people where you all were.

SZ So Tanzania is sub-Saharan Africa. So, it's just a little bit west and south of the Sahara. So the lifestyle is very much rural in the Lake Victoria area. And the hospital is a very rural hospital. The people pretty much farm. Men still have sometimes multiple wives. And there is a senior wife who dictates the younger wives. They usually have many children, because children are considered an asset to work on their farm and to work in their fields. So it's not unusual for one family to have 12 children, maybe by three different women. It's very hard work. The women do most of the work. They cook, they farm, they educate the children if the children don't go to school. But the trend is now to have most of the children go to school.

SM What does health care like there?

SZ A hospital is a very different thing there. So before they go to a hospital, they usually go to a natural healer and they will try those options first. And the hospital, maybe a long distance from where they live. So a hospital is kind of a last resort. For example, most women's babies are born at home. And they may labor for a day and a half or two days before they decide to go to the hospital. And it's the male's decision whether or not the wife or the children get health care. It's still a very male-dominant society since they wait so long to go to the hospital, in some households the hospital's known as the place to die. It's a last resort place. So sometimes by the time they get there, it's been so long that it's too late to intervene. So another thing in the hospital that I neglected to say is that meals are not provided by the hospital. The families bring their meals, so the families stay there with their spouses, mothers, dads, children. This particular hospital had a foundation that provided one meal a day for children because they realized that nutrition is such an important part of healing. But for the most part, the families stay, and they provide the meals for their patients, for their family members. They're there the whole time. They're involved in the care they give part of the care they do all the feeding, unlike our hospitals there.

SM I understand you and your students and other teachers actually went there for one purpose, and that was to help them with the rise in cases of type two diabetes all across sub-Saharan Africa. It's surprising me to think of a rise in this type of diabetes in a place where so many people are farmers.

SZ So weís think that that would be true. And it was true for a very long time. When you think of any African country, you would think of the infectious diseases. Like things that are caused by poor water quality or HIV, for example. So that's changing in Africa. We're not really quite sure why - we think some of it is lifestyle, because our Western society has also gotten over there, unfortunately. But one of the things we identified last year when we were there is that diabetes is on the rise. And we know that from the statistics in Tanzania is one of the top three countries in Africa as far as incidence of diabetes goes. Diabetes is on the rise, but the treatment has still not caught up with it because all of the aid goes for things like HIV and the infectious diseases.

SM Do you mean people aren't getting any diagnosis and treatment?

SZ It's one of the things that we identified is that people with diabetes take medication there, but they don't really know how effective it is. And so they may come in and get a blood sugar done. We're all familiar with the little fingerstick blood sugars, but a blood sugar only tells us what's happening right at that point of time. So if it's a blood sugar after you just ate, it's going to be elevated. If it's a blood sugar when you're fasting, it may be elevated, but not as much. But it doesn't tell us what's going on. Here in the U.S. we have a test that's called an A1C, that measures the average of your blood sugars over the last 90 days. They didn't have that at these hospitals that we had visited last year. So when we came back, I thought, wow, wonder if they would be interested in something like that. Emailed the chief medical officers there. So last year we took those machines over there. And those machines tell you - it's great for people that live a long distance from the hospital, because it tells us what their blood sugar was like over the last 90 days. And so we were interested this year to see how that's influenced the care at these two hospitals and if it's influenced the care, because we as Americans tend to be egotistical sometimes and we think we're gonna give them the best of everything. And things go over there and then they're not used again after you leave. So practices are very hard to change. Practice is really a difficult thing to change. Even here in the United States, it takes about seven years for something that we find in research to get implemented in our system. So, we didn't know if we would make a difference with this machine or not. We just knew we wanted to try.

SM And what did you learn? It seems to me that that would be more sophistication than you needed. I would think most people need the medicine or the needles or kits, things like that.

SZ So in one hospital that we were at, that hospital is called Shirati, and it's that hospital, which is a rural hospital. We found out there were people that were going to have this test done. They had to travel two days to get there, pay for an overnight and go to a larger hospital. So, that hospital might have an endocrinologist but might not. So what we hoped for was that we would have this machine, and even if they wanted the endocrinologist to take a look at it, they wouldn't have to travel there. Because that meant a family member had to go with them, it was an overnight and it was very expensive. So they never did it unless there was a crisis and then they would.

SM Could you tell the people in that community were suffering from the consequences of diabetes, or did you just want to make sure they had this tool in case they did?

SZ So they were suffering from the consequences of diabetes. There were loss of limbs. There was loss of vision. There was a loss of nerve conduction, what we call neuropathy here. And because they didn't have a good way to monitor how they were doing on the medicines or if the medicines need increased or changed. There was nothing that happened, like a medicine would be prescribed and they were just be on that medicine forever.

SM So was our main worry for these people that they don't know they have diabetes, or that they don't know the consequences of having diabetes, or that the entire population in some of these poorest countries will experience an enormous rise in numbers of cases?

SZ So I'd say C - all the above. They don't have the knowledge and the tools to use, to know how to control it. They don't frequently know that they have diabetes unless they're tested and they might not be tested until something happens, a consequence. And they say, oh, this could be a result of diabetes. They're not screened like we are here in the U.S. However, because it's on the rise in those countries, screening is starting to happen. Now after a certain age, we screen here in the United States and with a family history, we screen more often, but it's going to take time.

SM You know, this had to have been such an eye-opening and moving experience for your young nursing students. What do you think they saw that will really stay with them?

SZ I think the most impactful thing was seeing children die there, that we don't - that wouldn't die if they were receiving care here. Malaria is a big disease there, and malaria has fever and it also decreases oxygen levels in children. And once they get the respiratory complications, it's very hard for them to recover from it. So, if you don't bring a child to the hospital until they're in the late stages - for example, an O2 saturation here in the U.S., a normal one in a child would be in the 90 percent. And we saw a child that had an O2 saturation point by the time they were brought to the hospital, 40 percent. That's not even something we expect in an adult with heart failure here. You know, who would have problems with oxygen. So by the time that happens, it's really difficult to save that child.

SM That must have been heartbreaking for these young students.

SZ It's very difficult. So what I would see, is we would be over at the hospital to shift and the students would work with these children and we would go back and eat dinner and they would say, I want to go back to the hospital to see how that child's doing. And then inevitably, one or two of them the next day would have died. By the time we came back, and it's devastating. So some of these nursing students had never seen a death before, let alone a death of a child, let alone a death of a child that probably would have lived here in the U.S.

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SM Sharon Zook is a professor at the James Madison University School of Nursing. Major support for With Good Reason is provided by the law firm of McGuire Woods. With Good Reason is produced in Charlottesville by Virginia Humanities. Our production team is Allison Quantz, Cass Adair, Matt Darroch and Alison Byrne. Special thanks this week to Todd Washburn of WHRV and to Georgianna Reid. Some of the music is by Blue Dot Sessions for the podcast. Go to WithGoodReasonRadio.org. I'm Sarah McConnell, thanks for listening.