How yellow fever shaped 19th-century New Orleans: A Q&A

Stanford historian explains how frequent yellow fever epidemics in nineteenth-century Louisiana generated cultural and social norms in its fatal wake.

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I was intrigued when I came across the Stanford profile of Kathryn Olivarius, PhD, a historian of 19th-century America. Her research primarily explores how epidemic yellow fever disrupted society in the antebellum South, generating cultural and social norms in its fatal wake. To learn more, I spoke with her recently.

As a historian, what got you interested in fellow fever?

“When I embarked on my PhD, I wanted to write about how slavery changed in Louisiana after 1803 with the Louisiana Purchase, as the region shifted from Spanish and French to American rule. But while sitting in Tulane’s archives and perusing letters, diaries, plantation ledgers and ship manifests, what impressed me the most was how much people spoke about disease. And the disease they feared the most was undoubtedly yellow fever  — a disease that struck antebellum New Orleans at epidemic levels nearly every third summer.

Yellow fever victims experienced a sudden onset of headache, back pains, jaundice, nausea and chills. Within days, they oozed blood through their external orifices, writhed in pain and vomited up partly coagulated blood. About half of all people who contracted yellow fever in the 19th century died, while the survivors gained lifetime immunity.

In my view, yellow fever played a critical role in Louisiana’s asymmetrical social organization, on the schedule and character of the cotton market, on capitalism itself and on the entire system and ideology of racial slavery. So I decided to focus on the disease for my PhD and my forthcoming book.”

How did the disease impact the social structure of 19th-century Louisiana?

“Antebellum New Orleans sat at the heart of America’s slave and cotton kingdoms. But it was also the nation’s necropolis, the city of the dead, with yellow fever routinely killing about 8 percent of its population between July and October. In some neighborhoods — particularly those with high densities of immunologically-naive recent immigrants from Germany, Ireland and the American North — yellow fever deaths could reach 20 or even 30 percent.

These repeated epidemics generated a hierarchy of ‘acclimated’ survivors who leveraged their immunity for social, economic and political power and ‘unacclimated’ recent immigrants who languished in social and professional purgatory. Until whites could prove they were acclimated, they struggled to find steady, well-paid employment, housing, spouses and a political voice. From the employer’s perspective, it wasted time and money to train someone for a detail-oriented job only to watch him sicken and die by the autumn.”

How did this affect slavery?

“Because of the disease, the commercial-civic elite of New Orleans argued that they required large-scale black slavery — publicly proclaiming that black people were naturally immune to the disease based on spurious and racially-specific visions of medicine and biology. It became a powerful proslavery argument with many whites claiming that black slavery was natural, even humanitarian, as it distanced white people from labor, spaces and activities that would kill them. Some even argued black immunity signaled divine sanction for widespread slavery, with God creating black slaves specifically to labor in the cane and sugar fields of the Mississippi Valley.

But in private, most slavers would not buy an unacclimated slave. The slave market essentially shut down in August, September and October in order to protect the health of potential buyers and their valuable slave property. This inconsistency suggests that the widespread belief in black immunity was less a reflection of biological reality but instead a social tool, a means to epidemiologically-justify racial slavery.”

Do you believe anything similar is happening today?

“Yellow fever still kills thousands of people each year. It’s endemic in 47 countries, mostly in Africa and Central and South America. The Intergovernmental Panel on Climate Change’s report released last year also suggests that Americans may become more familiar with this disease again as ecologies change and mosquito populations migrate. Zika, spread by the same mosquito as yellow fever, has been an increasing problem in recent years.

In terms of the social impact of disease, there are certainly modern analogues of societies in the midst of terrifying epidemics rationalizing mass death or singling out certain marginalized groups as the cause. The most obvious comparison in the U.S. is probably HIV/AIDS in the 1980s with gay people, intravenous drug users and Haitians who were blamed for the disease’s spread and who faced severe discrimination on the basis of their alleged-vulnerability.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Blood test may detect early signs of lung-transplant rejection

New blood test measures the DNA fragments of lung transplant donors in the blood of recipients, in hopes of preventing organ rejection and saving lives.

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After receiving a lung transplant, patients face the likely chance that their body’s immune system will reject the transplanted organ. Rejection can happen at any time due to a variety of factors such as a lung infection or an injury to the lungs during transplant surgery. The most deadly type of rejection is chronic lung allograft rejection (CLAD), which develops slowly and often silently without obvious symptoms.

Now, researchers have developed a simple blood test that detects tissue graft injury within the first three months after lung transplant surgery. After further validation, this non-invasive test could identify patients with a high risk of CLAD or death due to graft failure, allowing doctors to intervene early and possibly prevent chronic rejection.

“This test solves a long-standing problem in lung transplants: detection of hidden signs of rejection,” said Hannah Valantine, MD, co-leader of the study and a senior investigator at the National Heart, Lung, and Blood Institute, in a recent news release. “We’re very excited about its potential to save lives, especially in the wake of a critical shortage of donor organs.”

Valantine is also a Stanford professor of medicine and Kiran Khush, MD, associate professor of medicine, is a co-senior author.

The new test measures the amount of DNA fragments circulating freely in a patient’s bloodstream. Since the lung donor and recipients have different genomes, the test can identify and quantify the fragments from both people. If there are a lot more donor DNA fragments, this indicates that the organ is injured.

As recently reported in EBioMedicine, the researchers regularly monitored blood samples from 106 lung transplant patients during the first three months after surgery at several institutions, including Stanford. After dividing the patients into three groups based on the level of donor-derived DNA fragments in their blood, the team found that patients with higher levels were six times more likely to subsequently develop transplant organ failure or die than those with lower levels. And many of these high-risk patients didn’t have symptoms.

“We showed for the first time that donor-derived DNA is a predictive marker for chronic lung rejection and death, and could provide critical time-points to intervene, perhaps preventing these outcomes,” Valantine said in the release. “Once rejection is detected early via this test, doctors would then have the option to increase the dosages of anti-rejection drugs, add new agents that reduce tissue inflammation, or take other measures to prevent or slow the progression.”

The researchers expect commercial versions of the blood test to be available for clinical use soon. They are also planning future studies to evaluate the blood test for other solid organ transplants.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

On the importance of including pregnant women in clinical trials: A Q&A

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Photo by StockSnap

As a research scientist, I’ve negotiated the complex nature of getting approval to image human subjects. So I know firsthand that it is common to exclude pregnant women from clinical trials. Although this practice is well-intentioned, it is also misguided — according to an opinion piece recently published in JAMA. To learn more, I spoke with one of the authors, Heather Byers, MD, a clinical assistant professor in pediatrics at Stanford.

Why are pregnant women excluded from clinical trials?

“Historically, women in general were excluded from clinical trials because men were thought to be a more homogenous group without hormonal cycles and other sex-based variables that might impact the medical conditions under study.

In addition, pregnant women are still classified as a ‘vulnerable’ population for all research studies, so investigators must take additional steps to enroll them to ensure minimum risk.

Also, the lack of data about what pregnant women can safely be exposed to leads to more uncertainty. So many investigators choose to exclude them, even if they might benefit from the study intervention.”

Why is this a problem?

“Excluding them is a problem because women don’t stop getting sick or stop having chronic medical conditions just because they are pregnant. The average woman is exposed to four medications during her pregnancy and over 80 percent of medications haven’t been studied in a like population. This forces pregnant women to take medications on an “off-label” basis — meaning, the medications weren’t studied or approved for use in pregnant women — because there’s no other option. Pregnant women deserve better. It’s a matter of justice.”

What are the barriers and how can we overcome them?

“First, we advocate reclassifying pregnant women from ‘vulnerable’ to ‘scientifically complex.’ Pregnancy doesn’t alter a woman’s capacity for autonomous decision-making. Indeed, a pregnant woman frequently makes complex medical decisions for herself and her fetus that reflect her family’s values.

Another barrier for medical investigators is the perceived legal risk regarding a potential adverse outcome in the fetus or mother. As we discuss in the JAMA Viewpoint, this barrier could be addressed by standardizing the informed consent process.

Finally, federal regulations don’t define ‘acceptable risk’ to the woman or fetus and this uncertainty is perceived as a risk in itself. But in some cases, pregnant women may accept the uncertainty and risk.

For example, it was imperative to reduce mother-to-child transmission of HIV. So obstetricians reluctantly included pregnant women with HIV in their study of antiretroviral treatments, since the risk of the drugs were thought to be low and the potential benefit high. And the effectiveness of this study helped transform the AIDS epidemic.”

Is progress being made?

“Although progress has been slow, there has been an increased effort to enroll pregnant women. Several high-profile clinical trials involving pregnant women recently completed and institutions like the National Institutes of Health are working to change their polices. For example, the NIH Task Force on Research Specific to Pregnant Women and Lactating Women recently issued a report that summarizes the current gaps in knowledge and provides recommendations for continued progress.”

How did you become involved?

“I first became interested in this subject as a medical student during my rotation at NIH with Pamela Stratton, MD, one of the obstetricians involved in the study of antiretrovirals to prevent vertical transmission of HIV.

Later, as an obstetrics resident, I was frustrated by the lack of information to share with my patients regarding the risk and clinical impact of various medications, vaccines and medical conditions in pregnancy. Every anecdotal story  — such as my patient who was hospitalized in intensive care for months with influenza because she’d been too afraid to get the flu vaccine earlier in her pregnancy — is one too many. The fear of uncertain risk can be dangerous. There should be a better way.

One thing that has changed is the rise of social media and patient support group accessibility. Although this should not replace the controlled setting of a clinical trial, partnerships between motivated patient advocacy groups and medical investigators can be a powerful tool for obtaining information about risk and benefits going forward.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Jamming with the Midnight Rounds: A Q&A

Photo by Victoria Bruzoni of Midnight Rounds band, from left to right: James Wall, Matias Bruzoni, Raji Koppolu, Yasser El-Sayed, Garret Vygantas, Jon Palma and Jeff Linnel

The next time you listen to music at a nearby pub or Bay Area event, double check to see who is playing. You just might see one of your Stanford physicians.

At a division holiday party in 2009, pediatric surgeon Matias Bruzoni, MD, on vocals, piano and guitar and nurse practitioner Raji Koppolu on vocals played acoustic versions of popular songs. Soon after, two more pediatric surgeons joined and the band Midnight Rounds was born. Over the years, the band has expanded to include piano, guitar, bass, percussion, drums, violin and vocals. I spoke with Bruzoni to learn more.

What is the origin of the name, Midnight Rounds?

“Our bass and guitar player James Wall, MD, and his family generously turn their guest house into a music studio whenever we need to practice. We all have very tight schedules due to our professional work, so once a week we practice late at night — many times going past midnight. As providers, we also make rounds every day to see our patients, so our drummer Yasser El-Sayed, MD, suggested we call ourselves Midnight Rounds.”

What kind of music do you play?

“Our repertoire includes oldies, country, 80’s, 90’s and more modern pop songs. We particularly enjoy creating mashups of songs, flipping back and forth between songs and adding our own twist. For instance, we like playing “Free” sung by the Zac Brown Band mashed up with “Into the Mystic” by Van Morrison and “Lodi” by Creedence Clearwater Revival mashed up with “Sloop John B” by the Beach Boys. Another favorite song is “Dixieland Delight” by Alabama, which features Jonathan Palma, MD, playing violin.”

Where do you play?

“We play in many different venues including weddings, wineries, local pubs, holiday parties, pumpkin festivals and wherever we’re invited. It varies, but we average a couple of events per month. We play quarterly at the Pioneer Saloon in Woodside — we’ll be there on January 12.

We sometimes make a little money during our performances at places like Pioneer. We decided as a group to donate the proceeds to different charity organizations that benefit women and children’s health.”

Is there any relation between playing in the band and medicine?

“For us, the band is a perfect excuse to get together outside of regular working hours. We feel this strengthens our relationships with each other in the hospital. It’s also a healthy way to recharge our batteries, avoid burn-out and thus take better care of our patients.

In addition, we’ve gotten to know a lot of people that work at Stanford — nurses, OR staff, social workers, interpreters and other docs like anesthesiologists — who come to our gigs. Our strongest crew are the NICU nurses and social workers, who follow us wherever we go. I think our patients definitely benefit, because teamwork is essential to patient care.

I also think performing under pressure is a great exercise since it is very similar to what we do every day here at the hospital. You get nervous even if you’re doing an acoustic session in front of 10 people, since you want to sound good. When I interview residents for positions here at Stanford, I pay a lot of attention to whether they excel in athletics or music, which gives me an idea on how well they can perform under pressure.”

Describe a favorite moment with the band.

“There are times when we have our kids sing or play an instrument with us. And that’s a very special moment. For instance, the other day we played at a pumpkin patch. People were playing games and stuff, not paying much attention to the band. But everyone went dead silent when my daughter came up to sing a Justin Bieber song. And then they started taping it. It was really magical.”

What’s next?

“We’re thinking about writing some original songs as an experiment. But mostly we just want to build up our repertoire. We started with maybe five songs and now we have about 50 songs that we can we can play — some of them without even practicing. We usually practice tow to three new songs for every new gig. Our band members have very different musical tastes, which makes it fun to blend all them together.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.