Tech Transfer • Gadgets 4 Health

mhealth revolution • Big data, Big problem • tech transfer • Gadgets 4 health

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special issue The Magazine of The Johns hopkins BlooMBerg school of puBlic healTh www.jhsph.edu 2012

worth an extra look Nostalgic about calculating statistical probabilities on a slide rule. Eager to immerse an avatar surgeon in a virtual operating room. More than two dozen JHSPH alumni share their visions from the nexus of technology and public health in personal essays and photos. 50% Total Recycled Fiber magazine.jhsph.edu/techessays 20% Post-consumer Fiber

next issue it takes a network colwell david

How do you protect the boys of Touba, Senegal and the rest of the country’s popu- lation from malaria? Defense may be the best offense against humanity’s perennial enemy. The Johns Hopkins Center for Communication Programs and its Net- Works project aim to cover every sleeping space in the country with a mosquito net. Don’t Blink Technology’s lightspeed transformation of public health Health International Advisory Board Honorary Committee Robert J. Abernethy** William Flumenbaum Roger C. Lipitz*+ Markus Altwegg President Senior Vice President Managing Member Chairman of the American Standard Capital Guardian Trust Company Ocean Assets, LLC Board of Directors Development Company Siegfried Holding AG Her mHealth is on the Line Howard E. Friedman Morris W. Offit** Ashok Agarwal Managing Partner Chairman Clateo Castellini Trustee Lanx Capital, LLC Offit Capital Advisors, LLC Former Chairman and CEO Indian Institute of Health BD (Becton, Dickinson and Management Research Douglass B. Given Karl P. Ronn Company) Partner Managing Director Lenox D. Baker, Jr.* Bay City Capital Innovation Portfolio Partners J.P. Garnier Mid-Atlantic Cardiothoracic Former CEO Surgeons, Ltd. Dean Goodermote Ira M. Rutkow GlaxoSmithKline Former Chairman and CEO Kenneth R. Banks Double-Take Software Beth Schnieders William H. Gates, Sr. President Huntington Sheldon** Co-Chairman Banks Contracting Company, Inc. Donald A. Henderson° Bill & Melinda Gates Foundation Dean Emeritus Michael J. Silver Ernest A. Bates** Johns Hopkins Bloomberg Partner Raymond Gilmartin Chairman and CEO School of Public Health Hogan Lovells US LLP Former Chairman, President American Shared Hospital and CEO Services, Inc. Margaret Conn Himelfarb Alfred Sommer° Merck & Co., Inc. Dean Emeritus Joseph A. Boystak Frank Hurley* Barbara A. Mikulski Chief Scientific Officer Johns Hopkins Bloomberg President and CEO School of Public Health U.S. Senator Brightwaters Capital, LLC and Co-Founder Maryland RRD International, LLC Shale D. Stiller** Michael G. Bronfein HM Queen Noor Christopher I.M. Jones Partner Managing Partner DLA Piper of Jordan Sterling Partners Ambassador James A. Joseph Nafis Sadik Professor and Director, United Dwight S. Taylor C. Sylvia Brown President Special Advisor to the States-Southern Africa Center for United Nations Secretary-General George L. Bunting, Jr.** Leadership and Public Values COPT Development & President Duke University Construction, LLC Yohei Sasakawa Bunting Management Group Adena W. Testa* Chairman Michael J. Klag The Nippon Foundation Constance Caplan** Dean Johns Hopkins Bloomberg Feike Sijbesma Paul J. Diaz School of Public Health CEO President and CEO Royal DSM NV Kindred Healthcare, Inc. Harry M. Jansen Kraemer, Jr. Executive Partner HRH Princess Maha Catharine C. Dorrier Madison Dearborn Chakri Sirindhorn Senior Technical Advisor Clinical Professor of Manage- of Thailand RRD International, LLC ment and Strategy, Northwestern Manuel Dupkin II** University *University Trustee Kellogg School of Management **University Emeritus/a Trustee Manfred Eggersdorfer °Honorary Member Carolyn P. Langfitt Senior Vice President + Chair of the Health DSM Nutritional Products Advisory Board Connect with the Global mHealth Initiative: www.jhumHealth.org

Everybody’s talking about Members of the Johns Hopkins University Global Magazine Team mHealth (mobile health), the mHealth Initiative (GmI) are advancing this new field Managing Editor Consulting Editor Associate Dean, External Affairs Johns Hopkins Bloomberg through early-stage technology innovation, rigorous Stacey dilorenzo Sue de Pasquale Joshua d. else School of Public Health Editor Staff Writer Director of Alumni Relations 615 N. wolfe Street, e2132 state-of-the-art strategy that’s research and the monitoring and evaluation of potential Baltimore, Md. 21205 high-impact health system solutions, while training the Brian w. Simpson Jackie Powder Philippa Moore revolutionizing public health by Phone: 410-955-5194 public health leaders of tomorrow. Associate Editor Design and Production Maryalice Yakutchik Konrad crispino Fax: 410-614-2405 making a difference in resource- email: [email protected] Senior Art Director Online Magazine Team limited settings where disease JHU GmI’s success depends on collaborations between Robert ollinger david croft web: jhsph.edu faculty across the University as well as on support from Michael a. Smith magazine.jhsph.edu burden and mortality are high. you. We welcome you to explore the many exciting Spencer Greer Free Subscription activities in mHealth going on across the University and magazine.jhsph.edu/subscribe learn about opportunities to support students engaged Get connected: The Johns hopkins university does not discriminate on the basis of race, color, gender, religion, age, sexual orientation, national or ethnic origin, dis- puBlicaTions Mail agreeMenT no. 41452530 in global mHealth research. www.jhumHealth.org ability, marital status or veteran status in any student program or activity administered by the university, or with regard to admission or employment. reTurn unDeliVeraBle canaDian aDDresses To Defense Department policies regarding sexual orientation in roTc programs conflict with this university policy. The university continues its roTc po BoX 503 program, but encourages a change in the Defense Department policy. rpo WesT BeaVer creek Questions regarding Title Vi, Title iX, and section 504 should be referred to the office of institutional equity, garland hall 130, Telephone: (410) 516- richMonD hill on l4B 4r6 8075, (TTY): (410) 516-6225. OpenMike Smart Technology

Michael J. Klag, MD, MPH

In early January, I attended a function at the Peabody Such technology is a huge benefit, but only Library, a beautiful building given to the people successful if it is socially and culturally appropriate. of Baltimore by philanthropist George Peabody. Let me give you an example. A longtime staple When the library building opened in 1878, access of malaria diagnosis is the blood smear. You draw to information was difficult. Peabody knew that by blood from a febrile person and examine the blood collecting books in one place, he would be promoting under the microscope for malaria parasites. It’s the educational, economic and social development straightforward, but in some African cultures people of the city that had helped him build his financial resist a blood draw, worrying their blood could be used empire. in witchcraft. Thus, a simple technology may not be When I was a medical resident in the early 1980s, culturally appropriate. (Two of our investigators at the information accumulation and sharing wasn’t much Johns Hopkins Malaria Research Institute, Sungano different from Peabody’s day. I went to the library, Mharakurwa and David Sullivan, are working to solve Technology photocopied journal articles and organized them to this problem with saliva- or urine-based alternatives.) create ready access to the latest information. Similarly, you also see lots of devices that are used offers incredible Since then, of course, the digital revolution has in wealthy countries without a second thought, but changed everything. Better technology has flooded they’re not appropriate in many places because they opportunities to us with data. We have oceans of data from genomic, require sustained electrical power. epigenetic and proteomic analyses. We have second- Technology also has permeated our educational improve health, by-second data on how the brain functions during mission. Thanks to the Web, we now can bring the sleep. And we gather libraries worth of data from School’s storehouse of knowledge to thousands of imaging studies, laboratory analyses and other sources. students, working professionals and others worldwide. but we must Of course, extracting knowledge from the In our MPH program, 250 students learn face-to-face profusion of data represents a huge challenge. here in Baltimore, while more than 400 have joined apply it wisely. That’s why we depend on biostatisticians to develop our Internet-based, part-time program. Over the past new methods of analysis—data are useless until we 15 years, our School has pioneered innovative ways separate signal from noise. With the right statistical to teach public health, allowing us to reach people methodologies, we can better understand the in ways never before possible. Distance Education architecture of sleep, uncover the links between air courses offer flexibility and are of such quality that pollution and mortality, and discover disease-gene more than 40 percent of the enrollment in online associations that heretofore went undetected. courses is by full-time students. As the demand for The pervasiveness of technology hits me in public health education grows, distance education the face whenever I travel to low-income countries. will help to fill that need. Because of the lack of preexisting infrastructure, many Technology offers incredible opportunities to have leapfrogged over us. I have written before about improve public health—as attested by the articles in HIV clinics in Africa that use text messages to track this special issue. That said, new technology alone will prescriptions, for example. And our faculty bring not solve the world’s health problems—effectively technology with them. In Macha, Zambia, and Rakai, managed programs, serious political will and sufficient Uganda, for example, our researchers utilize advanced money also are needed to save lives. equipment to generate laboratory data in the field. So how we use new tools is what matters: We The miniaturization of lab equipment and training of must continue to gain insight into determinants of local technicians and investigators has allowed us to health, design cost-effective studies, test innovative do research in situ while building the capacity of local interventions and develop rational policies based on scientists and technicians. At the same time, we avoid evidence. When we employ technology this way, it the difficulty of shipping specimens and dealing with will help us dramatically advance our public health export restrictions and cold-chain transport. mission. Features

Tools Whether high-, low- or medium-tech, these inventions are just right. Big Data by Maryalice Yakutchik & Ted Alcorn The data gold rush is Page 12 on, posing glittering promise and daunting challenges. by Jim Schnabel Page 20 mHealth Are mobile devices a lasting answer— or a dropped call? Tech Transfer by Christen Brownlee It’s patently obvious: Page 4 Why public health needs the market. by David Glenn Page 30

Health in the Digital Era The practice of global public health involves all the latest bells and whistles, not to mention a terrifying accumulation of terabytes. It also depends on the bubbling up of indigenous ideas and the crafting of nifty thingamajigs that are simple, resourceful... sublime. Here are tales of two techs—high and low—as well as a few in between. Cover and contents illustrations by Dung Hoang Stories contents 16 The Future Visionaries Thomas Hartung, Keith West and Ellen Silbergeld reveal crystal clear visions about PoT, hidden hunger and nanotech. By Ted Alcorn

18 First Person A ripening technology allows the author to rise up against MS—and avoid riding with fruits and veggies in freight elevators. By Sheila Fitzgerald

26 Mapping GIS marks the spot for Debra Furr-Holden and others studying everything from hantavirus to disaster response and substance abuse. By Lauren Glenn Manfuso

28 Education New technologies release education from the ties that bind. Your class starts anytime, anywhere. By Karen Nitkin

34 Images Two views from the public health lens: peering into nascent Mycobacterium tuberculosis and seeing health issues anew, from Baltimore to Shanghai. By Jackie Powder

36 Outcomes Health records and social networks yield rich returns for researchers mining them in innovative ways. By Ted Alcorn and Patricia McAdams

Departments 1 Open Mike We now have incredible technology and surging amounts of data, but we still must be smart in how we apply them to public health. 39 AfterWords Lessons on the limits of technology from a 200-year-old boy in Health in the Digital Era Philadelphia. 39 Letters Remembering the “great guru” Carl Taylor; on the forefront of peak oil and health; the local view on prevention; and more. 40 The Last Pixel Danger smolders from the fire inside. Cover and contents illustrations by Dung Hoang 4 Johns Hopkins Public Health / Technology 2012 mHealth

Johns Hopkins Public Health / Technology 2012 5 mHealth projects are launching at an exponential rate. How do we ensure they don’t become the public health equivalent of a dropped call?

On a recent Friday, Alain Labrique opened thousand words on how not to package mHealth projects are really working and his office door and noticed a new red and slides. worth the investment? How do you conquer yellow DHL package waiting for him on his “That’s mHealth 101 right there,” the phenomenon known as “pilotitis,” and desk. Labrique joked. scale effective strategies into health systems It looked a little worse for wear. “What’s mHealth is short for mobile health, that have regional or national impacts? And this?” he said to the visitor with him. He a growing field that takes advantage of how do you make sure these projects are tore into the package’s rumpled overwrap. mobile communications devices—mostly long-lasting additions, instead of the public As he lifted the beige plastic box inside, cell phones—to enhance access to health health equivalent of a dropped call? the unmistakable tinkling of broken glass information, improve distribution of routine With a new University-wide project emanated. and emergency health services, or provide called the JHU Global mHealth Initiative “That can’t be good,” mused Labrique, diagnostic services. With phones and other (see sidebar on page 9), Labrique, his PhD ’07, MHS ’99, MS, an assistant mobile technologies growing more ubiquitous faculty colleagues and students from professor in International Health. by the minute, it was only a matter of time across Johns Hopkins are coming together Cutting through the copious tape before public health researchers, practitioners to face these questions while building a binding the box closed, Labrique flipped and users took advantage of these media new community—one that embraces this open its top. Enclosed were several glass themselves. At the Bloomberg School, up evolving technology as a game-changer with slides with swipes of bacterial vaginosis, and running mHealth projects range from the potential of revolutionizing health. a disease that Labrique is well trained to saving the lives of pregnant women and diagnose, from women in rural Bangladesh. babies in Bangladesh to assessing drug use An Evolving Landscape About half the slides were broken into tiny patterns in inner city Baltimore. The mHealth movement has taken hold shards. But using phones to advance public of public health almost as fast as the Immediately, he pulled out his phone health isn’t as simple as it seems. Researchers exponential rise of cell phones themselves. and snapped a picture of the damage, are grappling with complex questions that As of early 2010, the number of cell phones sending it to his colleagues in Bangladesh—a have already doomed hundreds of mHealth in use worldwide had hit more than 4.6 technologically savvy image worth a projects: How do you know whether billion, according to the International

6 Johns Hopkins Public Health / Technology 2012 mHealth projects are launching at an exponential rate. How do we ensure they don’t become the public health equivalent of a dropped call?

Telecommunication Union, a UN agency. carry written memos by bus, so getting a eighth-grade education—went from having (To add some context, the world’s population simple answer to a question could be an all- no phones whatsoever, to almost every single hit 7 billion in late 2011.) A recent search day affair. “I joke when I lecture about this one carrying a personal phone,” Labrique of PubMed, the NIH biomedical research that we were seriously contemplating carrier says. database, yielded hundreds of articles pigeons,” he adds. Eventually, he and his colleagues started focused on the use of cell phones to improve By 2004, the first cell phones started noticing that cell phones were infiltrating the health or gather health information, most making their way through the area. With narratives they were collecting from women added in the last three years. just a single tower nearby, it still wasn’t a and their families to describe obstetric crises Labrique recalls seeing the change useful way for Labrique and his colleagues and maternal or infant deaths. When they himself over the past decade in rural to connect—it worked better as a landmark. crunched the numbers, they found that Bangladesh. When he started work 11 His research team counseled visitors driving about half the women in their study who’d years ago on the JiVitA project, a study to their site to travel north until they saw that experienced an obstetrical crisis had used a designed to understand the effects of cell phone tower, then take a left to reach the mobile phone to try to turn their situation supplementing pregnant women’s diets with field site. around—by calling a provider, arranging vitamin A, Labrique remembers the abysmal But in a few short years, the landscape transportation to a clinic, getting financial communication among members of the changed. As 30 new cell phone towers aid to pay providers or seeking out medical research team scattered throughout the rural popped up around the JiVitA site, more and advice. countryside dotted with green rice paddies. more of his local colleagues began using With access to cell phones skyrocketing The people were quick to offer a place to sit cell phones themselves—not just senior in the area, either through direct ownership and a betel nut to chew, but were stunningly managers in the study, who could easily or access to a village phone, Labrique and isolated. afford what started out as a luxury item, but, his colleagues decided to start up a mobile “We couldn’t make a phone call to eventually, grassroots-level field workers as phone–based labor and birth notification the next town,” Labrique says. The only well. system. In a recent study, led by International reliable way to pass information among “In the span of two years, these field Health Professor Parul Christian, when team members was to pay messengers to workers—who usually have no more than an pregnant women went into labor, they or

JohnsJohns HopkinsHopkins PublicPublic HealthHealth // TechnologyTechnology 20122012 77 When they were about to give birth, the pregnant Bangladeshi women texted a central number. A nurse-midwife team was quickly dispatched. their families called or sent text messages care as soon as possible. The phone is an in- It will send her reminders on her own phone, to a central number. This action dispatched expensive Chinese-made Android model— if she owns one, and to the community nurse-midwife teams to the women’s homes, an operating system well suited to mHealth health worker, who will stop by a couple of where 90 percent of births take place in applications because its open-source nature days before appointments to emphasize the rural Bangladesh. Results showed that makes it highly customizable to users’ needs. importance of each visit to the woman and about 89 percent of these births—which On their regular pregnancy surveillance her family. As with the previous study, each would normally have taken place without visits, these workers can use these phones to woman and her family will be encouraged any medical care—were attended by highly register their clients, possibly even snapping to notify the study by text when they go skilled health care workers with the new a quick picture so supervisors can verify into labor and if they need help, spurring a system. who they’re talking with in subsequent mobile health care team into action to attend Empowered by this success, Labrique’s visits. Guided by a customized app on the the birth or facilitate a referral to clinical team will launch a new project this year phone, the workers will then ask a series of care. If labor appears premature according to called mCARE that takes these previous questions incorporating lunar calendars and the system’s records, it then signals a special studies to a whole new level. Working local events, to sort out when the woman’s alert to the health care team that they may be closely with the Bangladeshi Ministry of last menstrual period took place. If it was dealing with a preterm baby that may have Health and Family Welfare, complementing more than five weeks ago, the app notifies more intense medical needs. Another text the government’s vision of a “Digital the worker that this client is potentially when the baby is born will trigger another Bangladesh,” supported by the UBS pregnant. series of visits one, three and five days later, Optimus Foundation, the researchers will That pivotal revelation will auto- to make sure that mother and baby are doing be supplying cell phones to the community matically trigger a series of other events. well. health workers who visit women periodically Based on the woman’s expected due date, the “Each action here stimulates a reaction,” to get those who are pregnant into prenatal app schedules several prenatal appointments. Labrique explains. “Rather than waiting

8 Johns Hopkins Public Health / Technology 2012 for a crisis to happen, we’re using mobile In 2009, when Jordan was serving have enrolled. But she and her colleagues technology to respond to potential problems on the board of directors at the National wanted to make sure that text4baby was a before they occur.” Healthy Mothers, Healthy Babies Coalition, success by other standards as well, so they The study’s impact on mortality is yet she heard of a project that would send text built in measures to evaluate the program to be measured, but based on the pilot work messages with health advice to pregnant from the start. with labor and birth notification systems women three times a week. Then, once they According to Piers Bocock, project and emergency dispatches of nurse-midwife gave birth, it would switch to health advice director for the Knowledge for Health teams, Labrique expects these efforts will for newborns, all based on the due date that Project, run by the Bloomberg School’s pay off through better prenatal care for enrollees provide when they sign up for the Center for Communication Programs mothers, more attended births and targeted service. (CCP), mHealth evaluation remains a huge care for infants (especially high-risk, preterm While many low-income women may hurdle. Governments and donors want to babies)—ultimately saving the lives of not have computers or pregnancy books, make sure that mHealth interventions can mothers and their infants. the coalition reasoned, many of them do be measured so they can make the right “The groundwork has been done to have phones—providing a way to deliver decisions about funding comprehensive demonstrate that these systems can work in information that could have enormous mHealth programs. “There are a lot of this challenging, resource-limited, remote impact on their health knowledge and pilots out there,” says Bocock, “but not a lot context,” he says. behavior and the health of their babies. at scale.” “I thought it was a fabulous idea,” CCP, which includes mHealth A Game Changer? Jordan recalls. “A 16-year-old inner city components in more than a dozen of its As Labrique and his astute colleagues pregnant teen may not be going to the library projects around the world, is constantly noticed, cell phones are an ideal solution to to read a pregnancy website or be able to working to understand how mobile efforts are connecting with low-resource populations. afford childbirth classes, but she might be adding to the effectiveness of its programs. But mHealth isn’t just for the developing willing to read the message that comes across “We all realize mHealth can be a game- world, according to Betty Jordan, an her phone.” changer, especially when it is part of other assistant professor in the Johns Hopkins In early 2010, text4baby launched across social and behavior change communication School of Nursing. the country. Since then, more than 260,000 activities,” says Bocock. “The question

A New Vision for mHealth The EXACT Science of HIV Treatments In late 2010, Alain Labrique, Betty Jordan and other colleagues at Johns As antiretroviral therapies became more effective and available, Gregory Hopkins came to the same realization: One way to move the mHealth field Kirk and his colleagues found that some participants in the ALIVE (AIDS forward as a useful public health strategy would be to compare notes Linked to the Intravenous Experience) study could stick with their therapy with as many people as possible. By learning from each other’s successes and fend off AIDS, while others couldn’t. and failures, researchers could grow the evidence base for solid mHealth Developing a good method to predict which drug users are likely strategies. With that goal, the Johns Hopkins University Global mHealth to adhere to treatment and which ones will fail is the goal of the EXACT Initiative (GmI) was born in mid-2011. (EXposure Assessment in Current Time) study, a subset of the decades- The team quickly found dozens of researchers across the schools of old ALIVE study. Public Health, Nursing, Medicine, and Engineering who were using cell EXACT collects real-time information from drug users to develop phones in their work and invited them to join up. predictive algorithms on what might cause them to use drugs, and Since then, he and other organizers have launched a speaker ultimately, why they might not fully adhere to HIV treatments. Pilot series and brought together Hopkins students and faculty members for studies using PalmPilots and wearable GPS devices yielded data multiple transformative, interdisciplinary collaborations. They plan to develop a times a day from current or former intravenous drug users with HIV in the curriculum around mHealth, starting new courses and infusing existing Baltimore-metro area. ones with lectures on mobile technologies. After getting a prompt from their PalmPilots, 89 volunteers answered GmI also plans on offering guidance to outside organizations, Jordan a series of questions on what they were up to and their stress levels, says, serving as a thought leader in the same way that other Hopkins moods and drug use. The GPS recorded their location. institutions have traditionally done. “Hopkins already has a footprint in Ultimately, Kirk says, he and his team hope the study will help the the global community for lots of things—basic research, clinical research, health care team focus more time and resources on patients more likely health care,” she says. “We believe that we could be the go-to place for to be nonadherent. Eventually, he adds, smartphones might help patients mHealth in the world.” —CB improve their health directly, alerting counselors such as peer navigators that patients need interventions. —CB

JohnsJohns HopkinsHopkins PublicPublic HealthHealth // TechnologyTechnology 20122012 99 Free phones and airtime for researchers and subjects have been the kiss of death for many mHealth pilot projects as they try to scale up to full-size programs. we want to answer is how to quantify its databases, many mHealth projects were researchers ask participants for their ZIP effectiveness within the context of broader found to have already ended, suggesting codes during registration. The result is a real- public health interventions.” their inability to transition from pilots to time map across the country that text4baby’s Garrett Mehl, PhD ’00, MHS ’94, scaled-up programs. Often projects, Mehl partners, including local health offices, a WHO scientist and a chair of its Health notes, are driven by the pleas of donors can access and watch enrollment numbers Data Forum Working Group on mHealth, to get implementations running quickly, change on a minute-by-minute basis. They notes that insufficient attention to the role of without any forethought about how to judge can also instantly see whether ads to entice research has been the downfall of countless success or pressure to plan for scale-up and women to sign up have the desired effect. An other mHealth projects. sustainability. ad for text4baby during the popular MTV “I think we can definitely say that there “You begin to worry that a lot of program 16 and Pregnant, caused a huge have been a considerable number of pilot investments are being made in this area, and spike in enrollment. mHealth projects, and a lot of them have if they fail, you worry that people won’t want “It’s a huge strength of the program failed in either their ability to demonstrate to continue to invest,” he says. Fortunately, to see whether we’re hitting our intended some health impact or in their ability to find Mehl notes that donors are now beginning audience,” Jordan says. a mechanism to sustain them,” he says. Mehl to pay more attention to evaluation and But demonstrating whether these texts adds that in a joint project with a Bloomberg invest in mHealth evidence generation and are improving outcomes for mothers and School intern that assessed the global state synthesis. babies is a much tougher problem to tackle, of evidence generation among mHealth To head off these problems, Jordan and Jordan notes. “It’s easy to tell whether women projects, a considerable proportion of the her colleagues incorporated some unique are enrolling, find out whether they like the projects were struggling with research—and evaluation methods into the fabric of messages or see if the number of texts they donor support—needed to validate their text4baby. For example, to see whether the get each week is acceptable,” she says. “It efforts. Despite their presence in public program is reaching its intended audience, takes a lot more time, effort and evaluation

10 Johns Hopkins Public Health / Technology 2012 connections

strategies to demonstrate knowledge and “It’s well known in this new field of behavior change.” mHealth that there’s not a lot of control One step toward judging whether data,” Cheskin says. “Doing a randomized they’re achieving this goal, Jordan adds, controlled trial is a high quality way of is a series of interactive modules that the seeing whether the outcome you’re hoping text4baby team recently began inserting into for is really there.” the typical texts that users receive. Around Evaluation isn’t the only tough the end of October 2011, they sent their problem in mHealth—scalability and first interactive module: a questionnaire sustainability are issues that have doomed on whether users had received the flu shot, many other mHealth projects, notes Patricia and if not, why. Within 48 hours, nearly Mechael, PhD ’98. She recently became the a third of the 96,000 users who received executive director of the mHealth Alliance, Real People, Real Solutions the module responded, giving Jordan and a Washington, D.C.–based organization A public health preoccupation today other researchers involved with the project hosted by the United Nations Foundation seems to be the creation of ever-more- reassurance that users were engaged and that serves as a convener of the mHealth elaborate technologies that harvest hitherto interested in sharing information, as well as community and provides guidance and unimaginable quantities of data. Never mind lending insight into their health behaviors. support for those using mHealth tools. For that the methodologies are ill-conceived or the Larry Cheskin, MD, an associate example, giving out phones to researchers questions inappropriate. Too often sidelined professor of Health, Behavior and Society, and subjects alike might be the kiss of death are the professionals who would translate and director of the Johns Hopkins Weight for many mHealth projects, according the findings into action. Usually the best Management Center, is hoping to get around to Mechael. For a small pilot project, equipped to fulfill such roles are rare creatures the evaluation problem by incorporating maintaining equipment and airtime might called “public health epidemiologists.” In mHealth into a randomized study—the gold be manageable, but continuing to provide establishing the Epidemic Intelligence Service, standard for other health interventions. equipment and airtime for a full-scale project the CDC’s Alex Langmuir, a former Hopkins He explains that the typical program at is oftentimes financially unsustainable. faculty member, emphasized the importance the Weight Management Center is a relatively Unless a country’s government or private of the “shoe leather epidemiologist,” who Free phones and airtime for researchers and subjects time- and resource-intense affair. On their sector investor can invest in buying a phone collected information in the field and devised have been the kiss of death for many mHealth pilot projects first visit, patients see a series of health care and minutes for the target population, solutions. providers—a dietitian, psychologist, exercise Mechael explains, that model simply won’t Better reporting systems are a priority. as they try to scale up to full-size programs. expert and Cheskin himself—and come work for the long haul. However, prospective solutions now focus back frequently for follow-up. This care Similarly, Mechael says, multiple projects on complex systems that minimize the need usually isn’t covered by insurance. Since have failed because there is no standard for human intervention. As one example, those of low socioeconomic status are more for them to integrate with one another. the U.S. now is planning to invest billions of likely to be obese in the U.S., it places the For example, she explains, there’s a missed dollars in two systems called BioWatch and program out of reach for those who probably opportunity if one mHealth intervention BioSense—one to detect virulent particles in need it the most. evaluates patients for tuberculosis symptoms the air and a second to analyze daily data on “It’s not translatable to the U.S. as a while another assesses HIV risk, but the clinic patients with complaints, like diarrhea or whole,” Cheskin notes. two aren’t designed to easily combine their cold symptoms. The hope was that they would Seeking a better way, he and his findings. Governments that are seeking a provide early warning of a developing epidemic. colleagues launched the TRIMM study— complete picture of these two diseases in So far, BioWatch—when it has worked—has short for Tailored Rapid Interactive Mobile the populations they serve will likely discard produced only false alarms; BioSense has Messaging—in 2011. They’re recruiting both programs. detected influenza outbreaks about as quickly 150 minority participants from inner city From the outset, Mechael says, programs as elementary school teachers note higher Baltimore who are interested in losing should examine how mobile technology can absenteeism. Neither is expected to be of help weight. All the participants will receive be leveraged to strengthen the health system in controlling an epidemic. Support for these comprehensive counseling on diet and as a whole and interact with other platforms, vagaries has come at the expense of state and exercise, but half will receive customized even if the initial funding is specifically local programs. It seems to me that it would be text messages several times a day that address targeting a particular health condition. far more effective to invest in the training and their self-identified problem areas. Cheskin “mHealth is a lot more complicated support of such professional staff. They are and his colleagues plan to see how the two than just giving out phones or developing what we need to develop real solutions. groups compare after six months—and then apps,” Mechael explains. “Technology after another six months, when the text is only as good as the systems that it D.A. Henderson, MD, MPH ’60, Dean Emeritus, messages are shut off. supports.” led the successful global smallpox eradication effort.

Johns Hopkins Public Health / Technology 2012 11 Gadgets Whether high-, low- or medium-tech, Stories Maryalice Yakutchik these inventions are just right. Illustration Joe Cepeda

A Turtle to the Rescue Driving Down Teen Collisions There’s water everywhere in Bangladesh where houses commonly are Compelled by chilling crash statistics and inspired by watching built on excavated mounds of earth and consequently surrounded by his son play Grand Prix video games, David M. Bishai, MD, PhD, ditches and ponds. As a result, 17,000 kids drown here annually (46 MPH, set out with a grant from the Center for Injury Research and every day) making it a leading cause of death in children ages 1 to 4. Policy (CIRP) to improve something that’s largely been neglected for The obvious solution—erecting barriers around the water— decades: driver’s education for teens. simply isn’t feasible. But perhaps the Safety Turtle is. “Hardly anyone’s examining what young drivers need to know Marketed to swimming pool owners in the U.S. and Canada to to be safe,” says Bishai, a professor in Population, Family and protect pets and children, the Safety Turtle is a personal immersion Reproductive Health. While yawn-inspiring old-school driver’s ed alarm with a wireless base unit that blares a warning when the device may be of questionable value, he contends that an engaging program (shaped like a small plastic turtle) hits water. The turtle can be affixed employing innovative software that emphasizes contemporary hazard- easily to a toddler’s wrist, says Adnan Ali Hyder, MD, PhD ’98, MPH recognition content could, in fact, make a life-and-death difference ’93, an associate professor in International Health who directs the in the same way that graduated licensing has. His aim: to create an International Injury Research Unit. interactive experience that teaches teens to anticipate road hazards. He and Alain Labrique, PhD ’07, MHS ’99, MS, assistant With Hopkins colleague Sara Johnson, PhD ’05, MPH ’01, professor in International Health, are pilot testing the device in the and Maria Schultheis, PhD, of Drexel University, Bishai is testing field—soggy as it is—to find out if it will work in a monsoon climate as the validity of a Digital Mediaworks driving simulator. The team has well as be culturally appropriate and socially acceptable. The research tested 10 subjects so far, correlating measures of driving performance is supported by a JHSPH Faculty Innovation Award to Labrique, who in the lab with measures of attention, risk-taking and intelligence. has worked in rural Bangladesh for more than a decade. Bishai’s goal now is to compare the performances of 100 16- to Although the $150 kit is prohibitively priced for use by most 18-year-old novices to more experienced drivers in the context of Bangladeshis, the researchers think one solution might be to divvy up routine driving as well as with added stresses such as phones ringing. the cost between a half dozen families living together in a community; As the simulator measures each subject’s specific competencies, it they could share a base unit connected to a dozen or more turtle also gives researchers insight into the teen brain. devices, each of which would cost relatively little. “We’re targeting “If we show the simulator can differentiate between good and this as a supervision aid for parents of toddlers,” Hyder says. “If they bad driving, and inexperienced and experienced drivers,” he says, are busy working and cooking and an alarm goes off, it will alert an “then we would have an ‘in virtuo’ model of the most lethal threat to entire community to look for the children and see who’s in the water.” teen health—driving.”

12 Johns Hopkins Public Health / Technology 2012 tools

Stories Maryalice Yakutchik Illustration Joe Cepeda

All Done with DUI Baby’s First Photos Imagine a smart steering wheel that could sense by the mere touch of Because gestational age is a critical indicator of newborn health, Parul a driver’s hand if he’s had one too many. This is the next generation Christian, DrPH ’96, MSc, MPH ’92, and colleagues enlisted 500 of alcohol-sensing interlock technology: Automatically activated and pregnant women in rural Bangladesh in a study that compared the pre-market installed, it would prevent a car from operating if a driver gold standard for determining precisely how long a baby spends in the is beyond a pre-set limit, even if he (mistakenly) thinks he’s safe to womb—ultrasound—with “last menstrual recall.” hit the road. The recall technique is shaky at best, particularly in the setting A steering wheel capable of calculating a driver’s blood-alcohol where Christian has spent a dozen years conducting research. It concentration based on the chemical properties of his skin may seem depends not only on whether a woman reliably recalls the first day of futuristic. But it is one example of technology being applied to a new her last menstrual period—which may in turn depend on her level of class of alcohol detection systems that are already in research and literacy—but also whether her cycles are regular. development by car manufacturers, says Shannon Frattaroli, PhD ’99, Neither assumptions nor the inherent uncertainty of memory MPH ’94, an assistant professor of Health Policy and Management bodes well for taking the critical first step in bringing about lifesaving with CIR P. policy changes: gathering good, accurate data. “It’ll no longer be a matter of figuring out strategies to discourage “In public health we’re interested in trying to figure out the people from drinking and driving,” she says. “Now, we can imagine factors that lead to preterm birth, which is associated with a high risk a time when drinking and driving and all the deaths, injuries and of mortality and morbidity,” Christian says. mayhem associated with it will just not be possible.” Having purchased a portable Sonosite Titan ultrasound device Injury prevention research has borne out the fact that passive for $14,000, Christian and Alison Gernand, PhD ’11, MPH, RD, interventions—those requiring no action on the part of users—are assembled a team in the JiVitA field site in rural Bangladesh, where very effective, Frattaroli says. Think airbags, for instance. 90 percent of women deliver at home. What society decides to do with this technology once it’s Trained technicians assessed women who visited a study clinic, available could have huge implications for public health. CIRP recording fetal crown-rump lengths on sonograms to estimate faculty members are monitoring the development of alcohol- gestational age at birth. A sample of the sonograms and measurements sensing technologies and the policy options under consideration for were reviewed for quality control by collaborator Frank Witter, MD, advancing their application. “If we can end the devastation caused of the Johns Hopkins School of Medicine. by drinking and driving—and it seems possible in the not-too- “This is an important technology to use in populations where we distant future—that’ll be an amazing advancement,” Frattaroli says. don’t really know the burden of preterm birth, or may have only an inaccurate estimate of its magnitude,” Christian says.

Johns Hopkins Public Health / Technology 2012 13 Tech Visionaries

A Map of the Human Toxome Seeking Hidden Hunger We like to think that manufactured products toxicity, Hartung wants to comprehensively The emblematic images of famine— have grown safer over the last century, that document the substance’s interactions with emaciated children, skin taut across delicate careful toxicological testing and stringent human cells and compile the results in an bones—have habituated Americans to regulation now protect us from medicines open-source database. think of malnutrition primarily as brutal that can poison and cosmetics that can blind “There are a couple of hundred ways to starvation. While famine relief is vitally us. The reality is not so rosy. Humans are kill a cell,” he elaborates. “If we had a map of important, too little recognized is the larger potentially exposed to 80,000 chemicals this, we could start to look into which cell problem of “hidden hunger.” Though their for which no toxicological assessment has has which of these pathways, and we might external symptoms aren’t necessarily obvious ever taken place. And the current methods start to understand why a substance is toxic nor is their prevalence in a population easy to of evaluation—high-dose animal tests for mice and not for rats, or why it affects gauge, micronutrient deficiencies affect one- extrapolated to human beings—are at best liver cells and not heart cells.” third of the world’s people and are a leading crude and at worst unscientific. With a $6 million NIH Director’s cause of child disability and mortality. Keith “The current toolbox simply doesn’t Grant, he has set out to do just that. “The P. West, Jr., DrPH ’87, MPH ’79, hopes allow us to do the testing we want,” says first step,” he says, “is to develop a language to research on protein biomarkers will bring the Thomas Hartung, MD, PhD, who saw the describe toxicity—describing these pathways problem into the light. limitations of these approaches in his previous in relation to the genes that are involved and Insufficient intake of a few dozen work as director of the European Center metabolic pathways that are involved.” With micronutrients essential to healthy for the Validation of Alternative Methods. this shared vocabulary, a global consortium development is implicated in a wide Now the Doerenkamp-Zbinden Endowed can begin contributing to the database and range of preventable illnesses. However, Chair in Evidence-Based Toxicology and building what he calls a “human toxome.” characterizing these deficiencies at the director of the Center for Alternatives to The need to improve present-day population level has been hampered by Animal Testing (CAAT), he says he was toxicological testing is apparent. From food the cost and difficulty of measurement. drawn to the Bloomberg School in 2009 additives to medications to the ubiquitous Blood samples drawn in the field must be by “the opportunity to become involved materials of our built environments, we are shipped to distant laboratories for analysis in something that could revolutionize the both surrounded by and dependent on novel with expensive machinery, and it may take field.” substances of unknown toxicological safety. years to assemble the results. Performing The opportunity he envisioned was “Products worth $10 trillion are rated with the recurrent tests necessary to maintain to identify and catalog comprehensively [the old] suite of toxicological tests, and consistent micronutrient surveillance is thus what are known as “pathways of toxicity” people know they aren’t necessarily making untenable; in Nepal, for example, the last (PoT): the molecular pathways that, when the best business decisions,” says Hartung, a time such data were collected was 1998, says perturbed, produce adverse health effects. professor of Environmental Health Sciences West, the George G. Graham Professor of Whereas current toxicological tests typically (EHS). “But technologies that are young, Infant and Child Nutrition. expose animals to a substance in order from the last few decades, offer a new “It dawned on us that we needed a to provide a crude characterization of its approach to solving this problem.” change in paradigm,” he recalls. West and

16 Johns Hopkins Public Health / Technology 2012 Tech Visionaries the future

Seeking Hidden Hunger A Red Flag for Nanotechnology his colleagues in the Bloomberg School While some visionaries extend the fellow scientists. “We’ve just had too much of and the Johns Hopkins School of Medicine boundaries of human investigation and a history of doing things where the promise aspire to identify a cheap and quick way problem solving, others bring the world was very great,” she says. to measure a spectrum of micronutrient that’s already visible into a remarkable, new Nanotechnologies raise a red flag deficiencies. They have focused on blood perspective. Ellen Silbergeld, PhD ’72, does because the deliberately engineered plasma, which contains a cross-section of both. An authority on the toxicology of lead properties that make them so valuable could the body’s proteins, and which the new field and mercury, she is now leading a push to make them hazardous. A molecule designed of proteomics has made more accessible. give the blooming field of nanotechnology to deliver a drug through a membrane, Since the proteins present in plasma at any more critical examination, before it’s too late. perhaps administered into the bloodstream, moment may reflect what is going on in Nanomaterials—often defined as could pick up mercury from the circulation the tissues, the investigators hypothesized smaller than a tenth of a micrometer in at least and deliver it instead to intracellular targets that changes in the concentration of certain one dimension—are being rapidly integrated like DNA. (Silbergeld describes this as proteins might indicate micronutrient into everyday life. The large surface area a “sorcerer’s apprentice” problem. The deficiencies. For example, measures of of nanoparticles relative to their volume nanotechnology is like the story’s enchanted the protein transthyretin may parallel the confers special properties. Nanotechnologies broom, which continues to draw water from plasma content of retinol (vitamin A). make fabrics stain-resistant, inhibit bacterial a well even after the room is flooded.) “The circulation becomes a window for growth in food packaging and increase More careful scrutiny can only be good viewing the way that nutrients and proteins the clarity of cosmetics. They also hold for nanotechnology in the long term, says interact in the body,” West explains. the promise to revolutionize medicine, by Silbergeld, since the belated emergence of What began as “a hobby that kept us up penetrating cells and delivering drugs with a hazards would almost certainly undermine late at night” has grown into a full-scale pilot precision that was previously impossible. the public’s confidence in the technology. project funded by the Gates Foundation. “I am as capable of being intrigued by But with an almost total lack of West and his colleagues have already nanomaterials as anybody and I think that information on the effect of chronic identified proteins that co-vary reliably with the promise is potentially very great,” she exposure to nanomaterials, a change in nutrient levels and, within the next 10 years, says. But having witnessed the trajectory course is overdue. “The most important step they are determined to develop an onsite, of other hyped technologies such as leaded a responsible society can take is to come to an real-time test for multiple micronutrient gasoline—which was trumpeted as a ‘gift agreement about the knowledge that’s needed deficiencies. This would allow investigators of God’ at the time of its introduction and to make decisions about nanotechnology, be to quickly and accurately profile an entire then, once its toxicity became apparent, it in the private sector in terms of product population and take effective action. took decades to remove from the market— development, in the public sector in terms of “It would change the entire information Silbergeld, an EHS professor, argues for a regulation and guidance, or in the public in landscape for making more rapid decisions more cautious approach, writing articles terms of acceptability,” she says. about the nutritional conditions of on the subject and chairing workshops to Stories Ted Alcorn, MHS ’10 populations affected today,” says West. engage the attention of government as well as Photos Chris Hartlove

Johns Hopkins Public Health / Technology 2012 17 18 Johns Hopkins Public Health / Technology 2012 chris hartlove first Walk with Me person After decades, I’m back on my own two feet. I feel joy—and a faint electric sting. Essay Sheila Fitzgerald

“Let’s take a walk.” to stop studying. Life was pretty good for optimistic and a bit of risk taker. When an Brian Murray, my physical therapist, five years. I continued my studies, completed opportunity presents itself, I give it a try. had made a few last adjustments to the my degree and then joined the faculty. The L300 consists of a heel sensor in technology banded about my knee and then Eventually, my endurance decreased. A full- my shoe, a control unit on a lanyard on my I took a step. And then another. time job, a long commute and maintaining neck and a device on my knee that stimulates It was a February morning in 2010 my family life became increasingly the nerves in my lower leg with a faint sting when we embarked on our trek from the challenging. Walking for any distance of electricity. Together they correct the foot- Department of Physical Medicine and became difficult. Trips to the grocery drop on my right side caused by MS. Rehabilitation at Johns Hopkins Hospital, store required exquisite planning or else I I can walk now. I can’t ski, I can’t run, down the hallway and then left past the would have to find a place to sit and rest. but I can greet people by looking them in cafeteria. “This is going to take time to Recouping my energies became a big part the eye. A colleague accustomed to seeing build up your strength and build up your of my day. Eventually, I purchased a scooter me scooter-bound said, “I didn’t realize you muscles,” he counseled. We stopped a few and a minivan with a mechanical lift. I are as tall as you are!” times as Brian made some more adjustments. could navigate the halls of the School and I’ve never been one to go out and get My legs were tense. My shoulders were tight. zip over to the nursing building to teach the latest gadget but have always appreciated I hadn’t been upright like this in many years. a class. (I had a reputation for driving technology. My experience with this device I was winded, but I kept moving. full-tilt. I never got a ticket, but I once has made me ever more hopeful for people. You’ve got to make this work, Sheila, I almost ran over former Dean Al Sommer.) I always hope no else will be diagnosed with told myself. Over the next two decades, I wore out three MS. Until then, this piece of technology has Those slow steps in the hospital were or four scooters and as many minivans. expanded my life. Used by 600 hospitals little miracles. In some ways, I began As my disease progressed, I found and clinics in the U.S., the L300 is helping that walk almost 30 years ago on North myself sitting more and walking less. It’s as thousands of people with MS, brain and Broadway, just west of the School. In 1981, I though my middle age was stolen from me. spinal cord injuries and strokes, to walk— was a PhD student in Environmental Health The scooter was helpful but it’s not the same though it doesn’t help everyone. With its Sciences. I had a husband, a seven-year-old as walking on your own steam. Accessibility steep cost of $7,900 (which is not covered daughter, a master’s in nursing, a dozen years was always a challenge. I had to be very by my insurance plan), it’s not yet a public of teaching and work experience and an creative in opening doors on my own. At health, population-level solution, but enthralling challenge studying individuals a conference in England, I had to swallow remember: Computers once filled rooms and with cardiovascular disease returning to hard when we found that the building had cost millions of dollars. Now they’re in our work. only one elevator: a freight elevator. Riding phones. This is translational research. With I started noticing that the late afternoon up with cabbages and overripe tomatoes isn’t future advances, this kind of technology will walk to my car parked on Broadway taxed necessarily glamorous, but it got me to the surely help more people and those with other me more than it should have. I had problems presentation. neurological diseases. The price will come with balance. A heaviness in my right leg I was fortunate to draw on many down as well. made me unsteady. The doctor confirmed resources as the disease slowly progressed. For the moment, I can tell you how this something was wrong. I relied on my family, my friends, my technology has changed my life. I realize Multiple sclerosis. The autoimmune coworkers and my income. Resources come now that there is nothing so wonderful as disease destroys the myelin sheath in a lot of different packages. After my to stand on your own two feet and negotiate protecting nerve cells in selected parts of the husband died and my daughter was married, the world. neuromuscular system. I was 35 years old, in I moved to a condominium in Baltimore the first year of my PhD, and I thought the and began swimming to regain my strength. world was going to end. Then, my physical therapist suggested I try Sheila Fitzgerald, PhD ’88, MSN, is an It didn’t. My husband, Bill, was very something called the NESS L300. He said associate professor of Environmental Health supportive and told me there was no reason it could help me walk again. I’m naturally Sciences.

Johns Hopkins Public Health / Technology 2012 19 20 Johns Hopkins Public Health / Technology 2012 bigdata

Overload The quest for knowledge in an era flooded with information

Story Jim Schnabel Illustration Michael Gibbs

Johns Hopkins Public Health / Technology 2012 21 Every step you take, every move you make… and connectivity at volumes on the order “How to design data collection properly, Science can learn from you. of a cubic millimeter. Next-gen genomics how to avoid bias, how best to represent The tech revolution that has put iPhones technologies can catalog DNA and gene- a population of interest—these sorts of in our pockets and a world of Google-able expression levels rapidly and with base-pair challenges may be even greater for the ultra- data at our fingertips has also been ushering precision. Medical records are migrating to large datasets than for the more manageable in a golden age of health research. Take, the digital and Web realms and containing ones with which we’ve traditionally dealt,” for example, work being done by Thomas ever more numeric and imagery-related says Bandeen-Roche. Glass, PhD, and Ciprian Crainiceanu, PhD, detail. This gold rush of data gathering For Crainiceanu and his team, the and their teams. They recently clipped represents “an opportunity not just in terms goal was to turn days of raw, wiggly, three- accelerometers—smaller than iPhones— of improving public health but also within axis accelerometer voltage readouts into onto the hips of elderly research subjects. biostatistics, for it gives us this tremendous meaningful interpretations of human The devices can record people’s motions new set of problems to work with,” says movements. Such a task essentially attempts in detail, for indefinite periods and in Karen Bandeen-Roche, PhD, MS, the Frank to reproduce—with an artificial sensor real time if needed. The immediate aim, Hurley and Catharine Dorrier Professor and system plus software processing—the says Crainiceanu, a Biostatistics associate Chair of Biostatistics. ability of higher organisms like mice or professor, is to devise a truer method of And the problems can be considerable. people to recognize individual movements recording the physical activity of the elderly. It’s not unusual for a public health study amid the vast, noisy streams of visual and But it’s the kind of approach that could dataset nowadays to require a storage somatosensory signals coming into their turbocharge a lot of other health-related capacity on the order of 10 trillion bytes (10 nervous systems. It’s a big-data-processing science. No more questionnaires, no more terabytes)—the equivalent of tens of millions skill that took us mammals tens of millions biased recollections, no more droopy-lidded of 1970s-era floppy disks. Larger datasets are of years to develop, and even in furry, small- grad students analyzing hours of grainy inherently better in the sense that they have brained ones it involves myriad wetware video. Just the cold, hard facts, folks. Just the greater statistical power to overcome random layers of filtering and logic. data. variations (known as noise) in data—just as Crainiceanu saw the parallels to neural “In principle, we could take inputs from 1,000 coin flips will be better than five coin processing right away, and chose speech a wide variety of sensors—say, heat sensors, flips at revealing the true 50/50 nature of a perception as a guiding analogy. “Movement or portable heart monitors sending data by coin flip. In practice, though, large health- is essentially like speech,” he says. “It Wi-Fi or cell phones,” Crainiceanu says. related datasets often contain a grab bag of involves units like words, which combine “Our imagination is the limit.” And it’s not information that isn’t always relevant and into meaningful sequences that are like just portable gadgets that are making this is distorted (biased) by hidden factors that sentences and paragraphs. So we started by possible. Brain imaging technology is still may confound the savviest statistician. processing the accelerometer data into the big and expensive, but its use is becoming Moreover, traditional data collection, storage smallest meaningful movement units, which more routine, and it now can deliver and analysis techniques can’t always be we called movelets.” information on neural activity and density straightforwardly scaled up to terabyte levels. Movelets represent short bursts of

5 STepS To Taming Big DaTa Where does big data 1. Accelerometers—small, 4. To tame the oceans of come from and how reliable recorders of information (think thousands do researchers make movement—are affixed of people monitored for at hip level to seniors in a a month), Crainiceanu’s sense of it all? study. statistical design team uses Ciprian Crainiceanu 2. Memory sticks in the software to break long strings walks us through devices record 30 observations of data into meaningful one example, from per second—10 each in three indicators of motion called collection to analysis. directions. movelets. 3. Raw data amassed over 5. Finally, movelets are hours, days or weeks are stitched together into downloaded into a computer. narratives that reveal the time (One hour yields 108,000 data and duration that subjects points per person—2.6 million sat, stood, walked or lay per day.) down—creating a true guide 22 Johns Hopkins Public Health / Technology 2012 to seniors’ daily activities. Blizzards of information in new studies yield great insights only after investigators solve the big problems of big data. motion data, roughly analogous to the algorithm essentially can crunch all these are having a hard time saving it on disks; phonemes that make up words. Breaking data—terabytes’ worth, for a large study— NIH has even been having meetings with down the voltage readouts into movelets into relatively compact histories of distinct experts in the field to figure out how we’re made manageable what would otherwise motions (now sitting … now getting up … going to store all these data or whether it have been an ocean of data. “We sample now walking…), just as a speech recognition would be more cost-effective just to generate the accelerometer data 10 times per second, algorithm can condense a storage-hogging it again whenever we need it.” so for three axes we’re gathering on the raw audio recording into a few pages of text. Genomic datasets also can be devilishly order of 30 observations per second,” says Crainiceanu’s colleague Rafael Irizarry, hard to analyze. Modern sequencing devices Crainiceanu. “And let’s say we want to PhD, a professor in Biostatistics, faces a typically generate raw data that represent the monitor hundreds or thousands of people similar challenge when he helps biologists color and intensity of fluorescent reporter for a week, or a month, with their data sift through gene-sequencing data. “Modern molecules linked to short stretches of DNA; continually being uploaded via the Web, for gene sequencing technology is generating these intensity levels have to be interpreted example.” His team’s movement-recognition such enormous datasets now that biologists into “reads” of the GATC genetic code.

Johns Hopkins Public Health / Technology 2012 23 connections One key to dealing with today’s ultra-large datasets is knowing what to leave out, says biostatistician Brian Caffo.

Each of these short, not necessarily error- predict ADHD diagnoses. The organizers free readouts of DNA then must be pattern- of the ADHD-200 Global Competition gave matched to the right location on a three- Caffo’s team, and 20 other academic teams, Get Dirty with Data billion-base-pair reference genome—a bit structural and functional MRI data on 700 Clearly, number-crunching technology makes like finding the right spot for a tiny piece in children to use in training their image-data- it possible to do studies that we could never a football-field-sized jigsaw puzzle. “When crunching algorithms. Then the teams were have done before. However, it is very easy now I first got one of these datasets,” Irizarry asked to use their algorithms to determine to push a button and lose a lot of insight in the says, “I wrote my own little software routine which of 200 new subjects had been process. to handle it and I ran it and waited … and diagnosed with ADHD. “With multiple The whole vitamin A–mortality con- then realized that it was going to take six images per subject and multiple processing nection… I wasn’t looking for that. I was months to finish!” Irizarry soon hired a stages, we ended up handling trillions looking for why some kids get eye disease. computer scientist, Ben Langmead, MS, of bytes of data,” Caffo says. “But the If I had asked a statistician to give me the who has expertise in solving this kind of predictive value of the imaging data turned associations for having vitamin A deficiency, problem quickly. Their group, working with out to be weak.” (In fact, a slightly higher- I would have seen associations with diet, Johns Hopkins Medicine geneticist Andrew scoring algorithm devised by a University of pneumonia, measles... and published a nice Feinberg, MD, MPH ’81, has since been Alberta team relied entirely on the handful paper about their correlation coefficients. putting out a steady stream of high-profile of non-imaging data given, such as IQ, Instead, I looked at the original data: 15 kids papers on the genetics and epigenetics of gender and age, and was disqualified by the had night blindness on round-one, and on tumor cells. (Epigenetics refers to reversible judges for failing to adhere to the spirit of the round-two, only four were still around. Hmmm. DNA-modifications that silence some genes competition.) What happened to those kids? I looked, and the and let others be active; derangements of the Knowing what to leave out is definitely data told me that they were dead. normal epigenetic patterns in cells may be as a part of the challenge of big datasets, Caffo You’ve got to get into the raw data—and important as genetic mutations in promoting says. feel it, smell it, touch it and think about it cancers.) Bandeen-Roche couldn’t agree more. and let it lead you, rather than going in with And then there is the uncertain value of “Sound statistical thinking is as needed a preconceived notion and pushing a button. some ultra-large datasets. “They often come or even more needed than ever to assure Click, done! Yes, you proved something or no, with lots of complications and biases that that what comes out of these tremendous you didn’t. You may miss the really important don’t exist in smaller datasets,” says Scott L. technological resources are really valuable, thing which had nothing to do with the question Zeger, PhD, the former chair of Biostatistics valid findings,” she says. you were originally asking, but is buried in the who is now the University’s vice provost Also needed more than ever, as these big- data. for Research. “A large observational study data challenges increase, are biostatisticians Vitamin A is the perfect example: I’m sure could be much less informative about the themselves. “The demand these days is I would have missed it if I hadn’t been so deep effects of a treatment than a smaller dataset always greater than the supply,” says Caffo. in the data. I’m absolutely confident things from a placebo-controlled clinical trial, for “In fact, statistics is often rebranded as like that are missed every day, because people example,” he says. Even among clinical trials, something else—sabermetrics [baseball don’t get dirty with their data. he adds, the traditional single-center study stat analysis] and Web analytics are two tends to be less noisy than the multi-center examples—in part because our field doesn’t Dean Emeritus Alfred Sommer, MD, MHS ’73, studies that are increasingly the norm in produce enough people to fill the need.” discovered in 1985 that twice-yearly vitamin many areas of health research. The intense math training needed, and A supplements reduced the number of child Even so, the promise of all that data the esoteric lingo—“Granger Causation,” deaths in Indonesia by 34 percent. This and now encourages researchers to go where they “Markov models,” “Pearson’s Chi-squared subsequent findings have led to hundreds of might have feared to go before. Brian Caffo, test” and so forth—probably has something thousands of lives being saved annually. PhD, associate professor of Biostatistics, to do with it. “We’re also poorly branded,” recently led a Johns Hopkins team in a Caffo says. “Biostatistics is actually one of competition to use neuroimaging data to the most exciting fields to go into right now.”

24 Johns Hopkins Public Health / Technology 2012 CoolCool Data Data

“Our computing and storage capacity has doubled every year for the past six years,

chris hartlove and there’s no end in sight.” —Fernando Pineda Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit Downlobortis in the nisl basement ut aliquip of ex the ea Bloombergcommodo consequat. 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Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam Inside that room, cold air blasts from two 10-ton air condition- machines that spew out massive data sets requiring complex analyses nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat ers, eachvolutpat. the Utsize wisi of enim two ad old minim telephone veniam, booths quis nostrud and capableexerci tation of cooling ullamcorper involvingvolutpat. mammoth Ut wisi enim calculations.” ad minim veniam, quis nostrud exerci tation ullamcorper aboutsuscipit 10 average-sized lobortis nisl uthomes. aliquip ex ea commodo consequat. suscipitFor instance, lobortis just nisl utone aliquip of the ex HPSCC’s ea commodo prolific consequat. customers (Andy “ComputersDuis autem like vel it cool,”eum iriure explains dolor Fernando in hendrerit Pineda, in vulputate PhD, direc velit -esse Feinberg’sDuis lab autem in the vel Center eum iriure for Epigeneticsdolor in hendrerit at the in Johns vulputate Hopkins velit esse tor ofmolestie the Department consequat, velof illumBiostatistics’ dolore eu Highfeugiat Performance nulla facilisis Scientificat vero eros et Schoolmolestie of Medicine) consequat, can vel illumgenerate dolore as eu much feugiat as nullaone facilisisterabyte at ofvero data eros et Computingaccumsan Core et iusto (HPSCC), odio dignissim half of qui which blandit is praesentnow housed luptatum here zzril since delenit everyaccumsan week. That’s et iusto 10 odio to thedignissim 12th bytes.qui blandit To put praesent this amountluptatum of zzril data delenit augue duis dolore te feugait nulla facilisi. Nam liber tempor cum soluta nobis augue duis dolore te feugait nulla facilisi. Nam liber tempor cum soluta nobis outgrowingeleifend optiona server congue room nihil on theimperdiet third floor.doming id quod mazim placerat facer in material-worldeleifend option congueterms, nihilyou imperdietcan think doming of one id quodterabyte mazim as placerat 50,000 facer possimConsuming assum. more than 30 kilowatts of power, these machines treespossim made assum.into paper and printed. Ten terabytes equals the entire generate Loremlots of ipsumheat anddolor depend sit amet, on consectetuerprodigious airadipiscing conditioning elit, sed to diam printed collectionLorem ipsum of thedolor U.S. sit Libraryamet, consectetuer of Congress. adipiscing And the elit,National sed diam avoidnonummy meltdowns. nibh euismod tincidunt. Archivesnonummy of Britain nibh euismod holds tinciduntmore than 900 years of written material, LoremThat ipsumthe facility—which dolor sit amet, consectetuer provides large-scale adipiscing researchelit, sed diam comput nonummy- which amounts to about 60 terabytes of data. nibh euismod tincidunt ut laoreet dolore magna aliquam erat volutpat. Ut ing and storage capabilities for Johns Hopkins researchers in bio- “We currently have capacity for 95 terabytes on spinning disk wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit statistics,lobortis statistical nisl ut aliquip genetics, ex ea commodogenomics, consequat. computational Duis autem biology vel eum and iriure and another 50 on tape,” Pineda says, indicating racks of storage de- bioinformatics—burstdolor in hendrerit in vulputateout of its velit original esse molestiephysical consequat, space not velfive illum years dolore vices, each of which someone has affectionately labeled with a name: aftereu it feugiatwas established nulla facilisis was at no vero great eros surprise et accumsan to Pineda, et iusto an odioassociate dignissim There’s Fran and Stan, and Thumper I and II. Luckily, there’s room professorqui blandit in Molecular praesent luptatumMicrobiology zzril delenit and Immunology. augue duis dolore te feugait nulla for the inevitable Fran II and Stan II, and Thumper III and IV. facilisi. “Genomics Lorem ipsumis very dolor computationally sit amet, consectetuer intensive,” adipiscing Pineda elit, says.sed diam “There’s always going to be more data,” Pineda says, explain- nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat “Ourvolutpat. computing Ut wisi and enim storage ad minim capacity veniam, has quis doubled nostrud exercievery tationyear forullamcorper the ing that sequencing costs soon are bound to drop below analysis and past suscipitsix years, lobortis and there’snisl ut aliquipno end ex in ea sight. commodo It’s aconsequat. chronic problem; not storage costs. a problemDuis you autem solve, velbut eum a problem iriure dolor you manage.”in hendrerit in vulputate velit esse Surprisingly, computing and storage capacity isn’t the issue that molestieSome of consequat, the HPSCC’s vel illum best dolore customers eu feugiat are nulla genetic facilisis epidemiolo at vero eros- et keeps Pineda awake at night. It’s the cooling, he says: “The power gistsaccumsan in the Department et iusto odio of dignissim Epidemiology. qui blandit They praesent analyze luptatum the 3 billionzzril delenit and the cooling. And of those two, the cooling is the big headache.” augue duis dolore te feugait nulla facilisi. Nam liber tempor cum soluta nobis or so base pairs that constitute the human genome to identify and —Maryalice Yakutchik eleifend option congue nihil imperdiet doming id quod mazim placerat facer possim assum. Johns Hopkins Public Health / Technology 2012 25 Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt. On Location

Place matters—that’s epidemiology 101. training but also offer multidimensional predict where assistance—such as bed net Until recently, gathering data and analyses, including environmental factors distribution—is most needed. charting it on maps meant going door to like elevation and climate. Either way, In earlier work, Glass used geographic door to survey families and then plotting the for scientists looking to demonstrate the mapping to predict an increased risk of findings on paper. It was a tedious process importance of place in public health, the hantavirus in certain areas, based on at best and mostly two-dimensional. Data options have far outstripped the tools of 20 increased precipitation and vegetation. More mapping might show, for instance, which years ago. vegetation means a booming population of households within a community had been “Some of the biggest advances made the rodents that carry hantavirus. affected by a certain disease or problem and have been in supporting technologies, like The resulting images vary depending on where the condition was most prominent, remote sensing of the environment using circumstances, sometimes appearing as heat but would most likely reveal nothing about satellites and finding out, for instance, maps—brightly colored maps resembling relevant climate or social demographics in the soil moisture in Zambia today versus those used by meteorologists, with the that particular area. two days ago. Those are things you highest risk areas showing a bright red. A Today’s tools for epidemiological certainly couldn’t have gotten in the past,” map of a predicted malaria outbreak, on the mapping offer much more, not only in says epidemiologist Greg Glass, PhD, a other hand, might illustrate which areas of detail but also in efficiency and ease. As a professor in the Department of Molecular Bangladesh are both highly populated and result, geographic information systems Microbiology and Immunology. highly vulnerable to malaria, encasing those (GIS) are changing the way epidemiologists Such environmental factors often areas in concentric circles. approach the entire concept of place as a correlate directly with epidemiological Shannon Doocy, PhD, with the Center component of public health. In some cases, concerns. Take, for instance, the relationship for Refugee and Disaster Response, often GIS mapping requires little more than basic between rainfall and the prevalence of uses GIS to study natural disasters and computer skills and a global positioning malaria-carrying mosquitoes. Knowing affected communities. system (GPS)-enabled cell phone. More which areas are more vulnerable to malaria She and her colleagues also use GIS complicated applications require extensive outbreaks, says Glass, allows aid workers to information to analyze approaching storms,

26 Johns Hopkins Public Health / Technology 2012 chris hartlove mapping

“One of the limitations we often cite is that we’re unclear about the effects of the environment on individuals and communities. GIS has brought a population-based approach that looks at the

relationship between people and place.”

On Location —Debra Furr-Holden

in hopes of anticipating which areas are says Debra Furr-Holden, PhD, an associate 300 feet of a church or school. “Using that most vulnerable. “If you can have a good professor in Mental Health. data, we were able to work with the city to understanding of where a hurricane is likely Much of Furr-Holden’s research centers identify which outlets were violating the law,” to hit and flooding is likely to occur,” she on the epidemiology of drug and alcohol Furr-Holden says. “They were actually able says, “you can plan humanitarian assistance abuse in Baltimore City. Using handheld to get some of those nonconforming outlets efforts with a better understanding of what GPS devices, she says, researchers can closed because we were able to make a strong to anticipate post-disaster.” venture into the community to collect data case from the public health perspective that One example, she says, was Cyclone about where they’re finding indications of there would be health improvements if they Nargis in Burma (Myanmar). “After that, violence, alcohol use, tobacco and drugs, as took this on.” we created a GIS model that estimated the well as potentially influencing factors such as That, she says, was made possible affected population,” explains Doocy, an poverty or crime rates. Meanwhile, the GPS through GIS. assistant professor in International Health. automatically records the location where “One of the limitations we often cite “There was an area where a lot of aid groups researchers are collecting data. in public health is that we’re unclear about were being restricted, and there wasn’t a lot One successful project occurred a the effects of the environment on individuals of access to information or good estimates of few years ago, when Furr-Holden and and communities,” she says. “I think GIS the affected population. The UN was able her colleagues were studying whether the has brought to public health a population- to use our maps and population estimates to proximity of liquor stores and bars to schools based approach that looks at the relationship inform their emergency response.” influenced the rate of underage drinking. between people and place. We now have the But determining the significance Not only did they find an increase in alcohol tools and capacity to look at the broader of place has historically proved more use in children, they linked it to poor impact of the environment on individuals complicated when studying less concrete academic and substance abuse outcomes. and communities and their health and issues, such as the role that one’s social Further still, researchers found that health behaviors.” environment might play in substance abuse. several establishments were violating a —Lauren Glenn Manfuso Here too, however, GIS is proving valuable, Baltimore law barring alcohol sales within

JohnsJohns HopkinsHopkins PublicPublic HealthHealth // TechnologyTechnology 20122012 2727 Knowledge Unbound

Degrees of Distance The Price Is Right: Free In 1997, the School offered its first online In the 2010–2011 academic year, online Ira Gooding gets queries from all over the courses, enrolling 36 students in a Graduate course enrollments reached 5,214, with world—from educators, health officials Certificate Program in Public Health full-time, onsite students accounting for 46 and independent learners—requesting sponsored by the Centers for Disease Control percent of those enrollments, perhaps taking permission to use the Bloomberg School and Prevention. online courses to ease scheduling conflicts or materials on OpenCourseWare (OCW). Since then, online learning has explore additional subjects, Yager says. His answer: You don’t even have to ask. become central to the School’s mission, and More than 400 students are currently OCW, launched at the School in 2005 many onsite courses have gotten better as enrolled part time in the Internet-based with a three-year grant from the William professors work with experts in the Center MPH Program, earning up to 80 percent of and Flora Hewlett Foundation, allows for Teaching and Learning with Technology their credits through online courses. They users to access material at no charge. In the (CTLT), says James Yager, PhD, senior complete their remaining coursework—and year ending mid-November, ocw.jhsph.edu associate dean for Academic Affairs and the meet other students in their cohort—onsite attracted 251,528 unique viewers from 1,981 Edyth H. Schoenrich Professor in Preventive in Baltimore or in Barcelona, Spain. cities around the world. Medicine. Yager, who teaches both online and “People who cannot come to the CTLT now has 28 staffers who work in the classroom, says he often has more School for a wide variety of reasons can closely with faculty to make the online interaction with students in online classes. still benefit from the educational resources experience as rich and accessible as possible, “The online students use bulletin boards produced in the teaching that goes on here,” both for distance learners and for students and they post questions there and you can says Gooding, MA, educational resources taking onsite classes supplemented by online look up who they are,” he says. On the other coordinator for the Center for Teaching and materials. hand, he says, students in online courses Learning with Technology (CTLT), which are “not here, having lunch together,” and develops the materials for online users. do not enjoy quite the same range of course There are no exams with OCW, 106 offerings. and users don’t receive academic credit. Online courses scheduled “It isn’t a matter of one being better than Participants include “the independent for 2011–2012 the other, it’s [just] a different experience,” he learner who wants to brush up on a topic, says. maybe a municipal health worker, or an educator putting together a course, and they’re looking for material so they don’t 15 have to reinvent the wheel,” says Gooding. New courses offered for 2011–2012 107 Number of courses available on OpenCourseWare education

ways the Web is transforming public health education 3 Certified Tobacco Fighters In developing countries in particular, China National Tobacco Corporation, the Learning from the Experts is useful for OCW provides public health information world’s largest tobacco company, is owned reaching low- and middle-income countries, that might not otherwise be available. As by the Chinese government. So it should where public health officials might not have one participant wrote: “Understanding the come as no surprise that tobacco use is widely the resources to travel or create training concept of social and behavioral theory will accepted in Chinese life. In fact, providing materials, says Cohen. In India, for example, help me achieve the community blood donor a gift of cigarettes is considered a sign of state and provincial health educators have mobilization strategy I am implementing in respect, says Joanna Cohen, PhD, MHSc, adapted the materials to make them locally Nigeria.” director of the Bloomberg School’s Institute relevant—particularly targeting the use of The courses—on subjects including for Global Tobacco Control (IGTC). inexpensive hand-rolled cigarettes called biostatistics, refugee health, HIV/AIDS and Though there’s still a long way to bidis. mental health—are offered as a combination go, public health officials and educators “With tobacco control, when of audio lectures, PowerPoint slides and in China are beginning to change that governments or donors decide to fund reading assignments. They are readily culture, with help from “Global Tobacco activity, a lot of the work requires human available for noncommercial use through Control: Learning from the Experts,” an resources, hiring people,” but there is often a Creative Commons licensing agreement, online training program from IGTC. Since a paucity of trained personnel, says Cohen, and are continually enriched and updated its 2007 launch, Learning from the Experts an associate professor in Health, Behavior by users, who make changes such as adding has exported its tools and information to and Society. Learning from the Experts, illustrations or translating to other languages. more than 175 countries—offering 40 she says, is “very helpful in settings that are Biostatistician John McGready, PhD lectures organized into 11 topic modules and ramping up.” ’07, MS, says he’s pleased to reach more available in six languages: Arabic, French, people through OCW. His materials Chinese, English, Russian and Spanish. with additional features like online class Users can access the materials free of 95 Percent of participants surveyed discussions are also available online for charge, on topics including the tobacco who plan to apply course insights to credit, which users must pay to access, so industry and its influence, the health impacts their work “it doesn’t create economic competition,” he of smoking, and smoking cessation methods. notes. Participants must earn 80 percent or higher Says McGready of OCW, “I certainly on the quiz at the end of each module to have benefited from people putting their receive a certificate of completion. materials out there, and I felt like I should return the favor.” 5,626 Participants enrolled to date in the 331,626 course “Global Tobacco Control: Story Karen Nitkin OpenCourseWare site visits made Learning from the Experts” Illustration Joe Cepeda from Nov. 2010 to Nov. 2011 Open for Business The market, once disdained by researchers focused on saving lives, may be the best way to move discoveries from the lab to the real world.

Here are some things that David Sullivan how to organize and finance large-scale trials because an effective replacement for blood- knows how to do: He knows how to manage of his malaria diagnostics. He doesn’t know based tests could have profound benefits a modestly sized biological lab. He knows how to secure international patent protection in combating the disease that kills nearly how to chemically test for proteins and for the devices. And he has no idea how to 700,000 people annually. “We’ve been other molecular markers of Plasmodium, find factories that might manufacture them using a more than 100-year-old test, jabbing the parasite that causes malaria. He knows on a mass basis. someone with a needle,” Sullivan says. “Our how to build simple prototypes of diagnostic To fill in those gaps—and to increase idea is to make malaria diagnostics more devices that can detect Plasmodium the odds that his lab’s ingenuity will actually accessible to people in the home, almost proteins in urine—a potentially enormous benefit people on the ground—Sullivan like a pregnancy test. This may enable faster breakthrough because such devices could turned to the Johns Hopkins Technology treatment and faster contact with health care eliminate the expense and risk of malarial Transfer Office. personnel.” blood screenings. Those are the kinds of In 2008, that office licensed Sullivan’s Sullivan’s project is just one of several tasks to which Sullivan, MD, an associate invention to Fyodor Biotechnologies, a small tech transfer ventures that have emerged professor in Molecular Microbiology and Baltimore company led by a former researcher from the Bloomberg School in recent years. Immunology, has given the last 20 years of from the Johns Hopkins School of Medicine. Those efforts don’t always come easily or his life. If all goes according to plan, Fyodor will naturally to public health scholars. “The But here are a few things that Sullivan conduct field trials of the urine diagnostic culture here has historically not been geared doesn’t know how to do: He doesn’t know in Mali this spring. Hopes are running high, toward tech transfer,” says Shyam Biswal,

3030 JohnsJohns HopkinsHopkins PublicPublic HealthHealth // TechnologyTechnology 20122012 tech transfer

Story David Glenn Illustrations Michael Morgenstern

PhD, a professor in Environmental Health on the vine,” Sullivan says. He is grateful ventures based at the Bloomberg School. Sciences and one of the founders of Cureveda, that Hopkins’ tech transfer staff brokered his They include a screening instrument a biotech venture that aims to create new lab’s relationship with Fyodor. If the Mali for identifying aging adults at highest therapies for inflammatory diseases. When trials go well, the company hopes to have the risk for intensive hospitalization; a set you’re working on problems that afflict malaria diagnostics certified by the WHO, of prospective new therapies for chronic people in severe poverty, revenue streams are opening the door to potential large-scale obstructive pulmonary disease; and a series probably the last thing on your mind. For purchases by The Global Fund. of instructional videos designed to teach their part, tech transfer offices haven’t always “In this day and age, if you just publish doctors how to candidly acknowledge and known what to do with public health ideas an idea, it probably won’t get done,” says apologize for medical errors. Then there is that might not have a market in the U.S. Wesley D. Blakeslee, director of the Johns the grandfather of Bloomberg School tech Slowly but surely, however, both parties are Hopkins Office of Technology Transfer. “I transfer efforts, which also happens to be the learning how to make this marriage work. think there’s more of a recognition now that most lucrative in Johns Hopkins University In certain circumstances, they have realized, biotech companies can be partners with us. history: the Adjusted Clinical Groups (ACG) the market might be the only way to ensure If you invent a cure for cancer and it only System. The software package allows public that a promising public health tool moves stays in the lab, doesn’t get out the door, then health agencies, insurers and scholars to from the lab into the real world. you haven’t had the impact.” analyze and predict patterns of illness across “The tech transfer process can be Sullivan’s malaria diagnostic is just large populations. More than two-thirds frustrating because so many good ideas die one among a diverse array of tech transfer of gross royalties from ACG (which was

JohnsJohns HopkinsHopkins PublicPublic HealthHealth // TechnologyTechnology 20122012 3131 “I’m hoping that we get the big blockbuster, for all the benefits that it would bring to our institution. We’ve come close a few times.” —Wesley D. Blakeslee first made commercially available in 1992) whether to roll the dice and invest the earlier. In 2010, Hopkins spent more than $8 have been poured back into the Bloomberg University’s own money in permanent patent million on patent filings (that figure includes School’s research programs. filings. the staff time of the tech transfer office’s in- The tech transfer process begins That was the dilemma that Sullivan’s house attorneys), and received $3.79 million when a scholar files a formal disclosure of urine-based malaria diagnostic faced in in patent fee reimbursements from licensees. invention to the University. If the idea seems early 2006, 12 months after his preliminary “We push our inventions continuously,” at all promising, the University then files patent application had been filed. In his case, Blakeslee says. “Today the biggest part of a provisional U.S. patent application—a the University decided to press forward with our job is to engage with industry to find out relatively low-cost step that posts a claim on a permanent application, and the gamble their needs, and when we do, we examine the concept for a 12-month period. Then paid off. Two years later, in 2008, Fyodor our entire portfolio for a fit.” the waiting game commences: If a company Biotechnologies licensed the technology— But even if a three-year wait is typical, it chooses to license the invention, that and agreed, as is typical in such cases, to was still disheartening for Sullivan, who says company usually assumes responsibility for reimburse the University for the money it he has seen many good public health ideas pursuing permanent patent protection—a had spent on patent fees. founder because they don’t fit the profit- process that can involve hundreds of That basic pattern is common, according making imperatives of the pharmaceutical thousands of dollars in legal fees. But if no to Blakeslee. Roughly 70 percent of the industry. “Timing is everything,” he says. “If suitor emerges during the 12-month period, licenses that Hopkins signs are for inventions a company is not ready to pick it up, then the then the tech transfer office needs to decide that had been developed at least three years idea just sits there.” He says that the Hopkins

32 Johns Hopkins Public Health / Technology 2012 connections tech transfer office seems to be stronger than Bloomberg School’s program of seed grants many of its counterparts at other universities for new tech transfer ventures. The School at breathing life into ideas aimed at the now awards up to three $50,000 grants developing world. each year for scholars who want to develop Blakeslee happily concedes he a business plan or to file patent applications. daydreams about lucrative pharmaceuticals Biswal has won two of those grants, and he with Western markets. “I’m hoping that we says that his Cureveda venture would have get the big blockbuster, for all the benefits been impossible without that initial support. that it would bring to our institution,” The grants allowed him and his colleagues to he says. “We’ve come close a few times.” develop an infrastructure and to hire a chief But he says his office also uses a variety of executive officer, he says—and it was only strategies to support low-profit-margin ideas after that foundation was in place that larger Keep in Touch like Sullivan’s. Last year, his office brought pharmaceutical companies began to knock It is exciting and fascinating to experience the together more than 80 scholars from across on his door. (Cureveda now has a three-year way science is unfolding at such a logarithmic Hopkins at a meeting with representatives research and development contract with rate. Technological innovations inspire a sense of GlaxoSmithKline’s “Open Lab” project, GlaxoSmithKline.) of wonder, especially for me as they are related a nonprofit effort to develop new drugs In the rare cases when university to my original profession as a physician. to treat tuberculosis and other diseases of inventions lead to lucrative products and Although many types of technology were the developing world. The University has services, they can generate substantial developed and then abandoned because they also made a low-cost licensing deal with streams of revenue. Under the terms of the didn’t really accomplish what was anticipated, the PATH Malaria Vaccine Initiative for Bayh-Dole Act of 1980, the federal law other kinds related to both diagnosis and a technology that was developed at the that established the modern day template treatment have grown and expanded in the Bloomberg School. for commercializing academic research, most incredible ways. For collecting data or One way for public health scholars universities must reinvest their licensing transmitting factual information, the latest to cope with economic constraints is to payments and royalties in their research technologies are of great value to humanity. be more strategic about their research programs. At Johns Hopkins, those revenues As a child, I remember visiting my father’s programs, according to Douglass B. Given, are generally allocated as follows: 35 percent family farm in Iowa, where they relied on a biotechnology investor who serves on the to the inventor, 15 percent to the inventor’s the party line telephone for communication. Bloomberg School’s Health Advisory Board. laboratory, 15 percent to the inventor’s At that time, we could never have imagined Given believes that scholars at Hopkins and department, 30 percent to the inventor’s that human-to-human communication would elsewhere should be more aggressive about school and 5 percent to the University as a achieve the speed, convenience and worldwide finding venture capitalists and philanthropic whole. reach that we now have available. partners to support the commercialization of ACG, for example, has brought revenue However, when communication goes new treatments for neglected diseases. The to the Department of Health Policy and beyond the cognitive, when it needs to serve key, Given says, is to spot emerging waves of Management—where one of its primary a purpose other than the transmission of research financing—say, a new international creators, Jonathan P. Weiner, DrPH ’81, MS, facts, that’s when I have concerns about our anti-tuberculosis campaign, or surging is based—and to the School. Most of this growing reliance on technology. Physical touch interest in particular kinds of recombinant revenue comes from insurance companies is very, very important. It has a deeply root- gene technology—and to concentrate an and public health systems in more than a ed biological basis. Human-to-human touch entire academic department’s resources on dozen nations—including the Medicaid builds relationships; it’s a crucial bonding those themes. “You need to think about programs of 15 U.S. states and systems in mechanism. To put one’s hand on a patient in where the government funding is and where Canada, Spain, Taiwan and the United distress, to hug a child—that kind of emotional the school’s strengths lie,” says Given. “If you Kingdom—that use ACG’s software to communication depends on our basic biology. don’t use those kinds of strategies and screens analyze patterns of health care delivery and I would be very sad if our species, with all its when you hire faculty members, then you costs. But Weiner emphasizes that the system emphasis on and fascination with technology, can wind up in a funding no-man’s-land.” is also available to academic researchers at lost that. Biswal, the inflammatory disease low or no cost. “We’ve developed a huge Technologies are not the creations of researcher, says that the tech transfer climate research and development program out of gods. They are simply tools we have invented to at Johns Hopkins has “radically improved” this,” he says. “It’s not just about industry.” facilitate meeting our needs. If all we needed since he first dipped his toes in the water seven Weiner believes he and his colleagues was technology, then why do politicians still years ago, but he believes much more can be struck the optimal balance: They kept reach out to shake so many hands? done. One element that he does praise is the Continued on page 38 Edyth Schoenrich, MD, MPH ‘71, a former senior associate dean at the School, is now director of the Part-time Professional Programs and Johns Hopkins Public Health / Technology 2012 33 associate chair of the MPH Program.

Through the Lens larry canner

Diagnosing TB on the Cheap An inexpensive microscope, a cell phone and the Internet are the developing countries, a critical shortage of TB diagnostics suitable main ingredients in a promising method to diagnose tuberculosis in for use in areas with few health services hampers efforts to control the the poorest and most remote areas of the world. disease, experts say. “You can’t treat well if you can’t diagnose well,” The system is the work of a Peru-based research team led by says Gilman, who has conducted infectious disease research in Peru Mirko Zimic, PhD ’08, MHS ’01, MSc, a professor at the Universidad for more than 25 years. Peruana Cayetano Heredia (UPCH), and Patricia Sheen, PhD ’08. To bring MODS technology to areas in need, Zimic’s team set Zimic describes the technology as a “complement” to microscopic- out to build a more affordable—and digital—inverted microscope. observation drug-susceptibility (MODS). Parts include a $1 halogen lamp and stock optical components. Total That innovative TB diagnostic was developed in 2000 by Luz cost: about $400. Caviedes, MHS ’10, under the supervision of International Health In this model, a technician places the MODS assay plate professor Robert Gilman, MD, researchers from UPCH and others. containing a patient’s sputum samples on the microscope and MODS is a cheaper, faster and more sensitive alternative to takes a digital photo. He then sends it, via Internet or cell phone, standard TB culture tests that can take as long as four months to to a computer server at UPCH that analyzes the image using a detect multidrug-resistant tuberculosis (MDR-TB). Especially mathematical algorithm. Within 15 seconds, the diagnosis is delivered vulnerable are patients with a dual diagnosis of HIV and MDR- by text message or email to the lab. TB, Gilman says. Half of them may die within two months without Studies on proof-of-principle experiments, published in PLoS appropriate treatment. ONE and the Journal of Microscopy, confirmed the method’s accuracy. The breakthroughs of MODS, which can diagnose TB within 7 Now, Zimic’s research team is at work on a pilot project in the to 14 days, centered on the discoveries that Mycobacterium tuberculosis Trujillo region of northwest Peru to test TB telediagnostics based grows in liquid media faster than in solid media and that the rod- on MODS. The goal is to bring the system to low-resource areas shaped TB colonies can be viewed microscopically. But the method with high TB burdens. His lab is also working on image-analysis presents formidable challenges for remote, low-resource regions in diagnostics to analyze Pap smears and skin lesions. developing countries. It requires an inverted microscope, which costs Says Zimic: “If you have an algorithm to interpret the images about $5,000, as well as trained technicians, says Zimic. remotely, then you can use the same method.” Despite the benefits of MODS, which is in place in several —Jackie Powder

34 Johns Hopkins Public Health / Technology 2012 images larry canner

City Life at Shutter Speed A boy chews tobacco in Delhi. An open dumping area spoils a in photography basics. And before the kids trained their cameras on Shanghai neighborhood. In Baltimore, an overweight adolescent girl the neighborhood, study investigators posed some general questions smokes a cigarette. about health. What do health and well-being look like? What are The striking images are the work of young people who took on threats to it? How do young people stay healthy? an assignment to photograph images of health—good and bad—in After each photo session, the group reviewed the day’s pictures the cities that they call home. on a laptop and discussed the images. The teens wrote captions for Researchers from the Bloomberg School will use the more than the pictures they selected for inclusion in the study, Marshall says. 10,000 pictures snapped by approximately 60 teens in six study In the analysis phase of the project, researchers will review the sites—Baltimore; Delhi; Ibadan, Nigeria; Johannesburg; Shanghai; photos and code the captions and discussions to identify themes. The and Rio de Janeiro—to gain insights into the lives and health of dis- next step is to develop questions based on the collected data to sur- advantaged adolescents as part of the Well-Being of Adolescents in vey approximately 2,400 adolescents—400 from each study site—on Vulnerable Environments (WAVE) study. their health needs. The answers will help design more effective health Led by the School’s Center for Adolescent Health and the Uni- interventions for young people in vulnerable environments. versity’s Urban Health Institute, the research is funded by AstraZen- “So many conceptual frameworks start with identifying a need, eca’s Young Health Programme. making the assumption that we know about young people and their Photovoice, a component of the WAVE study, uses “participato- health needs,” Marshall says. “We have to understand how they see ry photography” to give marginalized communities the opportunity health before putting an intervention in place.” to tell their stories through pictures. Lashira Darby, 18, who took pictures of the Baltimore neighbor- “It gives them a different way to express themselves versus us hood where she’s lived her entire life, says that she came away from sitting and asking them questions about health issues,” says Beth the project with basic photography skills and a broader understand- Marshall, DrPH ’10, MPH, assistant director of the Center for Ado- ing of what health means. lescent Health. “The best thing was learning how to use the camera bet- Marshall spent four days last July in East Baltimore with 11 ter,” says Darby. “It also taught us to help the neighborhood. teens taking photos with digital cameras provided by the study. The We have to set an example for the younger kids and not smoke and youths first met with a photojournalist who gave them a crash course drink but do positive things.” —JP

Johns Hopkins Public Health / Technology 2012 35 Breakout Innovations chris hartlove

Mining Health Records In what is commonly described as the founding act of public health system to actually ask questions about how the community might be science, John Snow noticed a spatial pattern to the casualties of an 1854 contributing to health problems, I think, is unique and ahead of the cholera outbreak in London and identified the source of exposure: curve,” he says. the Broad Street pump. Today, Brian Schwartz, MD, MS, a professor Detailed data from the EHRs are a huge leap forward from self- in Environmental Health Sciences, is exploring the environmental reported health data, the previous mainstay for this kind of research. influences on health at a level of complexity and sophistication that The Geisinger population is also several orders of magnitude larger Snow never would have dreamt possible. than earlier sampling methods—such as random-digit dialing— Schwartz’s partner in this work is the Geisinger Health System, would have allowed. “A lot of epidemiological modeling to date which provides primary care services to more than 400,000 people has been kind of deterministic, and one risk factor at a time,” says in Pennsylvania. The electronic health records (EHR) of those Schwartz. individuals who do not opt out are made available for research. While In contrast, by analyzing a large sample with numerous variables, public discussion has focused on how EHRs might reduce medical Schwartz and his colleagues can use complex dynamic systems errors and improve diagnoses, Schwartz saw an opportunity to use the modeling to explore manifold interconnections, feedbacks and health system data to evaluate environmental exposures in daily life. unexpected properties. They are researching or initiating projects on Once they are coded according to a patient’s locale, (geocoded), diabetes, obesity, asthma and MRSA, among other topics. EHRs can reveal exposure to a spectrum of environmental variables. “As more and more health care is captured by EHRs, there’s going The features incorporated into various models range from playgrounds to be an increasing ability for this kind of research,” says Schwartz. to abandoned coal mines to animal feeding operations. Physicians “So I actually think we’re early in this period. It’s a huge growth area, historically have done a poor job connecting their patients’ illnesses and it’s going to continue to grow for the foreseeable future.” to these kinds of influences, Schwartz points out. “For a health —Ted Alcorn, MHS ’10

36 Johns Hopkins Public Health / Technology 2012 outcomes Social Media vs. Social Disease With 19 million new sexually transmitted infections (STIs) each year The survey results will help inform the design of a in the U.S., notifying partners is a crucial public health responsibility. user-friendly website, tentatively scheduled to launch next But financially strapped local health departments often lack the summer through a nonprofit called Sexual Health Innovations, which resources to personally notify partners of an infected person. Ladd just founded. Pending funding, the site will allow individuals Can tech pick up the slack? to anonymously tell their partners that they have been exposed to Charlotte Gaydos, DrPH ’93, MPH, MS, and Jessica Ladd, an STI and should see their doctor or health department for testing. MPH ’11, decided to find out. They developed a survey, targeted at The site will be designed to maximize privacy and minimize false teens and young adults, to learn whether anonymous emails, e-cards, reporting. text messages or letters would be an acceptable tool for sending and Gaydos is optimistic that the website will be effective—a receiving partner notifications regarding a possible STI. confidence based on the success of an increasingly popular website The survey was posted as a Facebook Event for two weeks in she and her team developed in 2004: I Want The Kit (IWTK), at early September, successfully recruiting more than 500 individuals. iwantthekit.org. Of these, 343 met the criteria for the study. “People can go online to request collection kits to test for While their preliminary analysis is ongoing, Ladd says that the STIs,” Gaydos says. “This is a form of social media where we allow vast majority of survey participants preferred a phone call from a individuals to collect samples in the privacy of their own homes and health department disease intervention specialist (DIS) as the means mail them in. Such an approach is especially useful for, say, a 15-year- of partner notification. If calls were not an option, participants old girl who doesn’t want her parents to know she’s having sex, but rated emails as the next best option. Only a minority of participants who knows she might have been exposed to an STI.” favored sending or receiving partner notification via anonymous text Individuals can receive notice of their test results however they messages, e-cards or letters. request; texting is popular with many. “That 15-year old girl, for But the survey response doesn’t negate the value of social media, example, is not going to want a call to her house,” Gaydos says. “The says Gaydos, a professor in the Division of Infectious Diseases at message is coded, so we are not giving out any private information, the Johns Hopkins School of Medicine, with joint appointments in nor do we text any positive results.” Epidemiology and in Population, Family and Reproductive Health at There are limits, of course, to the use of technology and social the Bloomberg School. networking for certain purposes. As Gaydos points out, human “Some people said texting was okay,” she notes. “It could be contact, even via the phone, is still more important for many people. that some people know their partners well enough to say that, ‘Yeah, Because their recent Facebook survey was small and participants he’s on his cell phone all the time, so he will be most receptive to a were mostly college-educated white women, Gaydos and Ladd are text message.’ Because everyone’s experiences are different, building conducting a similar survey with Baltimore Health Department flexibility into the system is good.” patients, who are primarily inner-city African-Americans. Ladd, a PhD student in Epidemiology at the School, notes But according to Gaydos, the survey results have “definitely” another positive outcome of the survey: “[It] shows that a social helped public health researchers better target future efforts on network such as Facebook could be used to enroll large numbers of this and other health issues. “Social media is a great way to reach participants at little or no cost.” Furthermore, she believes the results adolescents and young people,” she says, “and that is exactly where confer “a high potential” for using email as a means of anonymous most STIs are—in men and women under the age of 25.” notification. —Patricia M cAdams

“It shows that a social network such as Facebook could be used to enroll large numbers of

participants at little or no cost.” —Jessica Ladd

Johns Hopkins Public Health / Technology 2012 37 “What kind of biomedical scientist leaves the bench and goes around scrounging up funding and planning factories? But I actually see this as a continuation of my life’s work.” —Eddy Agbo

continued from page 33 the ACG venture under the Hopkins roof tech transfer office and began to secure their signed the pledge—but many others have rather than simply selling it to an external intellectual property. The process was a not. company. “Sometimes academics start a minor headache, he says, but his problem In response, Blakeslee says: “Hopkins is company or sell their patent,” he says, “but was solved. Whenever rogue versions of fully committed to the ideals of assuring that then that company is gobbled up seven times Guided Care emerge, the University’s tech essential medicines are widely available.” over and the project all but disappears.” By transfer office sends a cease-and-desist letter. Across town at the University of keeping ACG in-house, Weiner says, his At the same time, Boult has insisted on Maryland Biopark, Eddy Agbo, PhD, DVM, team has been able to maintain the concept’s keeping the licensing fees low. (Depending reflects on his latest venture in business and quality through nine or 10 iterations. on how many Guided Care nurses are life. A Nigerian-born biomedical researcher Quality control has also become crucial employed, health care systems pay between who was a research fellow at Johns Hopkins to Charles E. Boult, MD, MPH, MBA, a $1,000 and $50,000 for a three-year license.) School of Medicine, Agbo leads Fyodor professor of Health Policy and Management, “This model was developed with taxpayer (the small firm that is developing Sullivan’s who helped to develop Guided Care, a health money, and I feel an obligation to make it urine-based malaria diagnostic). care delivery model aimed at improving available to American taxpayers,” Boult says. “Ten years ago, this is something I never services for older adults with multiple “If we’re licensing it in the United States, would have imagined myself doing,” says chronic illnesses. In the Guided Care system, price should not be a barrier.” Agbo. “What kind of biomedical scientist a single health care worker—typically a Some activists at the Bloomberg School leaves the bench and goes around scrounging nurse—collaborates with several physicians carry that sentiment further: They believe up funding and planning factories? But I to coordinate each patient’s care, ensuring price shouldn’t be a barrier to Hopkins- actually see this as a continuation of my life’s that their needs are met and that various generated innovations anywhere in the work. The only difference is that now, there’s providers are not duplicating care or working world. Kaci Hickox, who completed an MPH a very targeted goal. We’re trying to bring at cross-purposes. A randomized trial found in December, has been a member of the some products to market and bring some that the system improved the quality of Hopkins chapter of the University Alliance tangible change to society.” Agbo hopes patients’ care and tended to reduce the use of for Essential Medicines, an international that someday these urine-based malarial expensive services. campaign to ensure that medicines and diagnostics could be packaged together with For the first two years of the model’s medical devices are accessible in the small doses of medication, so that families existence, Boult and his colleagues simply developing world. “When I worked in could diagnose themselves at home and released it into the public domain, with no Burma with Doctors Without Borders, I begin treatment promptly. intention of patenting, trademarking or saw up close how important it is for people It has been a long road: Sullivan and licensing it. Then he began to hear from to have access to HIV medications,” Hickox his colleagues developed their diagnostic federal agencies that other people around the says. concept nearly a decade ago. “One thing country were claiming to use “Guided Care” For the near term, the Hopkins I’ve learned is that you need to be patient,” in their grant applications—but drastically chapter’s goal is to persuade the University says Sullivan. For now, he is doing what he watered-down versions of Boult’s original to sign on to the Statement of Principles and knows best and sticking to his Hopkins lab. model. “They were using ratios of one nurse Strategies for the Equitable Dissemination Among other things, he and his colleagues to 500 patients, whereas the Guided Care of Medical Technologies, which was are combing through a huge library of drugs model calls for ratios of 1 to 55,” Boult developed by the Association of University whose safety in humans has already been says. “They were basically going to erode Technology Managers. Universities that established, trying to learn if they might the system’s credibility … it was a far less sign the statement pledge to develop licenses have effectiveness against rare diseases of the intensive intervention than what had been that “align incentives among all stakeholders developing world. developed and tested.” to promote broad access to health-related If that research bears fruit, he will file So in early 2009, Boult and his technologies in developing countries.” Duke, a patent application—and steel himself for colleagues filed a disclosure with the Hopkins Harvard, Yale and 23 other institutions have another decade of patience.

38 Johns Hopkins Public Health / Technology 2012 After Words The Human Touch There is a boy in Philadelphia who, despite his It’s easy to get carried away with nifty gizmos that offer solutions age and considerable physical challenges, can to our many problems. So, in addition to reporting on some stunning write two poems in French and one in English. applications of technology to health, we’ve spiced this issue with a He patiently scribes them in flowing calligraphy. healthy dollop of skepticism. (Technology, after all, has given us He also has a repertoire of four drawings—one nuclear weapons and spam.) Environmental health expert Ellen of a Chinese temple. Silbergeld, for example, warns us about rushing to use nanoparticles The boy is 2 feet tall and 200 years old. without first investigating potential health risks. And when we sought He is an automaton designed by a Swiss watchmaker named Henri the perspectives of some public health legends (Edyth Schoenrich, Maillardet. An ineffably complex series of levers, rotating brass D.A. Henderson and Al Sommer), a surprising theme emerged. In disks and wind-up motors choreographed by Maillardet allow the our haste to invest in wondrous technologies, they point out, it’s too boy to write and draw so precisely, as a recent New York Times story easy to forget human beings. People know the right questions to ask, explained. people find meaning in raw data and people still can communicate The boy, who inspired the movie Hugo and “lives” in the with a simple touch. Franklin Institute in Philadelphia, must have wowed the early 19th- Technology alone will take us only so far. We also need to invest century crowds who came to see him. Even by today’s standards in in people who imagine, create, teach, research, collaborate, evaluate technical innovation, it’s impressive to watch a mechanical boy write and care. We have the inside track, after all, on what it means to be poems in elegant longhand. Like the amazed automaton-watchers, a human being full of messy complexities. And, with technology’s we are enthralled by the technology that our digital age produces help, we can best help others find their way to health. with ever-increasing speed. Public health is not exempt. In this special issue, we describe some ways that high- and low-tech tools are revolutionizing public health: the possibilities of mHealth, the power of big data, the marriage of geographic positioning systems with epidemiology, the Brian W. Simpson sheet-metal pill counter that simplifies field research, the global reach Editor, Johns Hopkins Public Health of Web-based education… [email protected]

Letters to the Editor Soliciting Solutions only viable ones? International Health needs to As a physician experienced both in urban tertiary This article [“Tough Oil,” Fall 2011] provides an understand environmental health. care and rural primary healthcare in Nigeria, and excellent overview of how peak oil impacts public Martin, France now taking a Master’s degree in International health. However, I am surprised and disappointed via Magazine Comments Healthcare Management, Economics and Policy, that there is little or no mention of how the field of I find the story of the late Dr. Carl Taylor very public health should respond. As a master’s student Three Thumbs Up for Taylor Video inspiring. I cannot think of a better time for the at JHSPH working in Bangladesh, and part of the I took as many courses from Dr. Taylor as I could world to come to the recognition of his genius. Social Science and Sustainability Working Group, [Online Extras, “Origins of International Health,” Luther-King, Milan, Italy I see environmental vulnerabilities impacting Fall 2011]. He has had a huge influence on my life. via Magazine Comments population health in real time. We scientists, Thank you for presenting him on video. trained to protect health and save lives, can’t stop Cheryl Polansky Baraty The 7 Billion at pointing out the problem without suggesting Milwaukee, Wisconsin It is true that all countries, especially developing some adaptive responses. nations, need to focus on educating girls to Kristyna Solawetz I vividly recall Dr. Taylor sharing his thoughts on prevent early pregnancies and early marriages, Dhaka, Bangladesh our trip to the villages of Himalayas, India. He engaging more males in family planning methods made it clear to the village headman that in order and addressing cultural issues that favor having The Environment of International Health to progress, it is very important to empower the numbers of children among some tribes. [“Global It is surprising that the field of International woman. His gentle but persuasive way made it Health Snapshot/Population,” Fall 2011] Health makes virtually no mention of water, possible for many to catch his vision. Eliudi Eliakimu sanitation and hygiene [“International Health at Dinesh Taylor Dar es Salaam, Tanzania Philadelphia, Pennsylvania 50,” Fall 2011]. Intrigued? Irate? Impressed? Send us Is the ultimate message of IH that prevention your comments: [email protected]. is a waste of time and curative approaches are the Johns HopkinsJohns Hopkins Public HealthPublic Health/ Technology / Fall 2010 2012 39 39 the last pixel

The Fire Inside Eight-year-old Aqila courts lung disease as she lights a brush fire in her family’s kitchen stove in the Afghan village of Ragshad. Indoor cooking using biomass (plant materials or animal waste) has been implicated in increasing environ- mental lung diseases among rural peo- ple in developing countries. Innovative cookstove technologies could improve the health of the more than 3 billion people exposed to high levels of indoor air pollution. “Since exposure occurs primarily during cooking, women and their children are at the highest risk,” says Shyam Biswal, PhD, Environmental Health Sciences professor and director of a new Indo-U.S. Center for Environ- mental Lung Diseases.

Photo: Shehzad Noorani

For this Ugandan girl and millions of others in developing countries who are HIV-positive, lifesaving highly active antiretroviral (HAART) drugs arrived relatively recently. By contrast, many in wealthy countries have been taking HAART as far back as 1996 and now are growing old with HIV. (See page 24.)

Photo: Shehzad Noorani 40 Johns Hopkins Public Health / Technology 2012 Health International Advisory Board Honorary Committee Robert J. Abernethy** William Flumenbaum Roger C. Lipitz*+ Markus Altwegg President Senior Vice President Managing Member Chairman of the American Standard Capital Guardian Trust Company Ocean Assets, LLC Board of Directors Development Company Siegfried Holding AG Her mHealth is on the Line Howard E. Friedman Morris W. Offit** Ashok Agarwal Managing Partner Chairman Clateo Castellini Trustee Lanx Capital, LLC Offit Capital Advisors, LLC Former Chairman and CEO Indian Institute of Health BD (Becton, Dickinson and Management Research Douglass B. Given Karl P. Ronn Company) Partner Managing Director Lenox D. Baker, Jr.* Bay City Capital Innovation Portfolio Partners J.P. Garnier Mid-Atlantic Cardiothoracic Former CEO Surgeons, Ltd. Dean Goodermote Ira M. Rutkow GlaxoSmithKline Former Chairman and CEO Kenneth R. Banks Double-Take Software Beth Schnieders William H. Gates, Sr. President Huntington Sheldon** Co-Chairman Banks Contracting Company, Inc. Donald A. Henderson° Bill & Melinda Gates Foundation Dean Emeritus Michael J. Silver Ernest A. Bates** Johns Hopkins Bloomberg Partner Raymond Gilmartin Chairman and CEO School of Public Health Hogan Lovells US LLP Former Chairman, President American Shared Hospital and CEO Services, Inc. Margaret Conn Himelfarb Alfred Sommer° Merck & Co., Inc. Dean Emeritus Joseph A. Boystak Frank Hurley* Barbara A. Mikulski Chief Scientific Officer Johns Hopkins Bloomberg President and CEO School of Public Health U.S. Senator Brightwaters Capital, LLC and Co-Founder Maryland RRD International, LLC Shale D. Stiller** Michael G. Bronfein HM Queen Noor Christopher I.M. Jones Partner Managing Partner DLA Piper of Jordan Sterling Partners Ambassador James A. Joseph Nafis Sadik Professor and Director, United Dwight S. Taylor C. Sylvia Brown President Special Advisor to the States-Southern Africa Center for United Nations Secretary-General George L. Bunting, Jr.** Leadership and Public Values COPT Development & President Duke University Construction, LLC Yohei Sasakawa Bunting Management Group Adena W. Testa* Chairman Michael J. Klag The Nippon Foundation Constance Caplan** Dean Johns Hopkins Bloomberg Feike Sijbesma Paul J. Diaz School of Public Health CEO President and CEO Royal DSM NV Kindred Healthcare, Inc. Harry M. Jansen Kraemer, Jr. Executive Partner HRH Princess Maha Catharine C. Dorrier Madison Dearborn Chakri Sirindhorn Senior Technical Advisor Clinical Professor of Manage- of Thailand RRD International, LLC ment and Strategy, Northwestern Manuel Dupkin II** University *University Trustee Kellogg School of Management **University Emeritus/a Trustee Manfred Eggersdorfer °Honorary Member Carolyn P. Langfitt Senior Vice President + Chair of the Health DSM Nutritional Products Advisory Board Connect with the Global mHealth Initiative: www.jhumHealth.org

Everybody’s talking about Members of the Johns Hopkins University Global Magazine Team mHealth (mobile health), the mHealth Initiative (GmI) are advancing this new field Managing Editor Consulting Editor Associate Dean, External Affairs Johns Hopkins Bloomberg through early-stage technology innovation, rigorous Stacey dilorenzo Sue de Pasquale Joshua d. else School of Public Health Editor Staff Writer Director of Alumni Relations 615 N. wolfe Street, e2132 state-of-the-art strategy that’s research and the monitoring and evaluation of potential Baltimore, Md. 21205 high-impact health system solutions, while training the Brian w. Simpson Jackie Powder Philippa Moore revolutionizing public health by Phone: 410-955-5194 public health leaders of tomorrow. Associate Editor Design and Production Maryalice Yakutchik Konrad crispino Fax: 410-614-2405 making a difference in resource- email: [email protected] Senior Art Director Online Magazine Team limited settings where disease JHU GmI’s success depends on collaborations between Robert ollinger david croft web: jhsph.edu faculty across the University as well as on support from Michael a. Smith magazine.jhsph.edu burden and mortality are high. you. We welcome you to explore the many exciting Spencer Greer Free Subscription activities in mHealth going on across the University and magazine.jhsph.edu/subscribe learn about opportunities to support students engaged Get connected: The Johns hopkins university does not discriminate on the basis of race, color, gender, religion, age, sexual orientation, national or ethnic origin, dis- puBlicaTions Mail agreeMenT no. 41452530 in global mHealth research. www.jhumHealth.org ability, marital status or veteran status in any student program or activity administered by the university, or with regard to admission or employment. reTurn unDeliVeraBle canaDian aDDresses To Defense Department policies regarding sexual orientation in roTc programs conflict with this university policy. The university continues its roTc po BoX 503 program, but encourages a change in the Defense Department policy. rpo WesT BeaVer creek Questions regarding Title Vi, Title iX, and section 504 should be referred to the office of institutional equity, garland hall 130, Telephone: (410) 516- richMonD hill on l4B 4r6 8075, (TTY): (410) 516-6225. mhealth revolution • Big data, Big problem • tech transfer • Gadgets 4 health

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worth an extra look Nostalgic about calculating statistical probabilities on a slide rule. Eager to immerse an avatar surgeon in a virtual operating room. More than two dozen JHSPH alumni share their visions from the nexus of technology and public health in personal essays and photos. 50% Total Recycled Fiber magazine.jhsph.edu/techessays 20% Post-consumer Fiber

next issue it takes a network colwell david

How do you protect the boys of Touba, Senegal and the rest of the country’s popu- lation from malaria? Defense may be the best offense against humanity’s perennial enemy. The Johns Hopkins Center for Communication Programs and its Net- Works project aim to cover every sleeping space in the country with a mosquito net. Don’t Blink Technology’s lightspeed transformation of public health