Evaluating Current Public Health Practices in Villa El Salvador, Peru

Catalyst Volume 6

Abstract

Initiatives in public health have gained more popularity in recent years due to their simplicity and effectiveness. The success rates of such projects depend heavily upon their adaptability to the community’s needs, which in turn depend on pre-existing health data. The purpose of this study was to formally quantify and evaluate the current health practices in Villa El Salvador, Peru. The study formally verifies the need for clean water and preventative care education public health projects to address the growing health concerns in this specific community.

Introduction

Public health is defined as the science and art of preventing disease, prolonging life, and promoting health and well-being through organized community effort for the sanitation of the environment.¹ While such practices can enhance health in many settings, recently the trend has been to study and apply these principles to smaller communities. The motivation in targeting smaller communities lies in enacting grassroots health movements, spreading awareness of basic, yet essential health measures to a specific population. By tailoring these efforts, specific areas of health salient to the community are emphasized. While their level of success has varied, the inception of such projects has drawn awareness to the field of public health and basic health issues worldwide.

Successful and sustainable public health programs must be well adapted to the unique needs of their target community.² However, a component frequently overlooked is feedback from the community. Prior data describing community needs is essential when planning and piloting person-specific initiatives. Despite the correlation between the availability of current public health data and the success of public health initiatives, many small communities do not have the resources to enact widespread studies.

One such example is Villa El Salvador, a community of over 400,000 people in Lima, Peru.³ Founded on May 11, 1971 by a group of nearly 200 families, Villa El Salvador continues to remain as a “self-managed” community with both commercial and residential areas. After many organized protests, most of Villa El Salvador today now has electricity and water. However, poverty is a major issue in the community. An estimated 21.9% and 0.8% of the population falls into the categories of “poverty” and “extreme poverty” respectively, according to official Peruvian standards: these levels correspond to a family of four members living with $2/$1 daily, respectively.⁴

As a result, nonessential “luxuries” are often spared from the budget. Healthcare is often one such example. Most people cannot afford the medical services offered by the four major hospitals in the area.⁵ In response, smaller community health clinics including “San Martín de Porres Centro de Salud” have attempted to bridge the socioeconomic gap of attaining quality care. People attend these clinics to receive affordable, and sometimes even free, medical attention. While such establishments have continued to serve the people of Villa El Salvador, many are unable to periodically seek medical assistance. A heightened awareness of preventative care is severely lacking in the community, which can be addressed through targeted public health initiatives. Unfortunately, accurate and current health data for Villa El Salvador does not exist.

The purpose of this study is to formally evaluate the health practices of people in Villa El Salvador. Through this initiative, I aim to provide basic, yet meaningful data through the use of surveys for future campaigns in public health and preventative care. Through the information attained from this study, I aspire to provide insight into valid points of focus for the overall improvement in community health. By attaining specific, quantifiable data firsthand from the citizens, future public health projects will be able to mold their initiatives based off of specific community needs and therefore enact consequential and sustainable change.

Experimental

I designed a public health survey to study potential factors contributing to the health issues in Villa El Salvador. After researching prior literature and assessing community needs I targeted several factors: exercise, nutrition, sources and amount of water, hindrances for medical attention, time spent washing hands, and vaccinations. The final version of the survey featured seven questions targeting the areas mentioned. All seven questions featured multiple-choice responses to minimize time spent completing the survey and maximize regularity to yield meaningful results.

I first distributed surveys on June 19, 2012 during the San Martin de Porres Centro de Salud Health Campaign, which offered free healthcare at a local park in Villa El Salvador. This event was specifically chosen as a starting point of the study to collect an accurate sample of the population, minimizing socioeconomic inequalities. The surveys were then distributed in San Martin de Porres Centro de Salud in the mornings for the following week to collect more responses. Respondents were randomly chosen as they waited for medical services offered at the center. After giving informed consent, subjects were told to mark the best response for each question with the exception of the final vaccine question, where all pertinent answer choices were selected.

A total of 98 responses were attained in the two-week span. Thirty-six respondents were between the ages of 15-30, 53 from the ages of 31-50, six from the ages of 51-65, and three from 65 years and above. Since most of the patients of the clinic are females, 19.4% of males were surveyed. Besides the differences in gender, the sample population accurately reflects the demographics of Villa El Salvador.

Results

From the population sampled, 19.4% of participants reported consuming more than two servings of fruits and vegetables combined (Figure 1). The majority of the population reported consuming 1/2 or one serving (35.7% for both categories, respectively). Furthermore, only 12.5% of the population above the age of 50 reported consuming more than one serving of fruits and vegetables daily. Finally, two percent of the respondents reported consuming no fruits and vegetables.

Forty percent of the sample population reported consuming eight or more glasses of liquid daily (Figure 2). According to the results attained, 33.7% of the people consume less than two servings of liquid. The most common source of water for the population sampled was tap by an overwhelming percentage (53%, Figure 3). Both bottle and cistern options yielded 23.5% respectively.

Cost served as the biggest obstacle to periodically visit a doctor for 38.8% of survey participants (Figure 4). However, many 17.3% of the respondents (17.3%) reported distance from a medical facility as the most significant hindrance, while fear for seeing a medical professional was the next most selected response (11.2%). It is important to note that when presented with this question, 9.2% of the respondents reported “trabajo” or work as their answer even though it was not an answer choice.

The majority of the population (52%) reported spending 10 seconds or less washing their hands per attempt, while the second most common response (30.6%) reported was up to twenty seconds (Figure 5). Only 11.2% reported spending up to 30 seconds per attempt, while more than 30 seconds was the least common response (6.2%).

Discussion

A majority of the respondents reported consuming either ½ or 1 serving of fruits and vegetables together. According to the United States Department of Agriculture, individuals should consume at least five to seven daily servings of fruits and vegetables combined, depending on factors such as gender and age.⁶ This survey finding contrasts the steady decrease in malnutrition Peru experienced nationwide from 2005-2010 and most significantly in small, semi-urban areas such as Villa El Salvador.⁷ It is clear that the majority of Peruvians are getting something to eat, at least from the perspective of the Peruvian government.

The issue then arises of what is being consumed. According to the World Health Organization, Peru is expected to have about two million people with diabetes by 2030, triple of what it had in 2010.⁸ The increasing prevalence of heart disease has also been documented⁹ An unhealthy diet may point to the rise in noncommunicable diseases in this community. The data I acquired from the study points to the reduced consumption of fruits and vegetables could serve as major reason for why this disturbing trend is present.

The third question on the survey originally asked for asked for a respondent’s daily water consumption, but much of the Peruvian diet involves juice, soup, and other milk-based products that contain water. Hence, to get an accurate tabulation of water intake, I included juice and milk in the survey. Experts recommend drinking seven to eight glasses of water daily. The majority of people consume two to five glasses of water-based liquids according to the data I attained. In addition, most people cited “tap” as their major source of water. While initiatives promoting the healthy benefits of drinking water would prove to be helpful by emphasizing the importance of increased water consumption daily, the issue of attaining clean water sources must also be addressed.

The principle of preventative care is often deemphasized in many small communities worldwide, regardless of socioeconomic status. For a community such as Villa El Salvador, the importance of this concept multiplies. Realistically, the majority of people in Villa El Salvador cannot financially afford to see a specialized healthcare professional. Hence, regular checkups with a physician to help monitor physical well-being serve as paramount health checkpoints for patients. The real issue is when even these checkups become too expensive. As discussed in the results section, this is unfortunately the case; the majority of people reported cost as their biggest obstacle to seeing the doctor periodically. Keeping in mind that they surveyed population is from a clinic that already provides relatively inexpensive medical services compared to those provided “on the street”, or outside of the clinic, the results are quite discouraging.

The health clinic cannot do much to reduce the cost; most of the employees are volunteers that work for little or no money, making layoffs and reductions in salaries imprudent. Paperwork and other administrative tasks could be streamlined via computers to help improve efficiency, but such a change would not occur overnight. Furthermore, there is always the issue of funds. While places such as the health clinic could redistribute their prices towards their more popular revenue streams and incentivize those that come often, simple public health outreach solutions could prove to be quite effective. Demonstrations in the community focusing on self-check and self-evaluations would increase accountability while upholding the idea of preventative care. In addition, other healthcare professionals besides doctors could make periodic home visits to “high-risk” patients as part of the care they receive from the Centro de Salud. While the latter would require more human resources, it could potentially give students from nearby universities the opportunity to engage in basic physical examination practices. This would be a unique outreach initiative the Centro de Salud could pilot to reduce its own patient inflow.

Hand washing is one of the most popular public health topics in terms of universality and applicability.¹⁰ Preventing the spread of infections and illnesses is key for a preventative care approach. The Centers of Disease Control and Prevention recommends washing hands for at least 20 seconds, and up to 40 seconds depending on the drying mechanism. Over 80% of the sample population reported washing hands for less than 20 seconds. This helps to explain the spread of sicknesses and parasites in Villa El Salvador. The frequency of hand washing could also play a role, though this was not evaluated in this study. There have been initiatives involving hand washing in Villa El Salvador (Centro de Salud has one once a year), but these projects are targeted towards children. While it is important for children to learn the proper technique, it is just as important (if not more) for adults to learn as well. The adults usually prepare the food, the latter serving as a major source of illness. Furthermore, they serve as role models for their children; if they engage in proper hand washing, their children are more likely to as well¹¹ In essence, while the community has shown its support for hand washing, the older generation must take the issue more seriously.

While access to care has improved significantly in Villa El Salvador with the emergence of smaller clinics, there is still room for much improvement for the overall health of the community. The aim of this study was to quantify the current health practices of the people of Villa El Salvador to provide community-specific data. The effectiveness of follow-up studies would increase if more people were surveyed in different areas of Villa El Salvador, particularly people over the age of 50 and males. Furthermore, delving into one specific topic, such as nutrition and hand washing, would provide more depth for the respective facet of health than this study presented. Regardless, the study was successfully completed and conveys tangible information concerning the health practices the target community. It is the hope that the investigation served as a solid starting point for prospective public health initiatives in Villa El Salvador and Peru at large.

Acknowledgements

I would like to thank Enrique Bossio Montellanos, Director of Cross Cultural Solutions in Lima, Peru and Carol Soto, Head Coordinator of the San Martin de Porres Centro de Salud and the entire San Martin de Porres Centro de Salud staff for all of their support. Also, I would like to thank The Rice University Loewenstern Fellowship, and the Rice University Community Involvement Center for funding my trip. Finally, a special thanks to Sarah Hodgkinson and Mac Griswold for all of their guidance.

References

1. Clinton County Health Department website. http://www.clintoncounty      gov.com/departments/health/aboutus.html (Accessed Jul. 7, 2012).
2. Trust for America’s Health: Examples of Successful Community-Based Public Health Interventions (State-by-State). http://www.cahpf.org/GoDocUserFiles/601.TFAH_Examplesbystate1009.pdf (Accessed Jul. 7, 2012).
3. Participant Handbook: Lima, Peru. New Rochelle: Cross Cultural Solutions, 2012.
4. Perspectivas Socioeconómicas para Villa El Salvador, Observatorio Socio       Económico Laboral, Lima Sur, Lima, Peru, Jul. 2009.
5. Portal de la Muncipalidad de Villa El Salvador. http://www.munives.gob.pe/index.php (Accessed Jul. 7, 2012).
6. Vegetables: Choose My Plate. USDA. http://www.choosemyplate.gov/food-groups/vegetables.html (Accessed Jul. 22, 2012).
7. Acosta, A. M. Working Papers at IDS. 2011, 367.
8. WHO Country and Regional Data on Diabetes. http://www.who.int/diabetes/facts/world_figures/en/ (Accessed Jul. 7, 2012).
9. Fraser, B. The Lancet. 2006, 367, 2049-50.
10. Vessel Sanitation Program. Centers for Disease Control and Prevention, http://www.cdc.gov/nceh/vsp/cruiselines/hand_hygiene_general.htm (Accessed Jul. 20, 2012).
11. Stephens, K. Parenting Exchange. 2004. 19, 1-2.

The Ghostly Haunting of Limb Lost

Catalyst Volume 6

The brain’s neural pathways are like a city’s infrastructure. Once the routes and support structures are firmly in place, it is difficult to remove them to construct a new route. This helps explain amputees’ reports of phantom limbs and the painful sensations they radiate. How much of the pain is real and how much is psychological has yet to be determined, but treatments address both sources.

The phantom limb was first documented by Dr. S. Weir Mitchell after observations with Civil War amputees.¹ It is a fascinating enigma that has appeared in literature: Captain Ahab’s missing leg in Herman Melville’s Moby Dick, Captain Hook’s lost hand in J. M. Barrie’s Peter Pan, and Long John Silver’s absent leg in Robert Louis Stevenson’s Treasure Island. Why does the brain yearn for the absent limb so much that fantasizes emerge? The answer may reside in ascending sensory pathways from the peripheral nervous system. Once established, the brain finds it difficult to change expected input from these neural pathways.

During infancy, the brain examines the body to understand itself spatially and topologically, building upon this image from the senses throughout life. Interestingly, those who undergo amputations in infancy experience neither the sensation nor the pain of phantom limbs because the missing limbs had not been there long enough to establish a solid pathway.² However, for those that retain their limbs, the development of the senses in early childhood is faster than at any other point. Changing body image at an advanced age is too drastic and demanding for the brain. One contributing factor is the elderly’s diminished brain size. On average, the brain loses 5-10% of its weight between the ages of 20 and 90, with a higher proportion lost with increasing age.³ In addition, the grooves on the surface widen while the swellings and depressions become smaller. Deep grooves in the brain indicate increased surface area for synapses, the connecting space between neurons, to form. Moreover, the formation of neurofibriallary tangles, decayed portions of the dendrites receiving the sensory information from other neurons, impede information transmission.³ Finally, abnormally hard clusters of damaged or dying neurons, known as “senile plaques,” emerge and accumulate. Neurons are not replaced when they die, so as one gets older, one literally has less to work with. Thus, with decreased plasticity, the body image becomes fixed with one’s brain regressing to the stage formed in earlier years.

This pathway, however, is not indestructible because amputees report that phantom limb sensations decrease with time. Due to the plasticity of the brain, the brain takes time to “rewire” itself by abolishing old connections in favor of new, useful connections elsewhere. For example, after an amputation, patients often describe the entire appendages, with the most awareness at the distal (end) portions of the limb (i.e. fingers and toes compared with the forearms and calves, respectively).^4,5 This is because distal anatomical structures contain the greatest amount of sensory nerves and command a larger portion of the somatosensory cortex. In time, however, the phantom limb perception shrinks until it disappears into the stump.^6-8

These concepts are visualized by the sensory homunculus (Figure 1), where the size of the appendage reflects the sensitivity and thus concentration of neurons there. Thus, infants use their hands, lips, and tongue frequency in order to shape and understand their world. Since more neurons are dedicated to these extremities, it takes longer to rewire the corresponding pathways. Instead, the brain completely rewires the proximal portions of the limb so that the phantom sensation in the length of the appendage seems to shrink faster than the distal portions.

When subjects encounter identical stimuli, the sensation experienced is usually comparable between them. For example, when we touch a pot on a lit stove, we feel burning and not tickling. With amputees, this precedence doesn’t hold. Each amputee’s phantom limb is unique: it can feel authentic and present but fake, painful, or painless. There is little to suggest that patients are lying about the pain, yet it is well known that the brain frequently tricks the body.

Psychological pain can also manifest itself as physical pain. Amputee patients who feared an inability to recover were hostile to and jealous of other members of society, consequently experiencing pain in the phantom limb with these heightened emotions. However, once these patients underwent therapy and obtained a positive attitude, the pain faded.²

Traditional approaches to alleviating pain, such as injection of nerve blocks, myoelectric prosthesis, and cordotomy, have been more procedural.^9,10 A nerve block is an injection of a local anesthetic to stop transmission of a message along the nerve so that the brain never receives the pain signal from the stump. A myoelectric prosthesis is an artificial limb, which uses electronic sensors to translate muscle and nerve activity into the intended movement. While the brain is manipulated into replacing the phantom limb with an artifical one, prosthetics often do not alleviate phantom pain. One theory for this is that since visual sensory information contradicts tactile sensory information, the brain refuses to be tricked. Cordotomy is the most invasive of the procedures listed because it requires a neurosurgeon to disable certain rising tracts in the spinal cord. Thus, it is only employed in severe cancer- or trauma-related cases. Despite the variety of approaches, the results are slightly effective at best.⁹

Recently, researchers have turned to mind-body therapies to relieve chronic phantom pain, yielding tentatively successful results. A review by Dr. Vera Moura of the Department of Physical Medicine and Rehabilitation on Integrative Medicine at University of North Carolina Hospitals tied together studies that used hypnosis, guided imagery, and biofeedback (such as visual mirror exercises).¹¹ These non-invasive mind-body alternatives consider the psychological aspect of pain. Hypnosis has been found to reduce postsurgical pain, so researchers attempted to transfer its effects to amputees.¹² In several studies, arm amputees varying in sex and age saw a reduction in pain frequency and intensity after attending hypnosis sessions.^13-15 These studies indicate that mind can truly triumph over matter, but caution must be taken because trial sizes were small and hypnosis is a murky field. Therefore, more research is necessary before any definite conclusions can be made.

Guided imagery is another mind-body approach that extends beyond the typical denotation of our senses, and it utilizes more neural pathways than normal to create a memorable, mental image. This treatment combines interactions between patient and therapist and patient and body image.⁹ In Zuckweiler’s experiment, 14 patients with diverse backgrounds had 5 to 15 imagery sessions, during which they attempted to reprogram their minds to accept the new body form.¹⁶ Patients were taught Zuckweiler Image Imprinting (ZIP), which involves taking an object and storing it as a mental image. They were then asked to compare their phantom limb pain to the object in their mental image and switch the sensations associated with the two objects. Over time, as the phantom sensation decreased by using different mental images, the discrepancy between the new body image without the limb and old body image with the limb was reconciled. Zuckweiler’s study showed successful pain intensity reduction within only six months. ZIP forces patients’ minds to accept their new bodies. Since his method encompasses visual, auditory, and kinesthetic learning, customized treatment allows patients to comprehend and create new connections.

The final mind-body approach is biofeedback, of which there are two popular kinds. Thermal biofeedback teaches patients to increase the peripheral skin temperature at the stump.¹⁷ This seems unlikely, since body temperature is an autonomic function along with vital processes such as heart rate and breathing. In some instances, however, an individual can have partial, conscious control. Although the hypothalamus is responsible for standard body temperature of 37.0°C (98.6°F), it is possible for consciousness to affect peripheral skin temperature. Successful patients begin to link skin temperature with pain.¹⁸ Physiologically, the regulation of one function often results in the coupling of the response to a stimulus. For example, thermal biofeedback was coupled with breathing relaxation techniques, which caused the temperature of the stump to increase and relax, decreasing the pain and thus increasing the patient’s ability to contend with remaining pain. It is unknown, however, if thermal biofeedback is an effective treatment for all phantom pain; like most areas of science and medicine, more research is needed.

The second biofeedback type, visual mirror feedback (VMF), uses a box with mirrors to fool the brain. A rectangular box with no top and two holes for each arm (or leg) is set in front of a patient. In the middle of the box is a one-sided mirror septum facing the limb that is intact (Figure 2). Patients are thus presented with the illusion that both appendages are whole. Dr. Ramachandran, the inventor of this technique, conducted a study in which 10 amputee patients were treated with VMF in six sessions of 5 to 15 minutes a day for several weeks.¹⁹ Every patient had a positive reaction that included reduced pain, pain intensity, mobility restriction, and spasms. Once again, there was a conscious effort to train the brain, so patients were able to redirect unpleasant sensations. This therapy is almost opposite to ZIP since the patient is picturing the limb as whole to alleviate the pain rather than ignoring it. VMF treatment is one of the most common due to its success amongst many different amputees.

A theory behind mind-body approaches’ emerging successes is the conscious effort patients put forth to overcome pain. In previously mentioned traditional procedural methods, patients passively receive a certain treatment and hope to obtain a positive result. In some cases, there are even negative side effects; for example, a nerve block may lead to rashes, itching, and an abnormal rise in blood sugar. Invasive procedural approaches like the cordotomy can only be attempted once. Mind-body approaches can be practiced, optimized over time, and are much safer than procedural methods.

Understanding of phantom pain has progressed significantly since its initial documentation during the Civil War. Traditional procedural methods to treat it have been developed, but recently, the psychological aspect of pain and sensation has been addressed in mind-body methods. Unfortunately, neither approach has achieved complete success, partially because of the individualistic nature of phantom limbs and the associated pain. The neurological explanations behind both phenomena are relatively unknown, but it is agreed the ghostly perceptions are a mixture of psychological and real sensations. Perhaps the most effective treatments are those that address both.

References

1. Lehrer, J. Proust Was a Neuroscientist; Houghton Mifflin: Boston, 2008
2. Kolb, L. C. The Painful Phantom, Psychology, Physiology, and Treatment; Charles C. Thomas: Springfield, Illinois, USA, 1954.
3. Guttman, M. The Aging Brain. USC Health Magazine http://www.usc.edu/hsc/info/pr/hmm/01spring/brain.html (Accessed Jan. 22, 2013).
4. Newton, A. Somatosensory Map. http://www.alinenewton.com/neuroscience.htm (Accessed Jan. 18, 2013).
5. Pain and Touch, Handbook of Perception and Cognition. 2nd ed. Lawrence Kruger, Ed.; Academic: San Diego. CA, 1996.
6. Jensen, T. S. Pain. 1985, 21, 267-78.
7. Hunter, J. P. Neuroscience. 2008, 156, 939-49.
8. Desmond, D. M. Int. J. Rehabil. Res. 2010, 33, 279-82
9. Lotze, M. Nat. Neurosci. 1992, 2, 501-2.
10. Pool, J. L. Ann. Surg. 1946, 124, 386-91.
11. Moura, V. L. Am. J. Phys. Med. Rehabil. 2012, 8, 701-14.
12. Black, L. M. J. Fam. Pract. 2009, 58, 155-8.
13. Oakley, D. A. Clin. Rehabil. 2002, 18, 84-92.
14. Bamford, C. Contemp. Hypn. 2006, 23, 115-26.
15. Rickard, J. A. Ph.D. Dissertation, Washington State University, Pullman, WA, 2004.
16. Zuckweiler, R. JPO. 2005, 17, 113-8.
17. Sherman, R. A. Am. J. Phys. Med. 1986, 65, 281-97.
18. Shaffer, F.; Moss, D. Textbook of Complementary and Alternative Medicine; 2nd Ed. Informa Healthcare: London, UK, 2006.
19. Ramachandran, V. S. Brain. 2009, 132, 1693-710.
20. Trivialperusal. Sensory Homunculus. http://trivialperusal.files.wordpress.com/2011/04/sensory_homunculus.jpg (Accessed Jan. 18,         2013).
21. Phelan, L. Mirror Box Therapy. http://farm3.static.flickr.com/2567/3927573088_aa057fcc61.jpg (Accessed Jan. 18, 2013).

The Bridge from Discovery to Care: Translational Biomedical Research

Catalyst Volume 6

Since the 1970s, both the number of molecular biology PhD scientists and the amount of biomedical research have grown rapidly, greatly expanding our knowledge of the cell.¹ This explosion has led to incredible scientific achievements, including development of the polymerase chain reaction in the 1980s and completion of the Human Genome Project in 2003.^2-4 The focus of research has shifted from single genes to all genes, from single proteins to all proteins. Neither scientists nor pharmaceutical companies, however, have been able to keep pace with the sheer quantity and complexity of modern biomedical research. Additionally, while the majority of medical researchers were once physician-scientists in the 1950s and 1960s, they are predominantly PhDs today.¹ Questions of basic and clinical research, once addressed side by side, are now separate.

The widening gap between scientific discovery and therapeutic impact is a result of these changes. In the United States, the dramatic increase in spending for pharmaceutical research and development has been offset by a disappointing decrease in therapeutic output (Figure 1). As this paradox becomes more apparent, translational research, which aims to convert laboratory findings into clinical successes, emerges as an increasingly important endeavor.^5,6

In 2006, the U.S. National Institutes of Health (NIH), the largest source of funding for medical research in the world, focused its attention on translational research by launching the Clinical and Translational Science Awards program.^7,8 However, implementing effective translational research is both time- and labor-intensive. According to Dr. Garret FitzGerald, Director of the Institute for Translational Medicine and Therapeutics at the University of Pennsylvania, challenges include a lack of human capital with translational skill sets, relevant information systems, and intellectual property incentives.⁹

During his leadership of the NIH from 2002 to 2008, Dr. Elias Zerhouni witnessed the consequences of clinicians lacking in training on the speed of scientific advancements for patient care.^10,11 Beyond the need for manpower, an open culture of communication between scientists and clinicians is necessary.

Drug development is a one-way process from benchside to bedside in which scientists identify drug targets, conduct clinical tests, and develop marketable drugs. Many argue, however, that the communication must run in the opposite direction, too; feedback from clinical trials and doctors is valuable because understanding their concerns allows researchers to improve drug development.¹² The third challenge derives from current institutional practices and regulations. An investigator’s publication record rather than their efforts to advance medicine determines success.¹³ Research funding is also granted on an individual basis, which does not promote the collaboration necessary for successful translational research. Lastly, the regulatory and patent processes governing drug development require much expertise and time to navigate, which offer little incentive for researchers to become involved.¹

To better integrate basic science with clinical science progress, countries such as the United States are building a new team of leaders in all aspects of clinical research: medicine, pharmacology, toxicology, intellectual property, manufacturing, and clinical trial design and regulation.¹³ Dr. Francis Collins, Director of the NIH since 2009, has called for a partnership between academia, government, private, and patient organizations to repurpose molecular compounds previously failing in their original use.^15,16 Historically, Collins referred excitedly to azidothymidine, a drug originally developed to treat cancer that later treated HIV/AIDS.¹⁴ Tremendous potential lies in applying scientific developments to other contexts, and the NIH has already drafted policy for this purpose.¹⁵

However, the growing support for translational research does not diminish the importance of basic scientific research, which poses the most interesting questions. Translational biomedical research creates an efficient environment for scientists to work at the interface of basic science and therapeutic development and to help fulfill the social contract between scientists and citizens. The full impact of translational initiatives has yet to be seen because the success of drug development, which can take up to 20 years, cannot be evaluated easily or quickly. For now, we can hope that integrating the work of scientists and clinicians will benefit both the patients, who await treatment, and the researchers, who only dream of seeing their discoveries transformed into new therapies for disease.

References

1. Butler, D. Nature. 2008, 453, 840–2.
2. Smithsonian Institution Archives. Smithsonian Videohistory Collection: The History of PCR (RU 9577). http://siarchives.si.edu/research/videohistory_catalog9577.html (Accessed Jan. 15, 2013).
3. National Center for Biotechnology Information (NCBI). Probe, Reagents for Functional Genomics: PCR. http://www.ncbi.nlm.nih.gov/projects/genome/probe/doc/TechPCR.shtml (Accessed Jan. 15, 2013).
4. Human Genome Project Information. About the Human Genome Project. http://www.ornl.gov/sci/techresources/Human_Genome/project/about.shtml (Accessed Jan. 15, 2013).
5. CTSI (Clinical and Translational Science Institute) at UCSF. Translational Medicine at UCSF: An Interview with Clay Johnston. http://ctsi.ucsf.edu/news/about-ctsi/translational-medicine-ucsf-interview-clay-johnston (Accessed Jan.15, 2013)
6. Helwick, C. Anticancer Drug Development Trends: Translational Medicine. American Health & Drug Benefits. http://www.ahdbonline.com/article/anticancer-drug-development-trends-translational-medicine (Accessed Jan. 15, 2013).
7. National Institutes of Health (NIH). About NIH. http://www.nih.gov/about/ (Accessed Jan. 15, 2013).
8. National Institutes of Health National Center for Advancing Translational Sciences (CTSA). About the CTSA Program. http://www.ncats.nih.gov/research/cts/ctsa/about/about.html (Accessed Jan. 15, 2013).
9. Pers. comm. Dr. Garret FitzGerald, Director of the Institute for Translational Medicine & Therapeutics at the University of Pennsylvania.
10. NIH News. Elias A. Zerhouni to End Tenure as Director of the National Institutes of Health. http://www.nih.gov/news/health/sep2008/od-24.htm (Accessed Jan. 15, 2013).
11. Wang, S.S. Sanofi’s Zerhouni on Translational Research: No Simple Solution. The Wall Street Journal. Health Blog 2011 http://blogs.wsj.com/health/2011/05/20/sanofis-zerhouni-on-translational-research-no-simple-solution/ (Accessed Jan. 15, 2013).
12. Ledford, H. Nature. 2008. 453, 843-5.
13. Nature. 2008, 543, 823.
14. TEDMED 2012. Francis Collins. http://youtu.be/spUoPC_TU_8 (Accessed Jan. 15, 2013).
15. Wang, S. Bridge the Gap Between Basic Research and Patient Care, NIH Head Urges. The Wall Street Journal Health Blog. http://blogs.wsj.com/health/2012/04/11/bridge-the-gap-between-basic      research-and-patient-care-nih-head-urges/ (Accessed Jan. 15, 2013).

Memory-Erasing Drugs: To Forget or Not to Forget?

Catalyst Volume 6

From recreational mind-altering drugs to pharmaceuticals that target neurotransmitter imbalances, a wide variety of chemical mechanisms can alter our thought processes and behaviors. While neural bases have long been known to play a role in shaping our thoughts and actions, recent advances in memory research have brought an evocative question to the forefront: what if we could change not only how we think and act, but also what we remember? The concept of a “forgetfulness” drug—an Eternal Sunshine-esque memory erasure treatment in pill form—is no longer a far-fetched fantasy. As researchers formulate a better understanding of how memories are formed and retrieved at the molecular level, the scientific community gains the ability to formulate targeted approaches to modifying the existence or emotional character of past memories. However, amid these developments, it is crucial that scientists, neuroethicists, and policymakers collaborate to evaluate the ethical costs and benefits of new therapies.

Currently, a number of drugs have shown utility in altering memory consolidation and retrieval. For example, propranolol, a beta-adrenergic blocker already approved by the FDA to treat hypertension, inhibits excess stress hormones released at the time of a psychologically traumatic event, the presence of which influences the memory consolidation of particularly emotional experiences.¹ When administered during this critical period shortly after trauma, propranolol has also been shown to prevent the formation of strong, intrusive memories of the event, as well as the associated fear and anxiety that contribute to the later development of posttraumatic stress disorder (PTSD). In fact, early studies from 2002 and 2003 have demonstrated that patients who received propranolol, first administered several hours after a traumatic event and continued over a seven- or ten-day regimen, experienced lower rates of PTSD than those who did not receive propranolol.^5,8

Memory-attenuating drugs can also be administered during subsequent periods of memory activation. More recently, advances in neuroscience have revealed that the process of retrieving memories is vastly different from the idea of simply activating consolidated memory traces from an archive. Instead, every time we recall a particular memory, it becomes unstable and must be re-consolidated in order to persist in the brain.⁷ Accordingly, a 2012 study conducted by clinical psychologists at the University of Amsterdam used propranolol to disrupt the memory reconsolidation of events associated with fear and anxiety in a learning context. Specifically, participants were threatened with painful electric shocks during a learning task; then, these acquired memories and fear conditioning were reactivated the following day during a repeat of the task. As predicted, participants who received propranolol during the memory reconsolidation process (upon activation of their memories from the previous day) showed lessened behavioral expressions and feelings of anxiety concerning the fear-related memory.⁷ Furthermore, within the past year, researchers have demonstrated that the injection of ζ-pseudosubstrate inhibitory peptide (ZIP) can induce cocaine-addicted rats to forget the locations where they had been receiving cocaine.⁴ Therefore, beyond diminishing the negative emotional experience of unpleasant memories, pharmaceutical treatments may also work toward erasing a memory altogether.

However, the power to eradicate memories comes with great responsibility—and a range of complex ethical implications. A decade ago, the President’s Council on Bioethics issued a report warning against the pharmaceutical modification of memories, citing various personal and social repercussions incurred by the use of any drugs that quell recollection of past events, regardless of how painful they may be.⁶ At the personal level, individuals might use such drugs to “numb” themselves from remembering incidents that could later prove to have adaptive value, thus obviating the process of learning and growing from negative experiences. On the greater social scale, some neuroethicists argue that if survivors and witnesses of catastrophic events (such as accidents, crimes, combat, or genocide) elect to eliminate the emotional charge of such memories, then their firsthand perceptions about the meaning and impact of these events—which are inevitably interlinked with powerful aversive emotions—would be altered substantially. In effect, these self-protective acts of deliberate forgetfulness would render emotionally devastating atrocities as less significant in the collective sense of justice and moral consciousness of society.⁶

On the other hand, not every negative memory has “redeeming” value. For example, individuals with PTSD experience recurrent traumatic memories that remain particularly vivid and emotionally distressing long after the event, often impeding day-to-day functioning. Accordingly, biomedical ethicists have likened the suffering resulting from agonizing memories to the experience of profound physical pain, the pharmaceutical alleviation of which is already a common, morally-accepted practice.²

Furthermore, a recent neuroethics editorial in Nature argued that fear surrounding the widespread abuse of pharmaceutical memory erasure is overblown and impedes the development of therapeutic applications to patients whose quality of life is curtailed by the residual effects of past traumatic experiences.³ After all, conscientious negotiation of legal policies and clinical guidelines for such drugs would reduce the possibility of large-scale abuse. From the drug administration perspective, clinicians and potential patients could work together to draft procedures for determining the types of cases in which the prescription of memory-dampening drugs is a viable option. Open communication between biomedical and legal experts would also be crucial in navigating high-stakes situations, such as when a traumatized sole witness to a violent crime seeks pharmaceutical memory erasure during an ongoing court case.

Ultimately, the ethical implications of erasing memories pose core questions surrounding our identity and humanity. Would electing to forget past events fundamentally change people—with the disappearance of certain salient memories potentially eroding away the basis of our individual perspectives and learning experiences? Or is simply forgetting a senselessly traumatic event sometimes the better option toward living a fully productive life? Although research on memory-erasing drugs is ongoing and the associated ethical issues of their implementation remain points of contention, the essence of the question lies at the individual level: if presented with the option, would you be willing to dull the emotional overtones of a personal memory, or erase that memory altogether?

References

1. Cahill, L., et al. Nature. 1994, 371, 702-704.
2. Illes, J. Am. J. Bioethics. 2007, 7(9), 1-2.
3. Kolber, A. J. Nature. 2011, 476, 275-276.
4. Li, Y-Q., et al. J. Neurosci. 2011, 31, 5436-5446.
5. Pitman, R. K., et al. Biol. Psychiatry. 2002, 51, 189-192.
6. President’s Council on Bioethics. Beyond Therapy: Biotechnology and the Pursuit of Human Happiness. 2003, 205-273.
7. Soeter, M., & Kindt, M. Psychoneuroendocrinology. 2012, 37, 1769-1779.
8. Vaiva, G., et al. Biol. Psychiatry. 2003, 54, 947-949.