11/19/08

 

BY STEPHANIE PAPPAS

	Steve Fisch Photography
	Ellen Jo Baron is introducing a new approach to training lab technicians, which is tailored to conditions in developing nations. To see more photos, click here.

Ellen Jo Baron, PhD, knows how to improvise. As director of the clinical microbiology lab for Stanford’s medical center, she has access to state-of-the-art diagnostic facilities. But as a volunteer microbiology advisor in Nepal, she’s had to reuse old whiskey bottles to culture blood. So it should come as no surprise that she’s revolutionizing microbiology instruction in the developing world with a few plastic binders.

Well-trained lab technicians are sorely needed in developing countries. Incorrect lab results can lead to misuse of antibiotics—a recipe for creating antibiotic-resistant microbes. Doctors who don’t trust lab results often misdiagnose patients, who then don’t get the treatment they need.

“Many, many kids have died” from inappropriate treatment, said Baron, who is also the acting director of the medical center’s clinical virology lab. “That’s the bottom line.”

Baron, professor of pathology at the School of Medicine, has been training technicians overseas since 1996. After following up with trainees, though, she found most of the instruction did not transfer back to their labs.

Baron figured out why during a microbiology workshop in Kuala Lumpur, Malaysia. Her students had questions that weren’t covered on her handouts, so she went looking for the Manual of Clinical Microbiology, a reference book she co-edited. She finally found a dusty, unused copy in a locked office. When she opened the book with her students surrounding her, she suddenly saw it through their eyes: two columns of small, dense text in English, lots of wordy instructions and no illustrations. “I realized that this thing just wasn’t going to fly,” she said.

She knew she needed to modify the trainings for non-native English speakers. Inspiration struck again in Cambodia, where she noticed flowcharts on the walls at the Angkor Hospital for Children. Flowcharts were the answer, she thought. But instead of words, she’d need pictures.

Using three-sided binders and waterproof page protectors, Baron created a basic microbiology primer. The binders can be propped up on a lab bench like easels. Flip through one side, and you’ll find tabs marking pages of handling instructions for different types of samples: urine, blood, cerebrospinal fluid. On the other side are flowcharts for identifying different microbes.

“Anything that is both eye-catching and full of useful content that people can have in front of them is an excellent teaching tool,” said Steven Specter, chair of the International Laboratory Capacity Building Committee of the American Society for Microbiology, which funds some of Baron’s workshops.

Baron, who is also associate chair of pathology for faculty development, took her binders on the road. She started in Colombia, where microbiology technicians are well-trained, and taught the workshop in Spanish. Later she presented in three cities in Cambodia, where lab technicians make the U.S. equivalent of $30 a month. In Battambang, Baron gave her workshop in a building that was half rubble. At one point, the electricity went off mid-demonstration. Her students found a lamp powered by a generator, and the show went on.

She also gave trainings in Laos and Botswana. And then there’s the domino effect: Her trainees in Botswana went home to their labs and trained techs there. Someone who attended the Botswana workshop presented the workshop in Zambia, and someone from that workshop is translating the materials into Portuguese and will train technicians in Mozambique this December. Baron is hoping to convince the Merieux Foundation, which has helped fund some of the training programs, to translate the binders into French. They’re already available in Spanish and Khmer.

Baron also has a related side project: rounding up sheep, whose blood is used to make bacterial culture media. In the United States, labs buy the blood from commercial suppliers—a luxury in much of the developing world, where climates are often too hot for sheep.

So Baron has become a sheep-wrangler, too. Her workshops include instruction on how to collect blood from a sheep. If she’s lucky, an actual sheep will be available. If not, she gets creative.

“In Botswana, I bled a person,” she said. One of the students in the class reluctantly volunteered for the honor. He might have been anxious, but the donor sheep aren’t.

“They don’t mind,” Baron said, shrugging to imitate the sheep’s lack of interest. “They don’t even flinch when you stick the needle in.”

The process is harder for the humans collecting the blood; the blood flows into a bottle that contains hundreds of small glass beads. To prevent clotting, the collector’s helper must shake the bottle constantly during and two minutes after collection. Then the blood has to be distributed, filtered for clots and checked for sterility—a process that requires dozens of tubes, bottles and stoppers. Afterward, everything, including the glass beads, has to be cleaned and re-sterilized.

Baron is determined to simplify that, too. She has recently showed that human-blood donation bags can be used for sheep blood. The use of donation bags will replace all of that shaking and filtering with three easy steps. The technician corrects the ratio of anticoagulants to match the volume of blood (sheep donors give less than humans), weighs the bag during collection to assure proper volume and tests the collected blood for sterility.

Now, when Baron isn’t lining up future trainings in El Salvador, Nigeria, Kenya and Brazil, she’s trying to secure funding to get hair sheep—a wool-free, parasite- and heat-resistant breed with blood just like regular sheep—to the technicians who need them. 

“All I have to do now is find some way to get hair sheep out into the developing world,” she said. “This is going to change everything.”

The microbiology training programs were funded by the Merieux Foundation in Laos and Cambodia; the International Laboratory Capacity Building Committee of the American Society for Microbiology in Botswana; and the American Society for Microbiology in Colombia.

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Stephanie Pappas is a science-writing intern in the medical school’s Office of Communications & Public Affairs.