Most of the stillbirths that occur around the world are among women who live in low- and middle-income countries. Some 2.5 million women suffer the heartbreaking loss each year.

Yet determining the causes and prevention of stillbirths has largely been ignored as a global health priority — the incidence not even included in the WHO Millennium Development Goals.

Stanford Health Policy’s Rosenkranz Prize Winner, Ashley Styczynski, MD, MPH, discovered the alarmingly high level of stillbirths while working in Bangladesh as a 2019-2020 Fogarty Fellow, studying antimicrobial resistance in newborns in the hospitals there.

The $100,000 Rosenkranz Prize is awarded to a Stanford researcher who is doing innovative work to improve health in the developing world.

“I was surprised to learn that the rates of stillbirths were comparable to sub-Saharan Africa and that in many cases they had no idea of the cause,” Styczynski said in a Skype call from Dhaka, where she has been living for eight months while conducting her antimicrobial resistance research.

Rosenkranz Prize Winner Ashley Styczynski takes specimen samples with women in Dhaka, Bangladesh, for her research on antimicrobial resistance in newborns. This research led to her prize-winning proposal to investigate the alarmingly high rate of stillbirths in the South Asian nation.

The South Asian nation is among the top 10 countries with the highest number of stillbirths, with an average of 25.4 stillbirths per 1,000 births. Studies have implicated maternal infections as the cause; one ongoing study in Bangladesh has recovered bacteria from blood samples in stillborn babies in whom no prior maternal infection was suspected.

Styczynski believes intrauterine infections may be an underrecognized factor contributing to the excess stillbirths in Bangladesh. She intends to perform metagenomic sequencing on placental tissues of stillborn babies, a process that will allow her to examine the genes in the organisms of those tissues and evaluate the bacterial diversity.

“The alternative hypothesis would be that stillbirths are caused by non-infectious etiologies, which I will be assessing through interviews,” Styczynski wrote in her Rosenkranz application.

Those interviews will be with mothers to evaluate for frequency of infectious symptoms during pregnancy, including fever, rash, cough, dysuria and diarrhea, as well as possible toxin exposures. She will compare the findings with the metagenomic sequencing results to determine how frequently potential pathogens may be presenting as subclinical infections.

“By applying advanced technologies and software platforms, this research will not only enhance our understanding of causes of stillbirths in Bangladesh, but it may also provide insights into causes of early neonatal deaths," Styczynski said.

Bangladesh, one of the poorest and most densely populated nations in the world, offers a rich variety of emerging and known diseases that go undetected.

“The panoply of infections that could contribute to stillbirths is really unknown,” Styczynski said. “That’s why metagenomics is a great tool here. It just hasn’t been accessible here because of the expense. Now this tool will begin to unpack what’s causing these stillbirths.”

The Rosenkranz Prize was started and endowed by the family of the late Dr. George Rosenkranz, who devoted his career to improving health-care access across the world and helped synthesize the active ingredient for the first oral birth control pill.

“No one is more deserving of the Rosenkranz Prize than Dr. Ashley Styczynski”, said Dr. Ricardo Rosenkranz. “Because of her tenacity, originality and focus, Dr. Styczynski exemplifies the ideal Rosenkranz Prize recipient. She has chosen an often overlooked adverse outcome that may prove to be mitigated by her findings. As a neonatologist interested in health disparities, I fully realize the potential relevance and urgency of her work and am excited to see it come to fruition. As the son of George Rosenkranz, for whom this prize is lovingly named, I know that my father would appreciate Dr. Styczynski’s pioneering spirit as well as her desire to affect global positive change by improving medical outcomes in vulnerable communities. We can’t wait to celebrate her work back at Stanford in the near future."

Sheltering in Place

Styczynski spoke from her flat in Dhaka, where she has been confined for three weeks as the world’s third-most populated city prepares for the onslaught of the coronavirus. The country is on lockdown; no international flights in or out.

As of Thursday, there were 1,572 cases in Bangladesh and 60 deaths, according to the widely used Johns Hopkins Coronavirus Map.

But Styczynski believes that’s about 1% of the actual disease activity in the country because testing was so slow to start. She said there is great stigma in the country over testing — red flags are put on the homes of those who have been diagnosed with COVID-19 — because it breaks up the unity of families and the surrounding community. Health-care workers are being kicked out of apartments by frightened landlords and people are afraid to use the health-care system for fear of infection.

“So, the hospitals are quite empty — more so than they’ve ever been,” she said.

Styczynski likened it to waiting for the tsunami that you know is coming.

“That’s why I wanted to jump in to stave off the morbidity and mortality that will be inundating one of the most populated countries in the world,” she said. Some 165 million people are packed into 50,250 square miles — a land mass about the same size as New York State, which has some 19.5 million people.

Ashley Styczynski goes through a thermoscanner was when I was testing out the triage system at an upazila health complex.

The Centers for Disease Control and Prevention (CDC) has a small team of four people working in Bangladesh. Having spent two years as an Epidemic Intelligence Service Officer at the CDC, Styczynski has now joined its Bangladesh team and is also working with the infection prevention and control team of the International Centre for Diarrhoeal Disease Research, Bangladesh.

“Many people here in Dhaka live in high-density apartments with six to 12 people living in the same room,” she said. “How do you isolate when you have a one-room home?”

Ninety percent of the population are daily wage earners, Styczynski noted, who say they’d rather take their chances with coronavirus than die of starvation.

They take those chances at great risk. There is one ventilator for every 100,000 people in Bangladesh and the district hospitals have maybe one to two days of oxygen supply, Styczynski said.

They started out training military hospitals on medical triage, quarantine and isolation, and infection prevention strategies.

“We’ve also been going to some district hospitals to assess some of the challenges they are facing and to identify some of the gaps in preparedness so that we can communicate back to the Ministry of Health how they can better support these district hospitals,” she said.

Her pandemic travels to the district hospitals and preparedness work has allowed her to gather contextual data for her colleagues back at Stanford who are working to address the lack of personal protective equipment (PPE) in low-resourced countries.

“We hope we can generate some evidence very quickly so that we can share some of this information to better protect health-care workers in other low-resource countries,” she said.

Despite her research being temporarily sidelined, Styczynski is upbeat.

“This is what I signed up for as a Fogarty fellow, to help build local capacity,” she said. “But I am also an infectious disease specialist, and these are the types of situations we run towards rather than away from. We build our career for moments like these.”

Protecting freedom of expression is essential to vibrant democracies and to meet the needs of people now and into the future, Indian historian Ramachandra Guha said at a Stanford event seeking to draw people together for policy-relevant discussions about India’s growth following 25 years of reforms.

Guha’s remarks were part of a colloquium titled “Eight Threats to Freedom of Expression in India,” and one in a series, co-hosted by the Shorenstein Asia-Pacific Research Center (APARC) and Center for South Asia.

The colloquia, which continue this spring, are motivated by an opportunity to garner reflections and expertise from Kathleen Stephens, the William J. Perry Fellow in the Freeman Spogli Institute, who served as chargé d'affaires at the U.S. Embassy New Delhi in 2014.

“As I was preparing to go to India, I read Ram’s extraordinary book India after Gandhi, which provided much-needed historical, cultural and political context,” Stephens said. “When I visited Bangalore, we met and instantly clicked as we talked about U.S.-India relations. It’s a pleasure to welcome him back to Stanford.”

Guha, a renowned author and scholar, has written numerous critically acclaimed books about India’s history and culture as well as social ecology, and is a frequent commentary contributor to publications such as The Telegraph and Hindustan Times. In 2000, Guha was a visiting professor at Stanford, where he taught courses on the politics and culture of South Asia and cross-cultural perspectives on the global environmental debate.

India is often referred to as the world’s largest democracy for its population size of 1.3 billion and system of governance since partition and independence in 1947. Guha said that, while India is “solidly and certifiably democratic,” there are serious flaws, including growing threats to freedom of expression of Indian artists, filmmakers and writers.

Indian society, Guha said, has become too sensitive to criticism, wherein “somebody will take objection” to any message. This kind of environment has encouraged newspaper editors to self-censor, for example, and led public figures to, at times, neglect to protect artists, filmmakers and writers.

In total, Guha detailed eight threats to freedom of expression in contemporary India: 1) archaic colonial laws affecting the first amendment, 2) imperfections in the judicial system, 3) rising importance of identity politics, 4) complicity of the police force, 5) pusillanimity of politicians, 6) dependence of media on government-sponsored advertisements, 7) dependence of media on commercially-sponsored advertisements and 8) ideologically–driven writers.

Would an absence of those threats imply freedom of expression? Responding to the question from the audience, Guha lamented that the answer wasn’t simple. His task was to offer a diagnosis of the challenges, he said, and not provide instruction on how to solve them, but in general, focused efforts bear change.

“Building democracies is about quiet persistent work,” Guha said of next steps in the process to extinguish threats to freedom of expression. “I think quiet persistent work in repairing our institutions, modernizing our laws and improving civil society institutions can still mitigate some of the threats.”

Guha expressed optimism about India’s civil society, noting an expansion in the supply of non-governmental organizations working on social issues and private philanthropists funding projects in that sector. But he tempered: “we could do more.”

Stephens ended the event by thanking Guha for leading the discussion, and referenced America’s first president George Washington, who at the end of his term in office, called upon citizens to be “‘anxious, jealous guardians of our democracy.’”

“And, I see that today in Ram and in the many people here – very jealous, anxious and passionate guardians of our democracy – who we can learn a lot from,” she said.

Listen to an audio recording of the colloquium.