Partners in Change

Friends and Family --

My entry from the aforementioned New Experiences in Narrative essay collection is now live on the Fogarty Scholars website. You can read all about one of the most memorable experiences I had during my Fulbright-Fogarty Fellowship year in Durban, and why I am so enthusiastic about the work I have been able to accomplish during my time in South Africa. Thanks for checking it out:

http://bit.ly/partnersinchange

In other exciting news, I am headed to the Massachusetts General Hospital for my residency in Internal Medicine. Smarter Than the Average Bearnot is headed to Boston. Huzzah!

New Experiences in Narrative -- Global Health Writing Project Launch

Over the course of the past year--during my fellowship in South Africa, and since I've been back--I have been working to solicit, edit, and publish an essay collection in collaboration with a number of other Fogarty Scholars and Fulbright-Fogarty Fellows. One of the products of this project--a collection entitled, New Experiences in Narrative--just went live on the Fogarty Scholars website, and I'd love it if you'd check it out! 

The first essay up, and the others will be posted weekly. Please feel free to share and repost any of them you find compelling. Thank you for your support!

http://fogartyscholars.org/program-history/new-experiences-in-narrative-fogarty-global-health-research-training/

Reading matériel

Things have gotten busy at work -- hence the lack of new content. But I have been doing a lot of reading, and would love to point you all towards some of the more interesting things I've come across in the past few days:


A fascinating study conducted by the Kaiser Family Foundation, in conjunction with NPR and the Harvard School of Public Health, takes an in-depth look at the impact of heath care costs and the economy in two of the most important swing states in the upcoming election: Florida and Ohio. I highly recommend you click through to take a look at the analysis of the surveys and at the NPR news coverage, providing insights into the way health care costs currently affect people's daily life decisions in these battleground states.

An article in The New Republic written by a health policy junkie by the name of Don McCanne, MD on the importance and inevitability of stand-alone single payer health care system in the US.

And finally, two articles of note from this week's New England Journal of Medicine:

The first is about "Nontraditional Medical Students" (this includes myself!!) and the future of medicine, written by the young and exciting physician/author, Sandeep Jauhar, who is currently the director of the Heart Failure Program at Long Island Jewish Medical Center.

The second is about the current state of premedical education in the United States, and was written by the dean of medical education at Harvard Medical School.

Hope you find some of these pieces interesting, and I'll hopefully be able to holler back at y'all with some new content before the weekend is out.

First I have to finish up this document outlining the tentative purview of the Executive Quality Council for the hospital. Maybe I'll even share some of the work I've been doing here with you guys as it gets closer to completion.

People Smarter Than I

Julie Solomon, author of the new book Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids, has been doing some guest posting over at the Freakonomics Blog on the New York Times website. She is an excellent journalist and is interested in many of the same health related issues that I spend my time thinking about. Here is a great excerpt from her first guest post entitled, Common Sense Health Care:

Our market economy approach to medicine has to change. There is “a fundamental illogic to trying to contain costs in a market-based system,” writes Dr. Marcia Angell in a thoughtful article about health reform in the April 21 issue of The American Prospect.

Dr. Angell, a senior lecturer at Harvard Medical School and a former editor-in-chief of The New England Journal of Medicine, was called “an unlikely muckraker” by The New York Times in 2004, when she published a powerful expose of the drug companies.
Her position on health reform appeals not to corporate interests but to common sense and the desire for good medical care, making it appear radical:

“The only workable solution is a single-payer system (there, I said it), in which everyone is provided with whatever care he or she needs regardless of age and medical condition,” she writes. “There would no longer be a private insurance industry, which adds little of value yet skims a substantial fraction of the health-care dollar right off the top.

“Employers, too, would no longer be involved in health care,” she continues. “Care would be provided in nonprofit facilities. The most progressive way to fund such a system would be through an earmarked income tax, which would be more than offset by eliminating premiums and out-of-pocket expenses.”

Brilliant (and ballsy) stuff, right? Thanks to my darling poet 2.0 Ms. Fjeld for tipping me off to these posts. I'll be back with another installment of my open letter to Edward shortly. Happy Friday, and I hope everyone has a wonderful weekend. Holler.

On Healthcare in the United States: an Open Letter (Part 1)

On Mon, Jul 7, 2008 at 1:25 PM, Eddie Bearnot [redacted]@gmail.com wrote:

benny -
i am lost as to what we need in regards [to] healthcare reform. talk to me. you can't possibly be that busy.

e

//

My little brother is quite right, if somewhat rude - there's no particularly good reason I haven't gotten back to him more quickly. I have plenty to share on the subject, and more time on my hands than I will at any point in the foreseeable future. In light of this, what follows is the first installment of what will be a serialized open-letter response to Eddie’s questions on healthcare and healthcare reform in the United States.

//


Yo Ed –

Thanks for being so persistent. Part of my reluctance in getting back to you has been the magnitude of the questions you are asking. I am very excited that you have been asked to think critically about the healthcare system in the US since arriving in Washington D.C. several weeks ago - but healthcare and related biomedical science are issues of particular significance to me, and I would be disappointed in myself if I supplied incomplete answers.

Because of the scale and infinite complexity of these topics, I will do my best to provide you with some concise answers in a format that you will hopefully find readily accessible. It’ll probably take me a couple of installments to get all of the salient points down, but I encourage you to ask for clarification whenever necessary. It’s important that I learn to write lucidly about these topics as well. Let’s get started then, shall we:

The most disheartening piece of the healthcare crisis in the United States – and the component that I will focus on for you here – is the system’s gross inefficiencies. The US spends approximately 15% of its GDP on healthcare each year. In 2006 this sum eclipsed $2 trillion, or $7,000 per American. And while this percentage and absolute total are the highest in the world by a significant margin, the United States lags behind many other developed countries in basic metrics of nationwide health (average life expectancy, infant mortality rates). This is even more problematic when coupled with the observation that there are still nearly 50 million Americans living without health insurance. In short: we are paying significantly more for our care while missing out on the benefits of this spending.

So, if this $2 trillion (that’s 2 followed by 12 zeros) isn’t going towards the provision of the best possible care, where is it going? Here is a partial list of the most conspicuous answers to that question as our health system is currently structured:

Expensive drugs and devices researched and developed by pharmaceutical companies. Because of the way US patent law works, these corporations have every incentive to charge usurious prices for these products during the finite number of years in which they are protected by patent. And while astute advocates of free-market economics correctly point out that these big paydays make it possible for big pharma to lavishly spend on the expensive basic science to develop and trial new and wonderful discoveries, many of the products brought to market are debatably superior to the preexisting drugs/devices in their class, while costing many times more.

Health Maintenance Organizations (HMOs). These private companies were originally designed to prevent unnecessary healthcare spending, pooling risk while simultaneously encouraging the “health maintenance” of policy holders by covering preventative care costs. But because these HMOs are private corporations, responsible to shareholders and board members, they are driven by their inherent profit motive to keep costs down and maximize income. This has resulted in systematic attempts to reject legitimate reimbursement claims submitted by physicians and patients, refuse coverage to patients deemed high risk, and to provide substandard compensation for the primary care physicians who act in the essential role of gatekeeper for further medical services – causing an increasing number of physicians to enter more specialized fields where they might be compensated more fairly.

I guess I’ll leave off here for now. Next time I’ll tell you more about the current state of medical malpractice and tort reform, the ongoing failure of Medicare and Medicaid to pull us out of this downward spiral, and expound further the intrinsic incompatibilities of excellent medical care and profit motive.

Hope you’re well and I can’t wait to talk with you again soon.

Love,
Ben

Lucian, you're like no other

Excerpts from an interview with Lucian Leape – an adjunct professor of health policy at Harvard School of Public Health – in a 2007 issue of Health Affairs.

[Buerhaus, Peter I. Is Hospital Patient Care Becoming Safer? A Conversation with Lucian Leape. Health Affairs. 26;6 (2007):687-96.]

Dr. Leape is well known for his ground-breaking research and thinking about patient safety, particularly on the need to focus on systems of care to prevent injury to patients, and, more recently on the need for full, open disclosure and apology when things go wrong.

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On reducing medical error to 0:

The most exciting thing that has happened recently in patient safety--something that has truly changed our agenda--is that it is now apparent that we can use perfection as a benchmark. This means that we can stop talking about reducing medication errors by 50 percent or improving hand washing by 30 percent, and so forth. We now have convincing demonstrations that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events. There is no reason to think that this cannot be expanded to the whole universe of adverse events.

On disclosure of medical errors and patient safety:

The need for full disclosure and compensation is finally on the patient safety agenda. Acknowledging mistakes when they occur, fully explaining what happened, apologizing for errors, and providing compensation for the cost of the injuries we cause are things that we have to do. Patients too often do not get the truth, the whole truth, and nothing but the truth, and it is time to stop that.

There are many reasons why physicians have been reluctant to be open and apologize after accidental injury, but a major factor has been bad advice from liability insurance carriers and hospital counsels, who have perpetuated the myth that informing the patient will increase the likelihood of being sued. There is not a shred of evidence to support this assertion--not a single study--yet the myth dies hard.

Although fear of litigation is very real, and understandable, I believe that a more powerful reason that doctors sometimes do not communicate fully with patients after a serious error is their sense of shame and guilt. Physicians hold themselves to high standards of performance. As a result, they find it difficult to deal with failure. And they get very little support, either from their colleagues or from risk management personnel. It turns out that full disclosure and apology when there has been an error are important for the physician as well as for the patient. We need to provide them with support to help make it happen.

On Pay for Performance (P4P) models of health care:

Essentially, it suggests that you can get quality by paying for it. The idea seems sound, but whether the results will confirm it remains to be seen. It certainly is a concept worth trying, given that our current system of paying for health care is rife with perverse incentives. As some wag observed, health care is the only industry where you get paid more for a defective product! But, it's true: Hospitals and doctors receive more income when things go wrong than when they go right. And it works both ways: You get paid less for good care. That is clearly not what we want.

Here is a classic example: A doctor does a good job treating patients with asthma, teaching them to manage themselves, and the end result is exactly what we want--patients have fewer attacks. They are not going to the doctor's office as often, they are not going to the emergency room, and they are not being admitted to the intensive care unit and being intubated. But the net result is that both the doctor and the hospital lose money. That does not make any sense, and we need to change that. Our fee-for-service system also emphasizes providing services rather than providing care, and that also needs to be changed. We should pay for good-quality care.

On the major flaws of current - and potentially all - P4P proposals:

Pay-for-performance, though, has some major problems that we have to sort out. I do not know how they are going to be resolved, but let me at least briefly mention a few. The first is whether you should pay for process or for outcomes. Second, how do you pay: Do you pay a bonus for good care, or do you punish people who fail?

Let us say you pay a bonus for somebody who does a better job of making sure that all patients who have a heart attack get beta-blockers afterward. We have pretty good data that this makes a difference in outcomes, so one thing to do is say, "If you achieve a high level--say, over 90 percent of your patients get beta blockers--we will pay a premium." Or do you not worry about that and focus on outcomes?

I am also concerned about the possibility of perverse effects. Any time you change payment, you change behavior, and that often has unintended consequences. If we concentrate on paying for outcomes, will we in effect devalue and direct attention away from the "soft stuff" that means so much to patients: time spent listening to them, caring about them, communicating with them? If we do not pay for that, then is it going to be diminished? I would hope not, but one must be aware of that possibility.

On the power of data collection as an engine of change in health care settings:

The second [effective] approach [to progress in healthcare quality and safety], which is even more powerful, is data and feedback. Everybody in medicine, perhaps everybody in health care, thinks they are from Lake Wobegon--that they are "above average." It is very hard for any doctor, for example, to be called average. And when they find out from the data that they are below average, they begin to do something about it.

And finally, on one of the major shortcomings of the current state of medical education:

The third barrier is that students in medicine, nursing, and pharmacy receive insufficient basic education in quality and safety. At a minimum, in the first year of school, all of them should learn the basics of error theory, why people make mistakes, and how to prevent them. Later, they should learn how to analyze systems, how to identify systems' failures, and how to redesign systems. As we mentioned, they need to learn how to work in teams by doing it, and doctors especially need to learn the basics of leadership. They need to learn much more about how to communicate more effectively, how to handle their own feelings and concerns, and how to handle the shame and guilt they will feel when things go wrong, so that they can still be effective caregivers. They need to learn how to apologize. These are things that are currently not being taught to our budding doctors. That has to change.

///

Oh man -- Dr. Leape presents puts forward so many outrageously smart and forward-thinking ideas in this interview. I hadn't come across his work until I started working with the Patient Safety and Risk Management teams at this hospital, but some very similar thoughts have been fermenting in my brain (albeit, phrased far less articulately) since my time in South Africa - especially after my experiences working alongside members of the Institute for Healthcare Improvement's developing countries team.

Preemptive Strike

A brief preface to some of the constructive criticism that might eventually stem from my experiences working in a giant public hospital:

Running a good hospital system is an incredibly difficult proposition. This is due in part to the fact that providing excellent health care requires a lot of different things being done well in unison. This is, as we all know, one of the hard parts of making any big system run efficiently.

Moreover, this intrinsic problem has been increasingly complicated by the development and entrenchment of our current privatized health care situation in the United States. Most health care not provided by the US government is provided by "health maintainance organizations" (HMOs), who incentive the use of exorbitantly expensive diagnostic tools and treatments for a small subset of the population (mostly the wealthy), while disincentivizing the provision of basic primary care for the everyone else.

And while many patients entering city's public hospitals ARE NOT covered by HMOs and rely primarily on insurance plans managed and paid for by the government (Medicare and Medicaid being the main programs), the incentive structure has been sufficiently warped by the influence of the private sector so as to create a similarly wacky organization of publicly financed care. This is sort of a complicated point - one which it behooves me to flesh out for you guys more thoroughly in the future.

With all of that said, there is a small but growing group of physicians (and MPHs, PhDs and JDs - and all of those degrees in combination) who are committed to figuring out how to make these public and private health systems work properly, providing excellent care at a reasonable cost. I'm meeting some of these inspirational characters in person in the hospital and reading about many more as part of my background reading for this job. In fact, I'll post up some interesting exerpts from an interview with one of the figureheads of this movement, Lucien Leape, in the near future.

Alright, that's all for now. Keep your eyes tuned to this space for more riveting (ha!) insights into (public) health care. Hopefully we'll all learn something along the way. Peace out.

hey yo, Sicko show like Mike Moore // my city ain't nothing like yours

Today I received my official Hospital ID. This may not sound like an achievement, but believe me – a celebration is most certainly in order. The process that has eventually led to me receiving this flimsy piece of plastic – with an appropriately unflattering picture of me inked on it – began in the last weeks of May and continued until 11:37am today, June 25. Here is a partial list of the things that
have happened in the interim:

I have completed two towering stacks of Human Resources forms, thesecond of which was so comically tall I laughed out loud when the clerk emerged with the paperwork;

spent approximately 40 hours in transit to and from the hospital's HR office to drop off transcripts, my resume, a copy of my passport, recommendations from former employers/advisers, and postmarked bank statements confirming my current address;

gone for a physical and taken two separate toxicology screens;

found an apartment to sublet with Jess for the summer;

and Euro 2008, a premier int'l soccer tournament, has gone from 16 teams to 4 (3 by the time you read this as Germany and Turkey have just kicked off. Go Turkey! They still probably won't let you into the European Union, but as this city hospital experience has taught me: keep working at it! Oh, and wear a goddamn tie, you slob – people take you more seriously when you dress up.)

However, it should also be noted that my lack of proper identification has not prevented me from starting my work here, sans pay. I have been coming in every day for more than a week now, sneaking past the security guards with my newly patented look of being extremely busy and excessively doctorly.

Fortunately, they have lots of work that needs to be done. I have already been given multiple potentially interesting responsibilities in the Risk and Quality Management departments, as well as the Medical Directors' Office. I have been exposed to the fascinating – while often depressing – administrative underbelly of the beast, and will share my observations from the front lines in short order.

Yeah I'm on the run // See where I'm coming from

spring seems to have arrived(!), and all is well in my world. just a few quick things on this beautiful day:

1. Now that it's finally been decided that I'm going to school in NYC, I'm looking for some summer work here. Nothing beats summer in the ci-tay, and I was sorry to miss it last year (no offense Durbs). Some early leads are at the NYU affiliated Bellevue Hospital - one of the biggest and oldest public hospitals in country - and with Médecins Sans Frontières (Doctors Without Borders, to those not down with its original French nom). Let's hope one of these opportunities pans out, and perhaps provides some $$ for me to sublet a place somewhere sweet.

2. Springtime has traditionally coincided with renewed personal attempts at physical fitness. I went for a hike with Jess yesterday and a short-ish -- by my admittedly skewed standards -- run today. One of the things that keeps me going during these bouts of athletic undertaking is exciting new music to listen to. Anyone have some good recommendations for me?? I know I've already asked some of you personally for leads, but: GIMME MO BEATS!!!

That is all. Oh wait, no wait, RUN!!!

Gnarls Barkley - Run [Live @ SNL]

Socially responsible physicians

My dad forwarded me an invitation to a talk at NYU -- my likely future medical school -- taking place this afternoon. The title of the lecture being given by Dr. Erica Frank intrigued me, and I've decided to go down and check it out.
In fact, a little preemptive internet research has revealed a bit more about what we'll likely be hearing about tonight. Very different than what I might have imagined from a talk including the phrase 'Climate Change' in it's title -- but an extremely important message all the same. Dr. Frank believes that physicians who preach what they practice (good diet and exercise habits; environmental consciousness) are more effective at providing care than those physicians who do not model these behaviors. I 'm not sure if I'm one hundred percent on board with her hypothesis off the bat, but I'm sure she'll have lots of interesting things to say in just a few short hours.

On a related note: I'm very much looking forward to getting back into school mode. Listening to interesting lectures and trying to wrap my mind around difficult concepts sounds like an exciting change of pace at the moment. I'm sure I'll be regretting these sentiments come August, but for now this evening's lecture will be a real treat. Holler.

From the Medscape Journal of Medicine:

Erica Frank, MD, MPH, Professor and Canada Research Chair; Founder and Executive Director; Founder and Principal Investigator; President-Elect

Physician well-being, patients' preventive care, and global warming: What do these 3 issues have in common? Both physician well-being and patients' preventive care are important contributors to climate change. Here's how it goes:

First, physician well-being: Contrary to myth, US physicians tend to live several years longer than nonphysicians, largely because we typically do have very good health habits; for example, very few of us smoke – about 4% of doctors in the States.

But there are 2 other important areas where our habits are better than others' but could still use considerable improvement. These are diet and exercise.

Second, patients' preventive care: Physicians tend to preach to patients what we ourselves practice. Many studies have now shown that (starting with freshman medical students) physicians with healthy personal habits are more likely to encourage our patients to adopt such habits.

This is specifically true for both diet and exercise: Physicians who eat less fat are half as likely to test patients' cholesterol,and those who exercise more are significantly more likely to counsel their patients about exercise. And it's also been shown that patients find doctors with healthier diet and exercise habits to be more believable and more successfully motivating in both diet and exercise.

So the last, the healthy climate preservation part, then is, if you eat lower on the food chain by eating less meat and more locally grown fruits and vegetables, and if you walk or bike more instead of driving, we will help our patients consume fewer resources and pollute less, too.

So, while behavioral change is complex, it's clear that our personal actions as physicians, and the way that our actions help our patients make better choices, are a good place to start healing ourselves, our patients, and our planet.

That's my opinion. I'm Dr. Erica Frank, Professor and Canada Research Chair at the University of British Columbia, and Founder and Principal Investigator of the Healthy Doc = Healthy Patient initiative.

Orphans of the Empire

In the run-up to last week's controversial elections in Zimbabwe, The Lancet published two excellent articles about deteriorating health care and human rights conditions in the struggling Southern African nation. At this moment it looks like Robert Mugabe -- Zim's despotic leader since independence in 1980 -- has lost the election by a fairly substantial margin, but has thus far refused to drop out of the race. Both sides have floated allegations of vote tampering, and the election totals are perhaps close enough to warrant a second round of voting in a few weeks time. Whatever happens, let's hope that conditions begin to improve in Zimbabwe, where inflation has recently surpassed the 100,000% mark and infant mortality rates are the highest in the world.

Here are links to the two articles from The Lancet, and a third from the New York Times about the ongoing saga surrounding Bob Mugabe and these current elections.

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Zimbabwe’s health-care system struggles on
To download:
http://www.scribd.com/doc/2436041/Lancet-Health-Care-and-Zimbabwe
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Health and human rights under assault in Zimbabwe
To download:
http://www.scribd.com/doc/2436042/Lancet-Human-Rights-and-Zimbabwe
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Mugabe Party Seems Poised to Fight for Presidency
//

In other -- far less important -- news, I still wish I could be more diligent about my writing. That's all for now.

A brief word about autism.

It has long been known that advancing maternal age is associated with an increased risk of genetic disorders in children. I haven't done enough research to tell you the precise mechanism(s) for this genetic degradation, but it seems clear that as eggs age their chromosomal material becomes less stable.

Similar studies on paternal age have been recently conducted, and the results have been surprisingly analogous: advanced paternal age is associated with an increased risk of Autism Spectrum Disorders (ASD). Researchers have even identified possible biological mechanisms, including de novo mutations associated with advancing age or alterations in genetic imprinting.

The most important important article on the subject can be found here on the Archives of General Psychiatry website.

It is important that this result be publicized as widely as possible for a number of reasons. Firstly, and most significantly, the number of autistic children is rising rapidly in the US and around the world. Secondly - and as a direct result of this unprecedented rise in ASD children - we have heard from an unfortunately large number of highly unscientific sources that regular childhood vaccinations might be contributing to the increasing number of autistic children. This unfounded concern has in turn led to a fewer parents immunizing their children, thus increasing the likelihood of an outbreak of measles or other traditionally childhood illness. There is absolutely no scientific evidence showing causal association between the measles-mumps-rubella vaccine (or the vaccine preservative thiomersal) and autism.

Hopefully as this finding - coupled with ongoing research in the field - is disseminated, it will finally convince parents and (malpractice-averse) physicians alike that Autism Spectrum Disorders are related to genetic mutations, most likely occurring during spermatogenesis.

My apologies if it feels like this post isn't fleshed out enough. I just wanted to get down some quick thoughts on the subject while it was on my mind. If you have any specific questions about the underlying science or research principles of anything you've read about, I would be happy to discuss them more thoroughly and/or in a way that doesn't rely on as much pre-existing understanding of medical biology. That's all for now.

the Funny Pages

Alright - I'mma actually try and post some stuff up here this week. The absence of new material from this blog is sort of inexcusable. It's another week plus until I start to hear back from other med schools -- and when I might, uncoincidently, begin to suffer from a terrible case of some senior-itis related illness -- but I might as well use this time to get some material up here. Let's start here, with a recent Doonesbury comic strip from G.B. Trudeau. This shit is just plain old funny, and very reminiscent of some of the nonsense taking place surrounding the drug-resistant TB epidemic in South Africa.

The hospital I was working at in Durban was started by a Christian missionary. As a result, many of the physicians (and also patients seeking treatment at the clinic) hold strongly Christian beliefs -- and some believe in the very strict interpretation of the biblical description of Creation, making them young earth creationists. Every day these physicians treated patients with newly evolved drug-resistant bugs, yet they didn't believe in Darwin's principles of natural selection and modern evolutionary theory. Weird, right? In any case, here's Trudeau's take on an appropriate punchline:




from: http://www.doonesbury.com

You had to be a big shot, didn't ya? You had to open up your mouth.

Here are some highlights of a recent interview with Kevin De Cock (heh), the current director of the WHO's HIV/AIDS Department. Clearly the WHO is a giant bureaucracy, and the words of a departmental director won't ensure that any of the changes he suggests will be made overnight - but it is extremely heartening to hear such an important figure in the global public health arena discuss the complexities of these overlapping issues of health care, poverty, and infectious disease in such a well-informed and accessible manner.

I've also pulled out some of the sections where he explicitly talks about the current state of affairs in South Africa. For those who might be interested, the full text of the interview is here. And I've linked to some of the writing I did in South Africa that relates to the points made - usually more succinctly - by Dr. De Cock.

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On the link between tuberculosis and HIV:

The recognition at the global level that these diseases are linked is a double-edged sword. On the one hand, the recognition is absolutely necessary; on the other hand, we must not forget that 89% of the world's tuberculosis is not HIV-related. But in Africa, the link between HIV and tuberculosis is particularly strong, especially in southern Africa, and a coordinated response to both is absolutely essential. When you add multidrug-resistant and extensively drug-resistant tuberculosis into that mix, it emphasizes the need for HIV and tuberculosis sectors to work together better.

Achieving this integration will be very challenging; there is not necessarily one model that works. Some parts of South Africa have done well in tackling the disease together, other parts considerably less well. As is often the case, individuals can make a big difference through their leadership, their own technical capacity, and so on. The HIV community has a lot of work do to. We are not doing particularly well, for example, in the screening of HIV-infected people for tuberculosis or in the implementation of preventive therapy for tuberculosis.

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On the disturbing history of HIV denialism within the South African health ministry:

Last year, I spoke at South Africa's third national AIDS conference. An encouraging spirit of consensus between civil society and government about what needs to be done on AIDS seems to have emerged in the past year or so. The South African government's commitment to tackling AIDS was evident when the Deputy President spoke in a very robust way at the national conference about implementing their new national AIDS plan. And a new national council to oversee implementation is jointly chaired by the Deputy President and a member of a leading civil society group. The rate of treatment scale-up seems to be improving.

However, they still have an enormous job to do. The problems of tuberculosis and HIV in South Africa, individually and combined, are so great—South Africa's HIV epidemic is the biggest of any country in the world. About one in six or one in seven people with HIV worldwide is living in South Africa. It dawned on me while I was there that what happens in South Africa is more important for the future of the HIV/AIDS epidemic than what happens anywhere else in the world. It's also so different from the other African countries; it has such resources available—financial, human, and infrastructural—that you think if they don't manage to get it right there, what is the likelihood of us doing it elsewhere in Africa?

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On the importance of women's empowerment in fighting the HIV epidemic:

Gender equity is extremely important for public health and for social justice. I think one needs to be careful before saying that there are macro-level explanations for the AIDS epidemic and that if we could only change that aspect it would all be fine. Botswana, for example, is a fair country in terms of the role of women and the respect for their rights, but it has one of the worst HIV/AIDS epidemics in the world. Some of the factors fuelling its high rate include rates of sexual partner change, lack of male circumcision, and high frequency of genital herpes. So you need to work on all these levels: behaviour change, biomedical interventions, human rights, and structural change.

However, for women's health in general, the issues of equity, economic empowerment, and human rights are all immensely important. And helping women to gain power over their sexual and reproductive choices is a key strategy to tackling the AIDS epidemic.

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On the role of male circumcision in HIV prevention strategies (and the danger that circumcised men might take fewer precautions during sex):

The recommendations issued last March by WHO and UNAIDS were carefully worded to say that male circumcision is only partly preventive (its efficacy is 50–60%) against heterosexual acquisition of HIV. However, it's not every day that we are offered an intervention with a protective efficacy of up to 60%. Yes, I wish it were a vaccine rather than a surgical procedure that has cultural connotations, but it is what it is. The recommendations are careful in pointing out that it is not a replacement strategy, rather it is an additional strategy that must be added to the other advice of partner reduction, correct and consistent condom use, and so on.

There is obviously the danger that men may feel they are protected and will not use other prevention measures—although the guidelines strongly warn about this—but there is the same danger with any intervention that is not 100% protective.

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On scaling up provider-initiated testing strategies:

First, knowledge of HIV serostatus is extremely low worldwide. Several studies in sub-Saharan Africa suggest that only about 12% of men and 10% of women had actually been tested for HIV and knew their HIV status. In mother-to-child transmission prevention programmes, only 10% of all women actually got tested for HIV. Tuberculosis patients are not being tested, so those who are HIV-infected are not accessing antiretroviral therapy or co-trimoxazole prophylaxis and have a mortality rate of 25% in 2 years.

This lack of knowledge translates into direct adverse effects—people won't get treatment early enough, they will present late with advanced disease, and the outcome is worse. Testing is the essential entry point to timely treatment. And from a prevention perspective, people who know their HIV-positive status tend to adapt their behaviour to avoid transmitting the infection. We are also aware that practice in health-care settings has been diverse. Many countries asked for guidelines for testing in health-care settings.

Verses from the Abstract

What follows are some exciting excerpts from the very first abstract to come out of the TB-HIV coinfection study I've been working on for the past 10 months. The finding described in the abstract - essentially, that there is a great deal of death and unexplained drop-out among patients poised to begin antiretroviral therapy (ART) in the clinic we've been working in - actually has little to do with TB in particular, although many of the mortalities described in the abstract were of HIV-positive patients thought to have active cases of TB.

This abstract has already been submitted for one of the big AIDS conference taking place in the United States in early 2008. Hopefully we'll be hearing back relatively soon if it was accepted or not!

I'm so not ready to leave this place just yet.

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Loss to Care and Death before ART: Patients Eligible for Treatment Who Do Not Make it in Durban, South Africa

Background: Early losses from care during antiretroviral therapy (ART) have been described for patients attending HIV or ART clinics in resource-limited settings. Our objective was to examine the loss to follow-up and mortality rates among ART-eligible patients who have not yet started therapy.

Methods: We performed a retrospective chart review for all HIV-infected adults who were eligible for ART training and treatment (CD4 ≤ 200/μl or clinical criteria) at an urban HIV clinic in Durban, South Africa from July-Dec. 2006. Patients who did not start ART and were lost to care prior to or within 3 months of the 1st of 3 ART training visits were phoned to ascertain their status.

Conclusions: Loss to follow-up and death occur frequently following first CD4 count but before starting ART in Durban, South Africa. Time from CD4 count to the initiation of ART training is months, even in those with the lowest CD4 counts. Interventions that improve linkage to care and prioritize ART initiation for those with low baseline CD4 counts are needed.

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As Q-Tip once famously said:

I'm movin, yes I'm groovin', becacuse my mouth is on the motor/
Use the Coast in the mornin' to avoid the funky odor/
Can't help bein' funky, I'm the funky Abstract brotha/

word.

Drop Knowledge, Not Bombs

Here are those TB-HIV slides I mentioned once upon a time:
























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ps. Monitoring and Evaluation is Awesome.

Moving from ‘Stats’ to M&E: Changing the way we think about numbers

1) Sharing our experiences with current data collection and reporting pathways

2) Make collection of daily/weekly/monthly numbers immediately relevant and practical for all clinic staff

• It is important that we receive relevant feedback on our work; it provides motivation, incentive, and recognition
• Statistics enable us to gauge where we are doing well and where we still have work to be done
• M&E as an essential part of comprehensive HIV care
• Assessing patients’ needs
• Measuring workloads
• Upreferral and downreferral pathways
• This is an area of our program that we are going to need everyone’s’ help to successfully accomplish.

3) Monitoring and Evaluation sounds pretty scary. What does it actually entail at your clinic?

Just five easy steps…
• Ongoing collection of specific, pre-determined indicators
• Compilation of numbers at the end of specified time periods
• Reporting of these figures on deadline to designated M&E staff
• Scheduling regular times to receive feedback of analysis of collected statistics
• Using Improvement Methodologies (which we will teach you!) to make small changes to current systems; addressing gaps in care and enabling proper allocation of resources

4) Our respective responsibilities

Partner Clinics
• Collect accurate statistics
• Meet reporting targets and deadlines
• Be open to systems development and change

Zoe-Life
• Provide M&E and Systems Development training/support for all staff
• Develop and implement streamlined data reporting structures
• Bring data supporters into clinics to help with collection of stats
• Provide regular feedback on progress

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I'm pretty sure that no one read to here (except for my mom: hi Mom), but thanks for trying.

Upgrade U

I'm still nursing this sore throat - my voice has that distinctively pubescent squeak to it - and I don't feel like I have much to contribute at the moment. So in lieu of my thoughts: here are a few items that are marginally more interesting than anything I have to say right now.

#1 An article in the American Journal of Epidemiology about how Cuba's economic crisis of the 1990's has led to dramatic country-wide decreases in cardiovascular disease and diabetes. More good analysis can be found here. One of the the less obvious corollarys of this article is that if we are to believe the papers' conclusions, we must also accept that obesity is not only a genetic condition. Instead, weight is the consequence of environmental and genetic interactions, and that environment - including diet and exercise - play large roles.

#2 There are some bad-ass surgeons living in Melborne, apparently. Five Australian surgeons at the Royal Melbourne Hospital removed this metal chair leg from a 20 year-old patient's eye socket, saving both the man's life and, miraculously, his eye - which had, I guess, been pushed aside at impact. The procedure was more than four hours long - including the reconstructive plastic surgery - and the guy walked out of the hospital 19 days later with 95% vision in the damaged eye. While I would still recommend not getting into brawls outside of nightclubs, it's pretty miraculous to think that modern medicine has developed the tools to repair such catastrophic injuries to the human body.

Isn't this a haunting image? Huh, I wonder if the radiologist saw the pathos.

#3 Gβ5-RGS complexes co-localize with mGluR6 in retinal ON-bipolar cells. Morgans C, Bearnot BI, et al. Coming soon to a copy of the European Journal of Neuroscience near you. Oh, you don't get that one? Neither does anybody. This was basic science research I did out at the Neurological Sciences Institute at OHSU in 2004 - but I'm really glad that they're finally getting around to publishing it. I feel like I did some mean confocal microscopy work that summer.

Red vs. Blue

This is what the problem looks like:

(from Corbet et al. Lancet 2006; 367: 926–37)

...and things have only gotten worse since 2000. I've seen many many charts and graphs about the problem of TB-HIV coinfection around the world - but is the most effective at visually demonstrating Southern Africa's disproportionate burden of this developing TB-HIV pandemic. The article that I pulled this figure from is one of the best I've come across, and has been tremendously helpful in putting together this presentation for all of my coworkers in the ARV decentralization project. Hopefully I'll get around to posting some of those slides when I finish them up.

Back to work. Holler.

Workinonit

Ben's 'Integration of Care' Propoganda for South Africa:

HIV/AIDS affects all members of our community, even those who aren’t infected.

If we are passive about treating a patient only for his or her particular symptoms, we often don’t include HIV as a possible complicating factor.

This short-term way of thinking about our patients requires an excessive number clinical hours and ignores the complex public health implications of the HIV epidemic.

We must be active in thinking about HIV in all patients that arrive at our clinics – even those who are not showing signs and symptoms of HIV/AIDS.

Comprehensive care - by definition - involves active case finding. We must increase the number of patients we are testing each year.

If we can identify those patients who are infected with HIV, but who are still clinically ‘well,’ we can more effectively prevent further impact on the community (sexual transmission, MTCT, OIs, STIs, and TB).

By promoting Wellness of our patients early in the course of illness, we can dramatically lessen the impact that HIV/AIDS is having on an individual and community level.

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Are you sold?

Prevent Defense

Big news from the HIV prevention community! The AIDS Vaccine Advocacy Coalition (AVAC) is very committed to this cause - as you might be able to guess from their name - but have yet to demonstrate any real success (they supported the failed microbicide trials in South Africa last year) . There are a few phase II clinical trials of HIV vaccines taking place in different parts of Sub-Saharan Africa; I imagine this money from Bill and Melinda will help to finance strategic scale-up and distribution of the drug if the studies prove to be successful. Unfortunately, the studies won't be completed until at least 2008 or 2009. Here's to hoping it all works out!

from The Lancet Blog:

US$14 million grant for HIV prevention campaign

Thursday August 23rd 2007

The AIDS Vaccine Advocacy Coalition is launching a new organization to promote the development of a wide variety of HIV prevention strategies, including microbicides and oral preventive drugs.

The launch of the new organization, called The HIV Prevention Research Advocacy Network, was announced by AVAC Tuesdsy, Aug 21 in Seattle at the AIDS Vaccine 2007 conference.

The initiative will be funded by five-year, US$14 million grant from the Bill & Melinda Gates Foundation

According to the press release announcing the network’s launch, the organization will:

•Develop international advocacy partnerships that support both the needs of communities involved in research and a global advocacy movement for HIV prevention research.

• Translate complex scientific ideas to communities AND translate community needs and perceptions to the scientific community.

• Work to hold both research agencies and advocates accountable for accelerating ethical prevention research and development.

• Help ensure that communities, policymakers, and civil society have realistic expectations about HIV prevention research and specific clinical trials.

• Work closely with other groups conducting HIV prevention research advocacy, including microbicide advocacy groups.

AVAC also released it annual report, which provides an overview of the state of HIV vaccine research today. Of particular interest is a section that looks at the slow uptake of both male circumcision as an HIV prevention strategy and the vaccine for human papilloma Virus (HPV). These case studies, the report argues, holds lessons for those seeking to implement other prevention strategies.

To visit AVAC site and download the new report go to: http://www.avac.org/

To visit the AIDS Vaccine 2007 conference website go to: www.hivvaccineenterprise.org/conference/index.html

By Michael McCarthy