Sim City

I'm about to go spend the rest of my morning playing with SimMan, a life-sized mannequin/patient simulator, with realistic anatomy and clinical functionality. I am really hoping to get a lesson on how to perform an intubation or, better yet, a cricothyrotomy. It's cool to know that these sophisticated educational tools are around to teach us noobs these extremely important clinical skills in a non-patient environment. Performing your first intubation on a real patient is a terrifying experience, I'm sure.

Also, because there hasn't been a post up here without some mention of health policy in a long time: here is a recent interview from the Brian Lehrer show on WNYC with analysis on Massachusetts' move towards universal healthcare. I must admit that I haven't listened to this piece myself just yet, but one of the participants is Dr. Stephanie Woolhandler -- a woman I admire tremendously, and who has incredibly persuasive and smart things to say (to Congressmen no less!) about the disastrous state of healthcare in America.

I've got to run off to play with my oversized doll. Lata', all.

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.

///

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.

Science Rules

Science is important. Consequently, the funding and policy decisions that the United States government makes about science and technology are vital to the progression of global innovation and economic development. These exceedingly important aspects of governance are often overlooked, however, and have been particularly absent in the ongoing wrangling for position by the three remaining presidential candidates in the upcoming US presidential election.

A coalition of important medical, scientific, and technological academies, in concert with a large number of concerned citizens -- like myself -- think this is a real problem and have joined an initiative called Science Debate 2008. This is our statement of purpose:

"Given the many urgent scientific and technological challenges facing America and the rest of the world, the increasing need for accurate scientific information in political decision making, and the vital role scientific innovation plays in spurring economic growth and competitiveness, we call for a public debate in which the U.S. presidential candidates share their views on the issues of The Environment, Health and Medicine, and Science and Technology Policy."

I recommend that everyone head over to their website and affiliated YouTube page (I've also posted these links up on my delicious page) and take a look. Hopefully the politicians vying for our country's top executive position will take notice.

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.

///

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.

///

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?

///

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.

///

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.

///

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.

The Truth

This is the truth.

[If you click through, take a minute to look around the site. This David Ng character - the main editor and presumably founder - of the Science Creative Quarterly seems full of interesting ideas. The SCQ was also behind the Science Scout badges I blogged about once upon when.]

I'm not a player, I just crush a lot

Oh yeah - I meant to mention this before, but it entirely slipped my mind. My homeboy, Dr. Atul Gawande, is a guest columnist over at the New York Times this month. I know I've waxed poetic about the many virtues of his writing in previous posts, but these editorial pieces that he's writing for the Times in May - while perhaps not as thorough or gripping as his other, longer works I've read - are smart, imminently digestible, and contain many interesting insights into the health care crisis in America.

Unfortunately, some of these articles are behind the ever-irritating Times Select paywall - but I'll take a look around and see if they are being published elsewhere. In the meantime, let me know if you'd like to get your hands on these editorials - and I would be happy to send them your way. The titles and brief descriptions of his writings so far are posted below for you to take a look at.

Rethinking Old Age
We don’t much talk about getting more control over our lives in nursing homes. And that’s a problem.

Let’s Talk About Sex
The four facts everyone needs to know about sex and contraception.

Doctors, Drugs And the Poor
The practice of medicine comes with certain moral obligations. The same goes for the manufacture of pharmaceuticals.

Bad Medicine, Sneaking In
Medicine’ s success and affordability critically depend on materials and distribution from around the globe. Yet market forces aren’t weeding out the shady operators.

Curing The System
It is possible to alter our health care system surgically enough to minimize harm while still channeling us onto a path out of our misery.

Can This Patient Be Saved?
Our health care system has eroded badly, but it has not collapsed. So we do nothing.

The Power Of Negative Thinking
We Americans believe instinctively in the power of positive thinking. But the real key is looking for, and sometimes expecting, failure.

Sometimes it's difficult for me to believe that this is my life. Part 2.

Here's an excellent article from the March 12, 2007 issue of the New Yorker written by Michael Specter that you all should read. It focuses on the Denial of AIDS and its deleterious effects on the efforts to combat the pandemic, particularly in South Africa. One particularly memorable quote to coax you to read the article:

"AIDS denial plays a corrosive role in the health policies of many countries, but South Africa provides the most extreme and enduring example. Five and a half million of the country’s 48 million people are infected by H.I.V. Today, only 200,000 receive AIDS drugs. In 2003, the South African government issued a comprehensive AIDS policy, but it wasn’t implemented. Mbeki has never disavowed his view that H.I.V. medicines are aimed at maiming Africans, and he’s never publicly acknowledged that H.I.V. causes AIDS."

The piece also contains an fantastic opening anecdote about a modern-day Sangoma (traditional Zulu healer) who claims that the cure for AIDS was given to him in a dream by his long-dead grandfather. The grandson now has a storefront in downtown Durban, which I am now hoping to check out in the coming weeks.

The article can be downloaded as a .pdf by clicking here. Let me know if that doesn't work; I'd be happy to send you the article directly.

Where science and public health do not intersect.

From a recently published article in the always excellent British medical journal Lancet:

“Infants who were breastfed but also received solids (generally home-prepared cereal or commercial infant porridges) any time after birth, were nearly 11 times more likely to acquire [HIV] infection than were exclusively breastfed children.”

Coovadia HM et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding: the first six months of life. Lancet 2007 [in press].

///

This article was written by Coovadia et al, a group based right here in Durban at the Nelson Mandela School of Medicine. This highly-relevant issue of whether children of HIV-infected mothers should or should not breastfeed is very interesting one both from a scientific and a public health standpoint.

It is counterintuitive for many (including myself) to imagine that an HIV-negative baby should be fed the virus-containing milk of its mother. Breastfeeding is well demonstrated to protect against a range of illness, but it is risky because of the opportunity for HIV transmission from an infected mother to her baby. However, the data from this extensive study shows that if the infant is fed EXCLUSIVELY breastmilk - and does not have any formula or other solid food - for the first 6 months of life, the practice of breastfeeding is very safe and greatly reduces the probability that the baby will become HIV-positive. The underlying science of this has to do with the fact that babies' digestive systems are unable to handle most other foods at this early developmental stage, leading to small lesions or gaps in the GI mucosa which leads to increased transmission of the virus when the baby consumes breast milk with a positive viral load.

However, the public health policies that will emerge from this finding are ambiguous at best. Working mothers, especially in the developing world, can't always make time to feed their babies on regular schedules. These women tend to work long shifts, travel great distances between home and work using public transportation, and often rely on other family members to help provide care for their children. Complicating this matter even further, baby formula is prohibitively expensive. The end result is that it is most convenient for mothers to feed their infants a mixture of breast milk along with other available foods in these resource-limited settings, dramatically increasing the likelihood that the child will become positive within the first six months of life.

Stopping the spread of HIV from mother to child is exceedingly important (for a whole host of reasons that I shouldn’t get into here), yet how can South Africa or the World Health Organization advise mothers in impoverished settings around the world to do what is essentially impossible? While the science underlying this paper is very strong, it is far less obvious to me – as well as to other members of the HIV/AIDS research community – what public health guidelines should arise from these findings.

Setting the stage

I am currently in the throes of putting together a primer on the growing epidemic of Tuberculosis in immunosuppressed South African populations (as well as elsewhere in the developing world). As I am no expert on the subject myself, I have been spending a lot of time assembling the proper sources and trying to figure out the best way to organize the discussion to include my personal observations alongside the growing mountain of medical and public health literature on the subject.

I actually knew very little about the burden of TB in the developing world before I arrived here, except for the early (largely pre-HIV) work done by Paul Farmer and his wonderful organization, Partners In Health, in Haiti. There has been an infinite amount of material for me to absorb over these past few months – and as I am rapidly finding out, writing about these topics is a really good way for me to start to make sense of things.

So, while you wait for my more substantive piece, here are two abstracts regarding TB/HIV from recently published papers I have found to be extremely illuminating. I have the full text of both of these papers, so feel free to drop me a line if you’re interested in reading on.

Hope you guys all have lovely weekends, and I'll catch up with you again soon. Hamba kahle.

The Prevention and Control of HIV/AIDS, TB and Vector-borne Diseases in Informal Settlements: Challenges, Opportunities and Insights.

David AM, Mercado SP, Becker D, Edmundo K, Mugisha F.

J Urban Health. 2007 Apr 12; [Epub ahead of print]

Health Partners, L.L.C., Tamuning, GU, USA, amdavid@guamcell.net.

Today's urban settings are redefining the field of public health. The complex dynamics of cities, with their concentration of the poorest and most vulnerable (even within the developed world) pose an urgent challenge to the health community. While retaining fidelity to the core principles of disease prevention and control, major adjustments are needed in the systems and approaches to effectively reach those with the greatest health risks (and the least resilience) within today's urban environment. This is particularly relevant to infectious disease prevention and control. Controlling and preventing HIV/AIDS, tuberculosis and vector-borne diseases like malaria are among the key global health priorities, particularly in poor urban settings. The challenge in slums and informal settlements is not in identifying which interventions work, but rather in ensuring that informal settlers: (1) are captured in health statistics that define disease epidemiology and (2) are provided opportunities equal to the rest of the population to access proven interventions. Growing international attention to the plight of slum dwellers and informal settlers, embodied by Goal 7 Target 11 of the Millennium Development Goals, and the considerable resources being mobilized by the Global Fund to fight AIDS, TB and malaria, among others, provide an unprecedented potential opportunity for countries to seriously address the structural and intermediate determinants of poor health in these settings. Viewed within the framework of the "social determinants of disease" model, preventing and controlling HIV/AIDS, TB and vector-borne diseases requires broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes for the urban poor. We examine insights into effective approaches to disease control and prevention within poor urban settings under a comprehensive social development agenda.

Tuberculosis, Drug Resistance, and HIV/AIDS: A Triple Threat.

Friedland G.

Curr Infect Dis Rep. 2007 May;9(3):252-261.

AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2483, USA. gerald.friedland@yale.edu.


The worldwide epidemics of tuberculosis (TB) and HIV/AIDS have been joined by an insidiously developing third epidemic of TB drug resistance. Fueled by the disruption of TB control programs and the explosive growth of HIV/AIDS, the presence of TB drug resistance, particularly multiple drug resistance, is worldwide and threatens the gains made in the past decades in the treatment of both TB and HIV. Although treatment success is possible, the diagnosis and treatment of drug-resistant TB is difficult. Advances in TB diagnosis and treatment have been minimal in the past 40 years, and there is an urgent need for wider distribution of available diagnostic technology and for the development and testing of newer rapid molecular diagnostic techniques and therapeutic agents. This review discusses current information about the distribution of multiple drug-resistant and newer extensively drug-resistant TB as well as available diagnostic and therapeutic strategies with an emphasis on the relationship between TB drug resistance and HIV/AIDS.

On the Frustrations of Working With the South African Department of Health

As you might have been able to guess, there are many challenges associated with rolling out antiretroviral medications and comprehensive HIV services to a clinic. Some of these difficulties are purely logistical (how to package and distribute ARVs from a centralized location, the mind-bending complexities surrounding transport of blood and sputum samples to the laboratory). Other difficulties are more deeply entrenched in the pre-existing health care systems (how to train the overworked and understaffed employees of a clinic about the importance of keeping quality data on HIV care provided to patients). However, all of these tribulations are rendered trivial when one realizes that all (please forgive the hyperbole) proposed solutions to the aforementioned complications must eventually be run by the South African Department of Health before implementation can take place.

Now while I may be young, I am not without experience working within bureaucratic systems. In my Program Manager position at New York Cares I spent significant amounts of time working with the New York City government and its ever-growing web of affiliated agencies. And while this was often a maddening process, I was able to take some solace in the fact that the lives of the physically and developmentally disabled individuals being served by these agencies were not imminently endangered by this inefficiency. I was working hard to help these organizations improve their programming, and I generally got the sense that the proposed expansion would eventually take place – even if it took unreasonably long.

However, my experiences with the SA Department of Health have been a different experience all together. Peoples’ lives are on the line here; any lag in implementing improved HIV services can be causally linked unnecessary morbidity and mortality of infected patients. This, one might imagine, would give this organization the moral imperative to act quickly and decisively to employ the most effective treatment regimens available. This, I have very quickly learned, is not at all the case.

After writing out my exhaustive laundry list of complaints about the DoH employees I have interacted with thus far, I decided that it would probably prudent to keep that inventory of in-/semi- competency to myself. You never know who is reading this thing, you know? And, more importantly, I don’t want anyone to think that my frustrations have arisen from feeling personally slighted by the Department. My objective criticisms stem mainly from the Department of Health’s inability to utilize what effectively amounts to free help. We (McCord Hospital, in affiliation with Zoe-Life) are offering to use a significant portion of the money granted to us by the US government to provide extra staff, increased trainings and mentorship, and strategic systems development at Department of Health clinics. And yet we are consistently met with unmotivated staff who seem relatively uninterested in helping us expedite comprehensive HIV prevention and care in KwaZulu Natal.

In discussing this issue with colleagues and friends here in Durban, there seem to be several prevailing sentiments about why the DoH comes across as such an ineffective organization. One line of reasoning centers around the difficulties of working for a governmental organization concerned with combating a pandemic that the highest levels of that very same government are committed to sweeping under the rug. Another thought we had involves the inevitable burnout that must come along with working tirelessly on a crisis fueled by many entwined social, economic, and medical features. And finally, some speculate that it is the burden of elevated unemployment that has caused the South African government to overstaff its Department of Health – resulting in the mess of red tape and infinite levels of sub specialization (with concomitant increases in managerial complexity – that is slowly grinding the DoH to a halt.

This discussion will, unfortunately, be limited to observation. At this relatively early stage in my experiences in South Africa it would be presumptuous of me to think that I could propose steps that might be taken by the South African government to mobilize change within the Department of Health. However, I thought you guys might appreciate an Insiders’ View of the pandemic – even if it is early on.

I think I could probably write a lot more about this subject, but the weekend us upon us! All of South Africa has another 3-day weekend ahead of it. It’s still unclear where I’ll be headed – but I’ll be sure to bring my camera along just in case. Later.

A Brief State of Our Union

There have been many interesting parts of writing this blog so far. It has obviously been – as any of us might have guessed even before I left - a nice way for me to keep in touch with you guys and for all of you to feel like you’re keeping in touch with me while I’m in Africa. However, this particular process has at times been seriously mitigated by my editorial sensibilities; I haven’t felt entirely comfortable sharing the aspects of this trip that have been particularly challenging for me. (I am of the mind that airing dirty laundry in public spaces is invariably a Bad Idea.) What has been of even greater surprise to me is how much I have enjoyed sharing my thoughts and experiences surrounding my work at the clinic. I have been intellectually engaged by the both the conceptual underpinnings and the practical execution; both the purely scientific and the wider policy-related aspects of the work have been eye opening and engaging.

Maybe I would like to try to spend some more time in my upcoming posts outlining some of what my projects have entailed – highlighting some of the features that have provided interesting insights into my own thinking about the health crisis in the developing world and my (possible? probable?) career in the health-sciences.

So, consider this a Heads Up. I will also do my best not to estrange that portion of my readership that only read my blog for all the juicy gossip and the gorgeous pictures of yours truly. I even have a music recommendation for those Hip Hop- and Motown- heads out there. That’s enough of a hint for the time being; I’ll try to post a proper write-up of the album in the next few days.

I’ve loved hearing from all of you guys – even when (especially when, I guess) things haven’t been going so well here. Please keep the posts and e-mails coming; they are greatly appreciated, and I’ll try to respond to you as quickly as possible.

time to count MCs in this place to be / not 5, not 4, not 2, just 3

Here are 3 (three!) very interesting blogs focusing on HIV/AIDS and the global policies surrounding the pandemic:

Politics and Policy of HIV/AIDS
http://blogs.law.harvard.edu/politicshiv/
The writing of several grad students and postdocs working on various parts of the politics and policies surrounding the HIV/AIDS pandemic

Princeton AIDS Initiative
https://blogs.princeton.edu/pai/
A great clearing house for speeches, reports, data, and analysis based out of Princeton

The Center for Global Development - Global Health Policy
http://blogs.cgdev.org/globalhealth/
An excellent resource for information about international aid, public health policy around the world, and the politics that influences both of these thing

If you have any free time, I highly recommend that you take a look. Happy holidays, everyone!

b