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Case Studies: CombinedSam Clark |
Jonathan Gorstein - Abstract |
Jonathan Gorstein - Outline |
Anne Marie Kimbal |
Ann Kurth Nevirapine to Prevent Mother to Child Transmission of HIVSam ClarkAbstract The drug nevirapine can be used in single dose to the mother just before delivery and following delivery by 72 hours to the newborn to dramatically reduce the likelihood of transmission of HIV from HIV+ mothers to their newborn children – see url below titled “Nevirapine - godsend or a drug from hell?” [I do not agree with all the conclusions of this piece, but it is written by a reputable colleague who is knowledgeable.] The object of this treatment is to dramatically reduce the number of HIV+ babies born to HIV+ mothers. The treatment described above is comparatively cheap and easy and very effective. However, it has many potential problems that need to be carefully considered before endorsing widespread implementation of nevirapine monodose therapy to prevent mother to child transmission. The first of these is that this treatment has no particular benefit for the mother. The drug has few side effects, but this still raises an ethical question regarding whether or not it is acceptable to submit the mother to a treatment that does have some individual-level side effects if she gains nothing from it. Second is the fact that this regimen has a non-negligible likelihood of quickly selecting for nevirapine-resistant strains of HIV, and these strains may linger as a significant fraction of a treated woman’s viral load for a number of months after treatment. This timescale is long enough for her to recover from the birth and resume sexual relationships that may mediate the transmission of nevirapine-resistant strains to her partners. Further, it turns out that nevirapine is very similar to another drug efaverenz and both of these are used routinely to treat adult HIV+ individuals. Worse, resistance to one usually means resistance to both. So, the bad news is that nevirapine monodose therapy to prevent mother to child transmission may accelerate the spread of nevirapine/efaverenz-resistant strains of HIV in the general population. Third, what happens to young children whose mothers are HIV+? The answer is nothing nice, including the imminent loss of the mother. Orphans of any kind face dramatically higher risks of dying, and this goes for both the HIV+ and HIV- children who are born to HIV+ mothers. The unpleasant reality is that nevirapine monodose therapy will likely save the child from HIV in order to let it die of “orphanhood”. How do we decide what to do? Disciplinary Basis: Public Health, Medicine, Demography, Sociology, Law (justice, philosophy?) Learning Objectives: See: Nevirapine - godsend or a drug from hell? http://www.scienceinafrica.co.za/2002/april/nevirapine.htm The elimination of iodine deficiency through universal salt iodizationJonathan GorsteinAbstract Iodine deficiency is the world’s most preventable cause of mental retardation, and places unnecessary constraints on the pace of social and economic development in a way that no nation can afford. It is therefore imperative that countries implement programs which assure the sustainable elimination of iodine deficiency disorders (IDD). Many countries throughout the world, both industrialized and developing, have adopted the international strategy of universal salt iodization (USI), i.e. the iodization of all the salt for human and animal consumption, including the salt used in food processing, as the main strategy for the prevention of iodine deficiency. The tools, equipment and procedures for salt iodization have become widely available and have made it possible for countries to implement large-scale programs. The ultimate goal of USI programs is to ensure that all salt reaching households and consumers is adequately iodized so as to satisfy the physiological requirements of iodine. However, while the concept of universal salt iodization seems quite simple, the practical realities of implementing such programs are challenging as these require a strong collaboration between Governments and salt producers. This public-private partnership has been essential in forging successful programs but there are delicate considerations when there are competing interests and potential implications of the private sector participating in a social program. In addition, there are issues with small-scale farmers, many of whom are subsistence producers who are very poor and cannot comply with mandatory salt iodization requirements. While their participation is vital, so as to avoid any non-iodized salt leaking to markets, coming up with feasible mechanisms to ensure that their salt is iodized has required innovative small business models, such as community co-operatives, to be developed in many settings . Finally, the selection of table salt as a fortification vehicle is based on the assumption that all populations consume salt in relatively consistent quantities regardless of socio-economic status. However, as hypertension and other chronic diseases emerge, the consumption of salt has declined, while in other settings, table salt is not as readily consumed as other salty condiments such as fish sauce or soy sauce, thereby calling into question the appropriateness of salt as a food vehicle. This case study will consider the many dimensions of designing and implementing a salt iodization program to address iodine deficiency and will consider the real practical issues of such a program. Disciplinary Areas: Nutrition, Public Health, Private-public partnerships Learning objectives for this capstone topic could include:
Oil rig worker in the PhilippinesAnn-Marie KimballAbstract Mario Nachor (fictitious) is a 40 year old father of five from the Philippines. He was raised in the countryside 60 km from Manila in a poor district. He pursued his education through high school, marrying his highschool girlfriend in a lavish Catholic ceremony. While they had hoped to defer a family, family planning was not an option in the Catholic family and community setting where he and his bride resided. Mario soon found himself struggling to support his family with manual labor jobs. Despite lots of looking, he was never fully employed, and funds for clothing, food and schooling were very tight. Mario did not want his wife to work, it was against his belief system. She had a full time job caring for the children. A cousin from Manila called him with an opportunity to go and work for an American Oil Company which was doing exploration in the empty quarter of the Saudi Peninsula. He leapt at the chance. To qualify for a visa to travel he had a health examination certified for a fee by a local physician known to his family. No physical exam was done, and it was difficult for Mario to afford the price of a chest x-ray, but he managed. Three months later he was taken from the airport to the rig by truck with many other workers from the Philippines, Pakistan, India and China. His job was to assure the alignment of the large drill which required daily inspection and servicing of its complex gears. The drill operated 24 hours a day. Mario lived in dormitory accommodations with forty other men. His bunk was adequate and he placed pictures of his wife and children prominently around his bed so he could remember why he had come so far to work. The pay was good, and he worked at the rig for 6 weeks of long shifts (14 to 18 hours) and then had two weeks off. Normally workers did not go home, but spend the two weeks in the capital in dormitory accommodations provided by the company. Most of the pay he sent back to his wife in Mindanao. His second week of work he felt very fatigued. The work was hard and the temperature was very hot during the day time. He checked into the rig clinic to consult the nurse about a heavy feeling in his chest and numbness in his arm, but the nurse reassured him that workers often had to adjust to the conditions. After dinner the following week he felt nauseous and had crushing chest pain. He was sweating and felt dizzy and short of breath. He collapsed on his way to see the nurse. He passed out. He awoke a day later in a strange hospital with IV tubes in his arms and a cardiac monitor. Mario was afraid and soon learned he had suffered a heart attack. Not to worry, he was assured, the company would pay his hospitalization costs. Three days later, he was discharged with a prescription for nitroglycerin and instructions to follow up with his own physician. He was dismayed to learn that his passage to Mindinao was paid, but he would not be allowed to return to the rig to work, and was being discharged for medical reasons. He would receive no compensation other than what he would have received for his six week stint. Dejected, he returned to Mindanao to face unemployment once again. Outbreak of TB among a Social Network in Seattle, WashingtonAnn KurthAbstract In King County, a TB (TB) outbreak occurred among a group of friends and associates beginning in late 2003. Most of the people affected were men in their late teens and early twenties, who were of East African origin. Most of these young men came to the United States as babies or small children with their families seeking to escape political turmoil and war in their home countries. Many had a history of incarceration at juvenile, adult, and INS detention facilities, and were involved both in dealing and actively using drugs (usually marijuana and crack cocaine). The members of this group also ‘hot boxed’, which in part accounts for the high rate of transmission within the group. (‘Hot boxing’ is getting high in a car with the windows rolled up, to maximize marijuana intake). Most of these young men had tenuous shelter, couch surfing in various apartments with friends for extended periods of time. One of the friends with whom the cases stayed was HIV-positive (thus at high risk for TB acquisition or relapse). The index case was a twenty-one year old male from Somalia who was diagnosed with TB while in a detention facility. In late February of 2004, he complained of two weeks of fever and weight loss. A chest x-ray showed left hilar adenopathy (one of the hallmark of TB). The source case was a twenty-year old male who came to the US from Ethiopia as an infant. He was hospitalized in early April of 2004. He had symptoms of cough, weight loss, and fever for several months. A chest x-ray revealed countless bilateral cavities and sputum smears were 4+ for acid-fast bacilli (AFB). This young man had sought treatment for the same symptoms in late December 2003 at an emergency room setting, where a chest x-ray revealed cavitary TB (a characteristic feature of ‘secondary’ or ‘adult type’) – but the diagnosis of TB was not recognized at the time, and the public health TB program was not notified. Between April and September of 2004, ten more cases linked to this outbreak were found. Six of the twelve cases had cavitary TB and were 3+ to 4+ smear positive for AFB. Three of the twelve cavitary cases had normal chest x-rays two months prior to diagnosis. All eleven of these cases completed treatment. The twelfth case was identified as a contact early in the outbreak. He had a positive PPD and normal chest x-ray. He declined treatment for latent TB infection in King county. He moved to another state, became symptomatic for TB and was diagnosed there with clinical TB—negative sputum cultures, but improved symptoms and chest x-ray while on treatment for TB. He returned to King county and continued with TB treatment here. Eventually, he refused further treatment and was lost to follow-up. In all, about 130 contacts were identified. Challenges in identification included the fact that some cases and contacts were reluctant to give contact information due to fears of police, INS, and the government. The team of nurses and other Health Department staff were able to overcome this by building trusting relationships, facilitating access to housing, food, public assistance, primary care, and assistance with legal issues (letters, visits in jail). Funding from the Centers for Disease Control allowed the Health Department to hire as a staffer someone who was a member of the patient community. Lack of Health Department resources meant that field-based directly observed preventive therapy was limited, and where it was done, involved a great deal of staff time ‘chasing after’ highly mobile clients from place to place via cellphone. Self-administered therapy (every day for 9 months) did not work well, as adherence was poor due to a variety of competing life concerns and the fact that therapy is required even though one doesn’t feel sick. Therefore most patients had to come in to the clinics for 6-month therapy, which meant that follow-up was not optimal. Very few of the 130 have received treatment for latent TB infection, because they have declined treatment. To date, no new cases have been identified in King County since September 2004, and monitoring by Health Department staff of a high-risk subset of individuals continues. Disciplinary basis: UW Epidemiology and Nursing (A. Kurth, CNM, PhD) and Public Health Seattle-King, (Darla Mosse, RN) Learning objectives:
The 3 by 5 InitiativeMartina MorrisOn World AIDS Day 2003, WHO and UNAIDS released a detailed and concrete plan to reach the 3 by 5 target of providing antiretroviral treatment to three million people living with AIDS in developing countries and those in transition by the end of 2005. This is a vital step towards the ultimate goal of providing universal access to AIDS treatment to all those who need it. The Problem is URGENT
Why antiretroviral therapy (ART)?
What will 3 by 5 DO? To reach the 3 by 5 target, WHO and UNAIDS will focus on five critical areas:
The funding gap: US$ 5.5 billion over current commitments. Potential Problems:
Disciplinary basis: Learning objectives:
‘The highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief, economic or social conditions’ What does it mean to say that “the highest attainable standard of health” is a right regardless of economic and social conditions? HIV positive woman seeking care for a compound fractureBeth RivinBvitri Susalo is 26 years old and on the orthopedic ward of a big hospital in Jakarta, Indonesia getting prepared for her operation. She needs a surgical repair of a complex fracture which she sustained when her husband threw her down the stairs one night after a fight they had. This happens often. He comes home late at night and hurts her. Bvitri doesn’t know if she should tell the doctor of her HIV positive status. She has been told by her activist friends that disclosing her status could hurt her and her family. After many hours of confusion about this, she finally decides to tell her surgeon that she is HIV positive. Within an hour of the disclosure, the nurses rush in and tell her that she should go home. The surgeon has cancelled the operation and has left the hospital for his private practice. She calls her friend who works for an NGO called Yayasan Spiritia. They are a resource for people like Bvitri. Yayasan and many other organizations working for the rights of PLWA start to look for an orthopedic surgeon who will operate on Bvitri. Female “Circumcision”: The Uneasy Alliance Between Health and Human RightsBettina Shell-DuncanAbstract Female “circumcision” is a practice involving the partial or complete removal of the external female genitalia. A recent study estimated that 132 million women worldwide experienced some form of genital cutting. Although this custom has been practiced for thousands of years in some parts of Africa, it only recently obtained enormous international attention, becoming the centerpiece of a global campaign aimed at eliminating “harmful traditional practices.” Although efforts to eliminate female circumcision have been underway since the early part of the 20th century, the current wave of opposition can be traced back to the U.N. Decade for Women (1975-1985), during which a series of conferences were held that drew international attention to the practice as one that should be ended with urging and aid from the international community. Intervention was at first justified on health grounds, arguing that that female genital cutting exposes women to unnecessary, and often severe, health risks, and consequently a medical argument formed the foundation of most anticircumcision campaigns. Under the impetus of an international women’s health movement, female circumcision has been targeted to be “eradicated” as though it were a disease. One outspoken advocate has written: “Genital mutilation should be treated as a public health problem and recognized as an impediment to development that can be prevented and eradicated much like any disease.” (Hosken, 1978: 155) This approach has spawned intervention efforts that feature education on health complications, assuming that as practitioners are made aware of the adverse health consequences, they will become motivated to abandon the practice. Two key problems have emerged from this approach: 1) the repeat recitation of the “medical sequelae” has drawn attention to the quality of epidemiological evidence on the adverse health consequences, and 2) many individuals convinced of the unnecessary health risks have, instead of abandoning the practice, sought medical assistance. In response to these problems, the practice is now being recast as a “human rights violation” rather than a health issue. However, the search for international human rights conventions that are applicable to the issue of female circumcision has been frought with problems, and most experts agree that the most tenable solution is to frame the issue as a “right to health.” Therefore, efforts to divorce the health approach from the human rights approach are unsuccessful. Disciplinary Areas: Anthropology, Public Health, Human Rights Law Learning objectives for this capstone topic could include:
Angry ManClarence SpignerAbstract The fact that Arnold Blackthorn was never legally married makes little difference to him. He has been divorced and is now without “wife” and child. Arnold is presently caught up in a bureaucratic maze of welfare rules and legalese that seems totally hostile to just him. He’s is worried to the point of hysteria about his 6 year-old daughter. He feels little Rayna’s situation grows worst by the minute due to her mothers’ negligence of which only he has witnessed, and possibly from the new man now in the house. Child Protective Services has no record of Rayna being abuse. Arnold is the one the case-workers do not like. His brooding mood and intense demeanor is off-putting, and his unscheduled drop-ins with complaints expressed in a rage does not his promote his alleged case of child abuse. Arnold knows the deck is stacked against him, but he can not understand why child’s mother is automatically given the benefit of the doubt? Arnold has a high school education. He works for a construction company by day and drives a cab at night. His dream is to start his own home repair business. Having been singled all of his adult life (he’s now 43 years old), Arnold use to live only for himself. Then he met Rayna’s mother, and her child came into his life. A system of child welfare seems built just to keep him away. Rayna is not Arnold’s biological child. When asked his relationship to the little girl, without hesitation he responded that he is her father. To him, this was a true statement. But he now realizes that the “truth” in his eyes will only diminish his credibility as a concerned “father.” He realizes when it’s found out that he lied to officials, his declaration of parent-hood will sink his case of the child being at-risk. All he can think about is the physical and psychological abuse that surely will be visited upon his daughter. Disciplinary Bases: Public Health; Social Work; Public Policy; Law; Psychology; Sociology Learning Objectives:
Child of GodClarence SpignerAbstract Elana Billings always knew she was adopted. She came from Philippines as a baby, and that is just about all information about her background she has been able to get from her parents. They lived on what was left of a farm in a back-water town of 15,000 people located somewhere in the northeast corner of the State of Oregon. Elena’s father, Jack Billings, was a red-neck with a heart-of-gold. You’d have to know Jack to understand that description. Her mother, Abigail, worked as a nurses’ aid in the State’s mental institution before it was converted to a minimum security prison. Jack now works as prison guard there. His job has done little to improve his view of humanity. When she reached age18, Elena won a scholarship and went away to college. With her long black hair, dark features and almond eyes, she was often mistaken for an American Indian, especially in her home-town. Now away at college, she “blended-in” with many of the other ethnic groups there. Many thought her to be a Latina, or from South Asia, or sometimes Italian, and once for a Sephardic Jew. Stories about the “nature” of Black inferiority still tore at her. Her mother cautioned that father’s opinions came from ignorance and his own sense of inferiority. Still, Elana wrestled with personal feelings of inferiority which exacerbated when she begin to suspect that her biological father might have been an African American soldier. Still, she gravitated towards her new found “blackness” both politically and socially at college. Blacks seem to reach out to her under a collective assumption that she obviously was “one of them.” She saw little reason to debate it since she enjoyed the social cohesion. She joined Black political and cultural organizations; dated Black, and studied African and African American history. She developed interests in biology and the social sciences, and combining them, built an academic background for a career in public health or cultural medicine. Her studies started focusing on the determinants of health: i.e., genetics, the role of the social and cultural environment, lifestyle factors, and the health delivery infrastructure. These approaches re-sparked her concern about just how “black” she might be. For instance, how biologically predisposed to certain diseases was she? Was she more or less vulnerable to certain socio-environmental assaults? Did culturally-based assumptions about health behaviors foster blame or credit; and how would she fit-into the status-quo of the health and medical establishment? Disciplinary Bases: Public Health; Sociology; Biology; Psychology; Semantics; Public Policy Learning Objectives:
The Un-ChosenClarence SpignerAbstract Jefro Snider was a very sick man. The night was cold and the pain in his side was excruciating. He urinated behind a dumpster in the alley, and could not tell if red color in his pee came as a result of the neon sign that reflected from a bar over-head or not. He shuffled to a doorway to sleep, and wait for the morning sun. Jefro grew up during the Jim Crow Era in South Carolina. His father, an impoverished share-cropper, died young, leaving him and his two younger brothers, Henry and John, to be were raised by their mother. The boys were all in their teens when their mother died, and so they moved north to New York City to make their way in the world. For a time, the brothers stuck together. Henry had only a high school diploma but found good employment working at a bank. John, the youngest, attended City College for a teaching certificate. But Jefro drifted… from a series of odd jobs such as dish-washer, janitor, day laborer, and for a while, as telephone installer/repairmen for New York Bell, but nothing lasted. When he met Cathy, a middle-class young woman from a troubled family, it was as if the two would form an everlasting bond and shelter each-other from a heartless world. But in less than a year, Cathy left. That was seven years ago and Jefro has been roaming the back allies of major American cities since. Disciplinary Bases: Public Health; Anthropology; Sociology; Public Policy; Geography; History Learning Objectives: To allow for a critical examination of health and homelessness. Are you really an Indian?Jonathan WarrenIn the municipal of Aracuai, located in the sertão (dry hinterlands) of northeastern Brazil which is also the poorest region in the country, two communities have emerged in the past ten years: an indigenous community called the Arana and a maroon community named the Bau. Until recently individuals in these communities identified as poor, mixed-race Brazilians. However, now they are asserting identities in which race is centered and that have very different meanings and consequences in the regional and national context where they reside. This raises a whole new set of opportunities and limitations to the difficult lives that most Brazilians confront in this region. To take a few examples: First their new identities are both stigmatized and not accepted. Indianness is both romanticized and denigrated, and the Arana, for example, are considered racial charlatans. What are constructive ways of dealing with such a symbolically violent context? Second, they are emphasizing memories that are both therapeutic and painful and that the broader society considers inappropriate to discuss. The Bau, for instance, have begun remembering and telling stories about its painful experiences with slavery – memories which most Brazilians choose to forget. How can a community be assisted in dealing with atrocities that they and their immediate relatives suffered? Third, they are identifying with communities, namely indigenous and black, that impose their own expectations for behavior and criteria for membership – the policing of which has even resulted in physical violence. Are their any strategies or skills that might help communities and its members navigate these tensions around community membership? There are other issues at play as well. In their endeavors to legitimate and develop their communities, both the Bau and Arana are attempting to be federally recognized as quilombo and indigenous communities respectfully. If they are recognized, tensions with the surrounding community could be heightened considerably. They are also seeking aide from international NGOs to help with the construction of an arts and crafts/community house, school and irrigation system. This means not only acquiring the knowledge of grant writing but also successfully navigating NGOs’ conceptions of authentic Indianness and Blackness; something that can be very different from how the federal government and surrounding communities define these racial locations. To get a better education, many young adults leave their communities for 2 or 3 years – leaving their children with their parents and sometimes creating a feeling of detachment between these individuals and their communities. Basic health care is of poor quality; the infant mortality rate, for example, is very high. How might these new identities affect, both positively and negatively, the quality of health care? Finally they are struggling with how to build the economic base of their communities; unemployment is rampant and will likely intensify as they assert their new identities. What sort of constraints and possibilities do their new identities present for micro-development projects? Learning Objectives:
Sex (workers) and the cityJoe ZuntAbstract Under Peru's criminal legislation, prostitution is not classified as an offense for persons who engage in it and are eighteen years of age or older. However, any person promoting or favoring the prostitution of another will be sentenced to a prison term of not less than two nor more than five years. The Barton Clinic in Lima’s port city of Callao, is one of four reference centers for sexually transmitted infections (STI) in the Lima metropolitan area. Under a national program organized by the Peruvian Ministry of Health’s Program for the Control of STI and AIDS (PROCETSS), the Clinic provides free periodic medical attention to female sex workers, including clinical evaluation, diagnostic testing and counseling services every 28 days. Each woman receives an official stamp on her carnet after each screening that she is required to show the brothel owner prior to renting a room for the day. The ability of the Clinic to offer diagnostic and treatment services depends upon availability of laboratory reagents, antibiotics and equipment from the Ministry of Health. Periodic shortages can limit the Clinic’s ability to provide some diagnostic services. The laboratory staff at the Clinic has adapted to deficiencies of equipment: lack of an ELISA reader for HIV testing means that ELISA results are interpreted manually; a broken incubator means that diagnosis of gonorrheal infection is based on Gram stain rather than culture. The centrifuge in use no longer functions correctly. After an afternoon of screening female sex workers for STI in the public health clinic, the social worker, physician and laboratory technologist have just enough time to grab an Inca cola and snack from a street vendor before loading up the mobile medical van with educational brochures and supplies before heading out to set up a temporary examination room in a nearby hostel. The social worker approaches a young woman standing on the corner outside a bar. Once the social worker identifies herself as part of a public health team providing healthcare to female sex workers, the young woman accepts an invitation to discuss STI and receive a gynecologic examination. The young woman is 16 years old and has heard of HIV and syphilis, but is unable to name any other STI or note what symptoms such infections may produce. She states she tries to use condoms with clients when condoms are available and the client is willing. Sometimes she’ll have sex without a condom if the client agrees to pay a higher price. She is the third of five children and completed grade school; her siblings earn money by selling newspapers and toys on the street corners. Her father is away most of the year working in the copper mines but occasionally sends money home to buy food. The examination does not reveal an STI, but her pregnancy test is positive. Disciplinary Perspectives: Public health, Public policy, International law, Medicine, Social work Learning Objectives:
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