Showing papers by "Nathan Ford published in 2008"

Substandard medicines in resource‐poor settings: a problem that can no longer be ignored

Abstract: The circulation of substandard medicines in the developing world is a serious clinical and public health concern. Problems include under or over concentration of ingredients, contamination, poor quality ingredients, poor stability and inadequate packaging. There are multiple causes. Drugs manufactured for export are not regulated to the same standard as those for domestic use, while regulatory agencies in the less-developed world are poorly equipped to assess and address the problem. A number of recent initiatives have been established to address the problem, most notably the WHO pre-qualification programme. However, much more action is required. Donors should encourage their partners to include more explicit quality requirements in their tender mechanisms, while purchasers should insist that producers and distributors supply drugs that comply with international quality standards. Governments in rich countries should not tolerate the export of substandard pharmaceutical products to poor countries, while developing country governments should improve their ability to detect substandard medicines.

Conflict in the Indian Kashmir Valley II: psychosocial impact.

Abstract: India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in high levels of exposure to violence among the civilian population of Kashmir (India). A survey was done as part of routine programme evaluation to assess confrontation with violence and its consequences on mental health, health service usage, and socio-economic functioning. We undertook a two-stage cluster household survey in two districts of Kashmir (India) using questionnaires adapted from other conflict areas. Analysis was stratified for gender. Over one-third of respondents (n = 510) were found to have symptoms of psychological distress (33.3%, CI: 28.3–38.4); women scoring significantly higher (OR 2.5; CI: 1.7–3.6). A third of respondents had contemplated suicide (33.3%, CI: 28.3–38.4). Feelings of insecurity were associated with higher levels of psychological distress for both genders (males: OR 2.4, CI: 1.3–4.4; females: OR 1.9, CI: 1.1–3.3). Among males, violation of modesty, (OR 3.3, CI: 1.6–6.8), forced displacement, (OR 3.5, CI: 1.7–7.1), and physical disability resulting from violence (OR 2.7, CI: 1.2–5.9) were associated with greater levels of psychological distress; for women, risk factors for psychological distress included dependency on others for daily living (OR 2.4, CI: 1.3–4.8), the witnessing of killing (OR 1.9, CI: 1.1–3.4), and torture (OR 2.1, CI: 1.2–3.7). Self-rated poor health (male: OR 4.4, CI: 2.4–8.1; female: OR 3.4, CI: 2.0–5.8) and being unable to work (male: OR 6.7, CI: 3.5–13.0; female: OR 2.6, CI: 1.5–4.4) were associated with mental distress. The ongoing conflict exacts a huge toll on the communities' mental well-being. We found high levels of psychological distress that impacts on daily life and places a burden on the health system. Ongoing feelings of personal vulnerability (not feeling safe) was associated with high levels of psychological distress. Community mental health programmes should be considered as a way reduce the pressure on the health system and improve socio-economic functioning of those suffering from mental health problems.

Conflict in the Indian Kashmir Valley I: exposure to violence.

Abstract: Background: India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in several conflicts since the end of partition in 1947. Very little is known about the prevalence of violence and insecurity in this population. Methods: We undertook a two-stage cluster household survey in two districts (30 villages) of the Indian part of Kashmir to assess experiences with violence and mental health status among the conflict-affected Kashmiri population. The article presents our findings for confrontations with violence. Data were collected for recent events (last 3 months) and those occurring since the start of the conflict. Informed consent was obtained for all interviews. Results: 510 interviews were completed. Respondents reported frequent direct confrontations with violence since the start of conflict, including exposure to crossfire (85.7%), round up raids (82.7%), the witnessing of torture (66.9%), rape (13.3%), and self-experience of forced labour (33.7%), arrests/kidnapping (16.9%), torture (12.9%), and sexual violence (11.6%). Males reported more confrontations with violence than females, and had an increased likelihood of having directly experienced physical/mental maltreatment (OR 3.9, CI: 2.7–5.7), violation of their modesty (OR 3.6, CI: 1.9–6.8) and injury (OR 3.5, CI: 1.4–8.7). Males also had high odds of self-being arrested/ kidnapped (OR 8.0, CI: 4.1–15.5). Conclusion: The civilian population in Kashmir is exposed to high levels of violence, as demonstrated by the high frequency of deliberate events as detention, hostage, and torture. The reported violence may result in substantial health, including mental health problems. Males reported significantly more confrontations with almost all violent events; this can be explained by higher participation in outdoor activities.

Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges?

Abstract: There is a critical need for appropriate technical innovation and development, as well as dramatically improved health sector financing In recent years the case for antiretroviral therapy (ART) in those countries hardest hit by the HIV pandemic is seldom contested. Prior to the widespread availability of antiretroviral therapy in many developing countries, there were however frequent concerns expressed about the safety and feasibility of promoting widespread access to ART in countries such as those in Southern Africa. These concerns were premised on the potential “anarchy” that might be the result of weak health systems leading to widespread virological resistance,1,2 on the grounds that there were more cost-effective interventions available given the limited funding baskets at the time,3 and on the potential to do more harm than good if introducing large and complex new interventions into already weak and fragmented health systems, further increasing inequities.4,5 The first public-sector ART treatment programmes in developing countries (with the exception of Brazil) date back to 2000,6 and data are now emerging on the effectiveness of the interventions. Three clear messages are emerging from the accumulating outcomes reporting from public-sector adult ART treatment programmes in poor countries. First, treatment is effective for those accessing ART. Hogan summarised eight programmes from resource-limited settings,7 demonstrating a range of survival outcomes at 1 and 2 years on ART, but all showing marked improvements over the anticipated natural history without ART. The comparative median survival in those eligible but not receiving ART is variously reported as 24 months, and less than a year for CD4 counts of less than 200 and less than 50 cells/μl, respectively.8 More recently the ART-LINC collaboration demonstrated cumulative mortality at 1 year of 6.4% in 2725 patients across 12 cohorts with active follow-up procedures in place. …

Exploring HIV risk perception and behaviour in the context of antiretroviral treatment: results from a township household survey

Abstract: The objective of this cross-sectional household survey was to assess factors influencing HIV risk perception, behaviour and intervention uptake in a community characterised by high HIV prevalence and availability of antiretroviral therapy (ART). The survey was conducted in Khayelitsha, South Africa and involved two-stage sampling with self-weighting clusters and random selection of households within clusters. One man and woman between 14 and 49 years old was interviewed in each household; 696 men and 879 women were interviewed for a response rate of 84% and 92% respectively. Ninety-three percent and 94% were sexually active with median age of sexual debut 15.3 and 16.5 years. Eighty-three percent and 82% reported a partner at the time of interview and 29% and 8% had additional partner(s). Forty-one percent and 33% reported condom use during the last sexual encounter. Thirty-seven percent of men not using condoms did not as they believed their partner to be faithful, whilst 27% of women did not as their partner refused. Twenty-eight percent and 53% had been tested for HIV. Having undergone HIV testing was not associated with condom usage, whilst current relationship status was the strongest association with condom usage for both men and women. In spite of a relatively high uptake of condoms and testing as well as ART availability, the HIV epidemic has continued unabated in Khayelitsha. Even greater coverage of preventive interventions is required, together with a national social and political environment that builds on the availability of both preventive and treatment services.

When Best Practice is Bad Medicine: A new approach to rationing tertiary health services in South Africa

Abstract: South Africa's democracy inherited a health system biased towards tertiary rather than primary health care. Attempts to reverse this imbalance in the Western Cape led to rancorous response from many sectors. We outline the debate and describe the international forces that push developing countries into spending excessive amounts on specialised services. An alternative way of rationing, utilising cost-effectiveness thresholds, is described.

How can South Africa's medical profession contribute to humanitarian action?

Abstract: Training opportunities in such areas as trauma and infectious disease management should be expanded with a view to supporting health professionals in the region. At the same time, because the majority of health staff in the region will not be fortunate enough to be able to travel to South Africa, training modules should be developed that can be replicated in neighbouring countries.