Showing papers by "Paul Farmer published in 2009"

On Suffering and Structural Violence: A View from Below

Abstract: veryone knows that suffering exists. The question is howtodefineit.Giventhateachperson’spainhasa degreeofrealityforhimorherthatthepainofothers cansurelyneverapproach,iswidespreadagreementonthesub jectpossible?Almostallofuswouldagreethatprematureand painfulillness,torture,andrapeconstituteextremesuffering. Mostwouldalsoagreethatinsidiousassaultsondignity,suchas institutionalizedracismandsexism,alsocausegreatandunjust injury. Givenourconsensusonsomeofthemoreconspicuousforms ofsuffering,anumberofcorollaryquestionscometothefore. Canweidentifythosemostatriskofgreatsuffering?Among those whose suffering is not mortal, is it possible to identify thosemostlikelytosustainpermanentanddisablingdamage? Arecertain“event”assaults,suchastortureorrape,morelikely toleadtolatesequelaethanaresustainedandinsidioussuffer ing,suchasthepainbornofdeeppovertyorofracism?Under thislatterrubric,arecertainformsofdiscriminationdemonstra blymorenoxiousthanothers? Anthropologistswhotaketheseasresearchquestionsstudy bothindividualexperienceandthelargersocialmatrixinwhich it is embedded in order to see how various large-scale social forcescometobetranslatedintopersonaldistressanddisease. Bywhatmechanismsdosocialforcesrangingfrompovertyto racismbecomeembodied asindividualexperience?Thishasbeen thefocusofmostofmyownresearchinHaiti,wherepolitical andeconomicforceshavestructuredriskforAIDS,tuberculosis, and,indeed,mostotherinfectiousandparasiticdiseases.Social forcesatworktherehavealsostructuredriskformostformsof extremesuffering,fromhungertotortureandrape.

Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa.

Abstract: Background Little is known about treatment of multidrug-resistant tuberculosis (MDR-TB) in high HIV-prevalence settings such as sub-Saharan Africa. Methodology/Principal Findings We did a retrospective analysis of early outcomes of the first cohort of patients registered in the Lesotho national MDR-TB program between July 21, 2007 and April 21, 2008. Seventy-six patients were included for analysis. Patient follow-up ended when an outcome was recorded, or on October 21, 2008 for those still on treatment. Fifty-six patients (74%) were infected with HIV; the median CD4 cell count was 184 cells/μl (range 5–824 cells/μl). By the end of the follow-up period, study patients had been followed for a median of 252 days (range 12–451 days). Twenty-two patients (29%) had died, and 52 patients (68%) were alive and in treatment. In patients who did not die, culture conversion was documented in 52/54 patients (96%). One patient had defaulted, and one patient had transferred out. Death occurred after a median of 66 days in treatment (range 12–374 days). Conclusions/Significance In a region where clinicians and program managers are increasingly confronted by drug-resistant tuberculosis, this report provides sobering evidence of the difficulty of MDR-TB treatment in high HIV-prevalence settings. In Lesotho, an innovative community-based treatment model that involved social and nutritional support, twice-daily directly observed treatment and early empiric use of second-line TB drugs was successful in reducing mortality of MDR-TB patients. Further research is urgently needed to improve MDR-TB treatment outcomes in high HIV-prevalence settings.

Global health in times of violence

Abstract: What are the prospects for human health in a world threatened by disease and violence? Since World War II, at least 160 wars have erupted around the globe. Over 24 million people have died in these conflicts, and millions more suffered illness and injury. In this volume, leading scholars and practitioners examine the impact of structural, military, and communal violence on health, psychosocial well-being, and health care delivery. By investigating the fields of violence that define our modern world, the authors are able to provide alternative global health paradigms that can be used to develop more effective policies and programs.

Improving quality in resource poor settings: observational study from rural Rwanda

Abstract: Routine care processes critical to hospital care are difficult to execute in overworked, understaffed, and under-resourced settings. The financial and material needs of developing nations have been well documented.[1][1] [2][2]More recently, shortages of human resources have been widely reported.[3

The role of reverse time migration in imaging and model estimation

Abstract: This article covers recent developments in the depth-imaging technology known as reverse time migration (RTM). RTM will be compared to Kirchhoff, beam, and other wave-equation migration techniques. Special emphasis will be placed on the practical application of this technology to reduce exploration cycle time and risk. Recent trends such as TTI anisotropy and wide-azimuth applications will also be discussed.

HIV, infant feeding and implementation failure: advancing policies for women with HIV infection and attaining the Millennium Development Goals

Abstract: Coutsoudis et al.1 offer a viewpoint on the WHO guidelines on HIV and infant feeding that suggests that the use of infant formula among HIV-positive women in the developing world is, to a large extent, currently untenable. The article has many valid arguments: it is well known that promotion of formula feeding among HIV-positive women within the context of inadequate community support, unreliable formula supply and contaminated drinking water can result in excess infant mortality.2 However, empirical data exist that counter some of the authors’ views. It has been demonstrated that formula feeding among HIV-positive women in a context with counselling support and education, access to clean water and uninterrupted availability of breast-milk substitutes can offset the risk of infant mortality. In Cote d’Ivoire, there were no differences in risks of diarrhoea, respiratory infection, malnutrition, hospitalization or death in breastfed versus formula-fed infants of HIV-positive women. The authors of this study suggest that offering safer conditions (clean water, free formula) and a more supportive environment (replacement feeding counselling and education) were elements that reduced the potential threat of mortality among formula-fed infants. These findings were sustained after a two-year follow-up period.3 With safe formula feeding, the vertical HIV transmission rate can be reduced to less than 2%; this is an attainable goal in a resource-limited setting as indicated by results from a preliminary study in Rwanda.4 In addition to a low transmission rate, the mortality rate reported was modest (21 per 1000 person-years) among those infants enrolled at birth in the Inshuti Mu Buzima prevention of mother-to-child transmission programme in rural Rwanda that were offered free formula, materials, education and support through community health workers. Evidence from South Africa offers a more complex picture of infant feeding outcomes in the context of HIV. There, formula feeding demonstrated a protective effect on HIV transmission per death among those living in households with piped water (hazard ratio, HR: 0.51; 95% confidence interval, CI: 0.31–0.84). Among those who had piped water and fuel and who disclosed their HIV status, the protective effect of formula was greater (HR: 0.32; 95% CI: 0.16–0.62). However, among women who did not have piped water or fuel and did not disclose their HIV status, formula feeding conferred an increased risk of HIV transmission per death by 3.5 fold (HR: 3.45; 95% CI: 1.89–6.32).5 These findings suggest that contextual factors are critical when considering the appropriate feeding option for HIV-positive women in resource-poor settings, indicating that in some settings the provision of formula would result in increased child mortality as Coutsoudis et al.1 argue. However, these findings also suggest that aggressive measures to improve water quality and access to other resources may reduce the risk of child mortality associated with provision of infant formula. In fact, improving access to potable water may be the most critical element in offering safe feeding alternatives to HIV-positive women with infants in developing countries and should not be considered an unattainable goal. One of the eight Millennium Development Goals (MDGs) is to “ensure environmental sustainability” (Goal 7) and one of the targets is to “reduce by half the proportion of people without sustainable access to safe drinking water”. Although addressing the global water crisis may not be immediate, as indicated by the MDGs, targets for improving access to potable water must be set and attained for the near future. One should not lose sight of the fact that progress has been made in the past 20 years: since 1990 approximately 1.6 billion people have gained access to safe drinking water. During this period, the child mortality rate for developing countries declined from 103 to 80 per 1000 live births, suggesting improvement with respect to MDG Goal 4 of reducing child mortality.6 Therefore, despite the suggestion that “poverty is not easily or quickly reversed”1, a positive, goal-directed outlook can offer results more quickly. If programmes reducing mother-to-child transmission of HIV through formula feeding are deemed not feasible in a large majority of settings throughout the developing world, thousands of infants will continue to die due to the presumed inability to offer access to clean drinking water and a safe environment for formula feeding. However, in settings where women are offered a safe and supportive environment, the potential for child mortality can be offset and the risk of HIV transmission can be dramatically reduced. The fight against HIV/AIDS can serve as an entry point to demonstrate to families in remote areas that access to clean water and reduction in HIV transmission as well as child mortality are attainable goals as we work collectively towards reaching the MDGs. ■

OA06-03. Dynamics of CTL epitope escape and reversion in an African subtype C cohort

Abstract: Background HIV immune escape follows a predictable mutational path in response to the HLA alleles carried by an individual. The kinetics of CTL epitope escape and reversion in subtype B HIV-1 infected individuals have recently been reported, however, the inferences drawn from them were limited by the absence of information about the transmitted sequence. To address these issues, we examined Gag, Pol and Nef sequences in both partners of 148 epidemiologically-linked transmission pairs from an African subtype C cohort.