Five Classic Articles in Public Health

In this brief review, Dr. Jonathan Borak comments on five seminal papers that helped shape the fields of epidemiology and public health. These papers include Hill’s criteria for inferring causality; the first proof of the multistage theory of cancer; the first evidence that subclinical lead exposures can cause neurobehavioral impairment in children; a simple yet robust study that had a major influence on setting current air pollution policies; and a landmark review of the general public’s perception of risk in relation to actual public health hazard.Dr. Jonathan Borak is a Clinical Professor of Epidemiology and Public Health at the Yale School of Public Health, Clinical Professor of Internal Medicine at the Yale School of Medicine, and Director of the Yale Interdisciplinary Risk Assessment Forum. In this article, Dr. Borak provides his perspective on five publications that significantly influenced the study and practice of epidemiology and public health. This article is the first in a series that will identify and provide commentary on the top five seminal papers published in a field related to biology and medicine.A former student, a member of the Yale Journal of Biology and Medicine’s Editorial Board, reminded me of a comment I made in class. I had described a particular assigned reading as “one of those classic articles” that should be read by everyone studying public health. Okay, he challenged me, what other “classic articles” were on my list? And so began the following: my short list of five articles that represent “must reading” for all students in public health.First, note that I do not speak for public health in general, a field of great breadth of interest and activity, but only the narrower slice, including toxicology, risk assessment, and related interests. Also, I was principally concerned to identify articles that provide models of critical thinking, addressed issues of substantial public health importance, and served as stepping stones for subsequent research and the formulation of public health policy. I also wanted to include articles that were observational and opportunistic, i.e., based on real world observations and available data, not complex laboratory models.My five choices below include: 1) a landmark presentation of criteria for inferring causality from observational data (Hill 1965); 2) a thought experiment based on the re-analysis of publicly available cancer mortality data, which shaped the fields of cancer biology and risk assessment (Armitrage & Doll, 1954); 3) an early study of the effects of lead exposure in school children (Needleman, 1979); 4) a study of the impact of air pollution on children’s health, which was enabled by a fortuitous labor dispute that shuttered a polluting steel mill (Ransom & Pope, 1992); and, 5) a critical literature review of cognitive psychology research that shaped our understanding about how public health risks are perceived (Slovic, 1987).     

Helping Science and Drug Development to Succeed through Pharma-Academia Partnerships: Yale Healthcare Conference 2013

The theme of the 2013 Yale Healthcare Conference was “Partnerships in Healthcare: Cultivating Collaborative Solutions.” The April conference brought together leaders across several sectors of health care, including academic research, pharmaceuticals, information technology, policy, and life sciences investing. In particular, the breakout session titled “Taking R&D Back to School: The Rise of Pharma-Academia Alliances” centered on the partnerships between academic institutions and pharmaceutical companies. Attendees of the session included members of the pharmaceutical industry, academic researchers, and physicians, as well as graduate and professional students. The discussion was led by Dr. Thomas Lynch of Yale University. Several topics emerged from the discussion, including resources for scientific discovery and the management of competing interests in collaborations between academia and the pharmaceutical industry.     

2009 Society for Medical Anthropology Conference: Reflections on the Future of Anthropology

In his plenary session entitled Five Questions on the Future, Harvard anthropologist Arthur Kleinman capitalized on the 2009 Society for Medical Anthropology Conference’s theme of Medical Anthropology at the Intersections to speculate on the future of the discipline.As he reflects on the field of anthropology, which had lacked theory, ethnography, and strong ties to public health and medicine, Harvard anthropologist Arthur Kleinman celebrates the accomplishments made by his contemporaries by saying, “My generation has made medical anthropology what it is today.” However, he is now looking to the future of the discipline, saying it must re-examine itself as a field.During the 2009 Society for Medical Anthropology Conference at Yale University, Kleinman capitalized on the theme of Medical Anthropology at the Intersections in his plenary session entitled Five Questions on the Future. Casting the conference itself as a kind of intersection, Kleinman not only lauded its size and diversity, but asserted that it marked a pivotal moment in which medical anthropology must re-evaluate its central questions.     

“Tazomoka Is Not a Problem”. Local Perspectives on Malaria,Fever Case Management and Bed Net Use in Madagascar

Background

Although its incidence has been decreasing during the last decade, malaria is still a major public health issue in Madagascar. The use of Long Lasting Insecticidal Nets (LLIN) remains a key malaria control intervention strategy in Madagascar, however, it encounters some obstacles. The present study aimed to explore the local terminology related to malaria, information channels about malaria, attitude towards bed nets, and health care seeking practices in case of fever. This article presents novel qualitative findings about malaria. Until now, no such data has been published for Madagascar.

Methods

A comparative qualitative study was carried out at four sites in Madagascar, each differing by malaria epidemiology and socio-cultural background of the populations. Seventy-one semi-structured interviews were conducted with biomedical and traditional caregivers, and members of the local population. In addition, observations of the living conditions and the uses of bed net were conducted.

Results

Due to the differences between local and biomedical perspectives on malaria, official messages did not have the expected impact on population in terms of prevention and care seeking behaviors. Rather, most information retained about malaria was spread through informal information circulation channels. Most interviewees perceived malaria as a disease that is simple to treat. Tazomoka (“mosquito fever”), the Malagasy biomedical word for malaria, was not used by populations. Tazo (“fever”) and tazomahery (“strong fever”) were the terms more commonly used by members of the local population to refer to malaria related symptoms. According to local perceptions in all areas, tazo and tazomahery were not caused by mosquitos. Each of these symptoms required specific health recourse. The usual fever management strategies consisted of self-medication or recourse to traditional and biomedical caregivers. Usage of bed nets was intermittent and was not directly linked to protection against malaria in the eyes of most Malagasy people.

Conclusions

This article highlights the conflicting understanding of malaria between local perceptions and the biomedical establishment in Madagascar. Local perceptions of malaria present a holistic vision of the disease that includes various social and cultural dimensions, rather than reflecting one universal understanding, as in the biomedical image. The consideration of this “holistic vision” and other socio-cultural aspects surrounding the understanding of malaria is essential in implementing successful control intervention strategies.     

2009 Society for Medical Anthropology Conference: Training,Communication, and Competence: The Making of Health Care Professionals

The role of medical anthropology in tackling the problems and challenges at the intersections of public health, medicine, and technology was addressed during the 2009 Society for Medical Anthropology Conference at Yale University in an interdisciplinary panel session entitled Training, Communication, and Competence: The Making of Health Care Professionals.The discipline of medical anthropology is not very formalized in the health setting. Although medical anthropologists work across a number of health organizations, including schools of public health, at the Centers for Disease Control (CDC), and at non-governmental organizations (NGOs), there is an emerging demand for an influential applied medical anthropology that contributes both pragmatically and theoretically to the health care field.The role of anthropology at the intersections of public health, medicine, and technology was addressed during the 2009 Society for Medical Anthropology Conference at Yale University in September. In a conference session entitled Training, Communication, and Competence: The Making of Health Care Professionals, health professional career issues, including training and education, medical entrepreneurship, and the maintenance of clinical relationships with patients were examined. The presentations encompassed macro approaches to institutional reform in training, education, and health care delivery, as well as micro studies of practitioner-patient interaction. Seemingly disparate methodological, disciplinary, and theoretical orientations were united to assess the increasing relevance of medically oriented anthropology in addressing the challenges of health care delivery, health education, and training.Margaret Bentley, a professor of public health at the University of North Carolina, Chapel Hill, spoke about the increasing “epidemic of global health” in universities, noting a doubling of global health majors within the past three years. Despite this expansion of the field, a common discipline of global health continues to be developed. In September, the Association of Schools of Public Health (ASPH) and the University of Minnesota hosted a Global Health Core Competency Development Consensus Conference with the initiative to explore “workforce needs, practice settings, and to identify core constructs, competency domains, and a preliminary global health competency model”¹. Given the current variability in training, Bentley believes medical anthropology is uniquely suited to inform training in global health because of its offerings in the way of interdisciplinary methods and team-based applied field experience.Anthropologists Carl Kendall of Tulane University and Laetitia Atlani of Université de Paris X Nanterre have seen medical anthropologists examine models of health strictly within a clinical experience. Understanding of the social determinants of epidemiology, methodological issues of population health, and survey research is crucial. However, training individuals through a more formalized program (currently in development in Europe) will allow anthropologists to better understand context, explain complex models, humanize aggregate statistics, and articulate methods of the multidimensional “social field” of health outside of the clinical experience.The social field of health, however, as Robert Like of the University of Medicine and Dentistry of New Jersey explained, shares an uncomfortable interface with clinical medicine. Recent efforts by the New Jersey Board of Examiners to incorporate cultural competency legislation have been robustly criticized. Evaluations of six-hour training sessions on cultural competency training have revealed health professionals’ frustration with the health care system’s inability to deal with “culturally different” individuals. In fact, the majority of health professionals who were required to complete the training believe cultural competency to be an area of study that is a “waste of time.”This opposition to cross-cultural education and the value of “cultural competence” training also has been a topic of great debate among anthropologists and health researchers. Despite the ubiquitous use of the term among research and health professionals, cultural competency is a term that cannot be defined precisely enough to operationalize.In “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It,” Arthur Kleinman and Peter Benson asserted that the static notion of culture in the medical field “suggests that a culture can be reduced to a technical skill for which clinicians can be trained to develop expertise” [1]. T.S. Harvey, a linguistic and medical anthropologist at the University of California, Riverside, expounded on Kleinman’s opposition to competence as an acquired “technical skill” [1] and suggested reconceptualizing the approach to competence as communication. Although Kleinman’s explanatory models approach [2] provides a health care professional with what to ask the patient, Harvey pulls from Dell Hymes’ communicative competence [3] to understand how to ask it. Harvey recommended viewing competence as a “sociolinguistic acquisition … like a foreign language” where competencies are rule-governed and communication and speech events are formulaic.Harvey also noted that the “onus of cultural competency” is too often placed on the practitioner. Inevitably, there is an asymmetry in every clinical encounter, whereby the “would-be patient” is perpetually considered the “passive receptor.” Patients also share a stake in their health and, as such, should be taught communicative competence as well.Harvey also noted that the “onus of cultural competency” is too often placed on the practitioner. Inevitably, there is an asymmetry in every clinical encounter, whereby the “would-be patient” is perpetually considered the “passive receptor.” Patients also share a stake in their health and, as such, should be taught communicative competence as well.The role of the patient is made ever more complex by the power relationship that exists in the patient-provider context. Through ethnographic research, Sylvie Fainzang, director of research in the Inserm (Cermes), examines how doctors and patients lie. She argues that lying, in the context of secrecy, is an indication of a power relationship [4]. Fainzaing’s further research on the relationship between doctors and patients has yielded additional information on how patients learn about their diagnoses and how they will react to these diagnoses. Though a clinical encounter between a doctor and patient is expected to be one of informed consent, doctors often judge patients upon their ability to “intellectually understand” [4] and assess who is “psychologically ready” [4] to bear the information. This leads to manipulated, misinformed, and “resigned consent” [4]. This sort of social training of obligation of a subject to medical authority provides the patient with the choice either to conform or overthrow the rules as defined by society.Collectively, this interdisciplinary panel worked to inform the discussion on how medical anthropology can address training, communication, and competence at the intersections of medicine, public health, and education. By reviewing health professionals’ growing interest in public health, training in health education and competence, and the patient-provider relationship, medical anthropology can be seen as both relevant and necessary to addressing the challenges faced by the medical and health community today.     

2009 Society for Medical Anthropology Conference: Changing Anthropology,Changing Society

Fifty years after the founding of the field of medical anthropology, the Society for Medical Anthropology of the American Anthropological Association held its first independent meeting on September 24-27, 2009, at Yale University.Fifty years after the founding of the field of medical anthropology, the Society for Medical Anthropology of the American Anthropological Association held its first independent meeting on September 24-27, 2009, at Yale University in New Haven, Connecticut. The conference, Medical Anthropology at the Intersections, drew an international audience of more than 1,000 scholars.In her opening remarks, program Chair Marcia Inhorn noted that medical anthropology has been interdisciplinary since its inception. This assertion was supported at a roundtable discussion, Founding Medical Anthropology and the Society for Medical Anthropology, which featured four of the field’s founders.Asked to identify the factors that led to the development of medical anthropology, the panelists emphasized the role of changes in the practice and landscape of medicine in the late 1950s and early 1960s in the United States. According to Hazel Weidman, who helped spearhead the Society for Medical Anthropology, medical personnel sought social scientists’ guidance in the new clinical environments created by the increasing involvement of U.S. physicians in global development work and by the community-oriented approach to mental health encouraged by the Community Mental Health Act of 1963. The novel inclusion of lifestyle as a determinant of health at this time also played a role, according to Clifford Barnett. Norman Scotch, author of a 1963 review that had helped define medical anthropology as a field, noted that physicians at the time were very interested in the possible applications of the social sciences to medicine [1,2]. Joan Ablon recalled that this emphasis on application led some academic anthropologists to dismiss the medical anthropologist as a “handmaiden to the doctors.” Despite such resistance, interest in medical anthropology as a sub-field was clearly growing among anthropologists. When Weidman helped organize the first gathering of medical anthropologists at an anthropology conference in 1967, attendance was twice what was expected. Panel organizer Alan Harwood noted that the Society for Medical Anthropology transformed its newsletter into a professional journal, Medical Anthropology Quarterly, in 1983. According to Inhorn, the society has 1,300 members today.For the panelists, medical anthropology’s potential for application makes it a compelling scholarly pursuit. As Barnett stated in explaining his decision to work in anthropology: “If you know how a society works, you can change it.”     

Patient Knowledge on Malaria Symptoms Is a Key to Promoting Universal Access of Patients to Effective Malaria Treatment in Palawan,the Philippines

Introduction

Palawan, where health care facilities are still limited, is one of the most malaria endemic provinces in the Philippines. Since 1999, microscopists (community health workers) have been trained in malaria diagnosis and feasibility of early diagnosis and treatments have been enhanced throughout the province. To accelerate the universal access of malaria patients to diagnostic testing in Palawan, positive health seeking behavior should be encouraged when malaria infection is suspected.

Methods

In this cross-sectional study, structured interviews were carried out with residents (N = 218) of 20 remote malaria-endemic villages throughout Palawan with a history of suspected malaria from January to February in 2012. Structural equation modeling (SEM) was conducted to determine factors associated with appropriate treatment, which included: (1) socio-demographic characteristics; (2) proximity to a health facility; (3) health seeking behavior; (4) knowledge on malaria; (5) participation in community awareness-raising activities.

Results

Three factors independently associated with appropriate treatment were identified by SEM (CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = .000): “living near microscopist” (p < 0.001), “not living near private pharmacy” (p < 0.01), and “having severe symptoms” (p < 0.01). “Severe symptoms” were positively correlated with more “knowledge on malaria symptoms” (p < 0.001). This knowledge was significantly increased by attending “community awareness-raising activities by microscopists” (p < 0.001).

Conclusions

In the resource-limited settings, microscopists played a significant role in providing appropriate treatment to all participants with severe malaria symptoms. However, it was considered that knowledge on malaria symptoms made participants more aware of their symptoms, and further progressed self-triage. Strengthening this recognition sensitivity and making residents aware of nearby microscopists may be the keys to accelerating universal access to effective malaria treatment in Palawan.     

Growing into My White Coat: Improving the Patient-Provider Relationship Through Diverse Patient Interviews

The “Patient Diversity” assignment is an integral component for all medical and other health care professional students rotating through the Surgery clerkship at the Yale School of Medicine. Students are instructed to interview a surgical patient who is of a varied social or cultural background to identify how psychosocial factors impact patient coping strategies. In the process, students often appreciate how health care providers’ own social and cultural backgrounds similarly shape their sentiments and reactions in patient care. In this interview with a 26-year-old surgical patient, one student strives to come to terms with her personal insecurities in patient interactions and seeks to overcome them through open conversation and honest introspection. By working to acknowledge and understand patient diversity, health care providers can enhance understanding of their patients’ conditions and form more trustful and empathic relationships with both their patients and colleagues.     

Perspectives on Efficiency and Quality in an Ever Changing System: Healthcare 2010

The Healthcare 2010 conference at the Omni New Haven Hotel at Yale in April focused on how different stakeholders in the healthcare industry can excel in light of the recent landmark health-reform bill. A session titled “Maintaining Efficiency and Quality in an Ever Changing System” provided valuable insights into several perceptions of these two tenets, with respect to both the current state of U.S. healthcare and the recent reform. The engaging dialog that ensued concerning payer, provider, public, and patient perspectives yielded a unique view of the dynamic interplay between efficiency and quality in the context of the current healthcare system. While the discussion highlighted differences in the definitions of efficiency and quality upheld by the various players, a unifying theme emerged: In order to excel in this ever changing system, incentive structures will have to evolve to take full advantage of the potential synergies between the two.The recent passage of a landmark health-reform bill has tremendous implications for the future of U.S. medicine and healthcare. The Healthcare 2010 conference, which took place in April at the Omni New Haven Hotel at Yale, focused on how different stakeholders in the healthcare industry should proceed in light of this legislation. While a hallmark of the reform bill is expanded access to healthcare for millions of Americans, analysts generally couple the need for access with the tenets of efficiency and quality, forming the “iron triangle” of health policy. A session titled “Maintaining Efficiency and Quality in an Ever Changing System” provided valuable insight into perceptions of efficiency and quality from several perspectives, with respect to both the current state of healthcare and the recent reform.The session began with the perspective of a private-sector payer. Dr. Ricardo Guggenheim, vice president of Care Management Strategy at McKesson Health Solutions, emphasized that a large fraction of non-sustainable increases in healthcare costs are derived from non-medical expenses. Studies have found that administrative costs are one of the fastest-growing components of hospital budgets [1]. Dr. Guggenheim also revealed that hospitals are not nimble in their operations due to a heavy reliance on bonds and many fixed costs. Along these lines, one study conducted in a large urban hospital determined that 84 percent of the hospital’s budget stemmed from expenses that were fixed [2]. Likening it to the banking industry two decades ago, Dr. Guggenheim suggested that the healthcare industry has been lagging behind every other industry in leveraging technology for improvement. In his view, this represents large-scale inefficiency that can only be surmounted by enhanced quality. However, while Dr. Guggenheim acknowledged that the objective of various stakeholders in the healthcare sector is high quality of care, he asserted that cost-effective means should be developed to reach this eventual destination. The potential synergy between efficiency and quality was further elucidated from the provider perspective, represented by Dr. Leora Horwitz, an assistant professor at the Yale School of Medicine and a past Robert Wood Johnson Clinical Scholar. Dr. Horwitz highlighted how providers conceptualize fiscal efficiency in terms of maintaining revenues and minimizing costs, while also considering throughput efficiency in terms of patient flow as well as personnel efficiency, improved by reducing turnover and ensuring that work is done by the most qualified employee. Shifting to the issue of quality, she explained that while stakeholders in the health sector largely agree on the objective of high quality, varying — and sometimes conflicting — ideas of what constitutes high quality complicates policy decisions. Providers rely primarily on process measures and some outcome measures to assess quality in response to external mandates, including publicly reported CMS measures and malpractice drivers, and internal mandates, such as a hospital’s yearly quality plan or board of trustees’ reports. Dr. Horwitz then noted some points of divergence between efficiency and quality from the provider’s perspective. For instance, decreased lengths of stay may result in increased readmissions and using less expensive equipment can be more conducive to failed procedures. Yet she also outlined examples of how better quality may improve efficiency, such as when better discharge care results in fewer readmissions. Greater efficiency also can improve quality in her opinion, as exemplified by fewer medical errors with the advent of electronic medical records. Finally, Dr. Horwitz concluded that incentives are the primary determinant of whether quality and efficiency operate in conflict or synergy. A proper payment structure should incentivize efficiency, while internal and external mandates should work to incentivize quality.Dr. Elizabeth Drye, director of Quality Measurement Programs at Yale-New Haven Hospital Health Services Corp., followed with the public perspective, based on her extensive public health policy work in senior government positions in Washington, D.C. According to Dr. Drye, quality was not an issue given much emphasis in the United States before the Institute of Medicine (IOM) issued a report in 2001, entitled Crossing the Quality Chasm. This report established six aims in order to improve healthcare quality: safety, efficiency, effectiveness, timeliness, patient-centeredness, and equity [3]. Dr. Drye emphasized that existing methods of ensuring quality, such as accreditation and threats of malpractice, are not sufficient to improve quality. Building upon Dr. Horwitz’s call for a change in incentive structures, she advocated pay-for-performance using tools such as Healthcare Effectiveness Data and Information Set (HEDIS) scores to influence physician decision making. She added that the major problem in determining a measurable way to achieve high-quality care is that determining what constitutes the “right” care is a very polarizing issue. A solution sometimes employed by both the government and private health plans is to leave the decision of determining the “right” amount of care to providers. Dr. Drye specifically supported a semi-capitated system that gives providers a certain amount of money and allows them to determine how best to use it. She then detailed an array of new potential policy levers that the government could implement to enhance existing incentive structures, such as increasing public reporting of outcome measures, incorporating more quality measures, building broad coalitions in the private sector, instituting pay-for-performance, and using Medicare to test novel approaches.The conversation later shifted to the patient perspective, and the group questioned how the drive toward efficiency and quality could maintain respect for the views of the patient. Dr. Horwitz responded that providers could rely on results from publicly reported patient-satisfaction surveys. The Consumer Assessment of Health Plans (CAHPS) project and the Picker Institute, for instance, have developed valid and reliable patient survey instruments that provide useful qualitative data that have been increasingly publicly distributed [4]. Responding to the apparent shift toward considering the patient’s experience, Dr. Drye cautioned that patients may not always be in a position to make accurate assessments of quality. On a broader scale, she also worried that improved access, as laid out in the health-reform bill, may not necessarily lead to improved quality on its own.In sum, the engaging dialog concerning the payer, provider, public, and patient perspectives yielded unique insight into the dynamic interplay between efficiency and quality in the context of the current healthcare system. The recent healthcare reform has taken some steps toward achieving greater efficiency and quality, but the discussion at the conference highlighted the urgent need for additional progress. Looking ahead, different stakeholders in the healthcare space can borrow from other industries for innovative solutions. While the session highlighted differences in the definitions of efficiency and quality among the different players, a unifying theme emerged: To excel in this ever-changing healthcare system, incentive structures must evolve to foster potential synergies between the two.     

AN “INTEGRATION CONFERENCE” IN A GENERAL HOSPITAL

An “integration conference” has been devised to bring about an integrated approach by the whole staff of a hospital to the whole patient in his whole environment. The aspects of the environment which the conference served to integrate included the family, the hospital, and all its disciplines, and the community and all its available resources. The conference was found to be of value to the patient, his parents, the interns and residents, the specialties in the hospital, the hospital as a whole and the community.     

Ten simple rules for switching from face-to-face to remote conference: An opportunity to estimate the reduction in GHG emissions

In 2020, the world faced the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic that drastically altered people’s lives. Since then, many countries have been forced to suspend public gatherings, leading to many conference cancellations, postponements, or reorganizations. Switching from a face-to-face to a remote conference became inevitable and the ultimate solution to sustain scientific exchanges at the national and the international levels. The same year, as a committee, we were in charge of organizing the major French annual conference that covers all computational biology areas: The “Journées Ouvertes en Biologie, Informatique et Mathématiques” (JOBIM). Despite the health crisis, we succeeded in changing the conference format from face to face to remote in a very short amount of time. Here, we propose 10 simple rules based on this experience to modify a conference format in an optimized and cost-effective way. In addition to the suggested rules, we decided to emphasize an unexpected benefit of this situation: a significant reduction in greenhouse gas (GHG) emissions related to travel for scientific conference attendance. We believe that even once the SARS-CoV-2 crisis is over, we collectively will have an opportunity to think about the way we approach such scientific events over the longer term.     

Four Children and Yale: The Making of a Human Geneticist: The Grover Powers Lecture 2014

Dr. Leon E. Rosenberg delivered the following presentation as the Grover Powers Lecturer on May 14, 2014, which served as the focal point of his return to his “adult home” as a Visiting Professor in the Department of Pediatrics. Grover F. Powers, MD, was one of the most influential figures in American Pediatrics and certainly the leader who created the modern Department of Pediatrics at Yale when he was recruited in 1921 from Johns Hopkins and then served as its second chairman from 1927 to 1951. Dr. Powers was an astute clinician and compassionate physician and fostered and shaped the careers of countless professors, chairs, and outstanding pediatricians throughout the country. This lectureship has continued yearly since it first honored Dr. Powers in 1956. The selection of Dr. Rosenberg for this honor recognizes his seminal role at Yale and throughout the world in the fostering and cultivating of the field of human genetics. Dr. Rosenberg served as the inaugural Chief of a joint Division of Medical Genetics in the Departments of Pediatrics and Internal Medicine; he became Chair when this attained Departmental status. Then he served as Dean of the Medical School from 1984 to 1991, before he became President of the Pharmaceutical Research Institute at Bristol-Myers Squibb and later Senior Molecular Biologist and Professor at Princeton University, until his recent retirement. Dr. Rosenberg has received numerous honors that include the Borden Award from the American Academy of Pediatrics, the McKusick Leadership Award from the American Society for Human Genetics, and election to the Institute of Medicine and the National Academy of Sciences.     

First Barcelona Conference on Epigenetics and Cancer

The Barcelona Conference on Epigenetics and Cancer (BCEC) entitled “Challenges, opportunities and perspectives” took place November 21–22, 2013 in Barcelona. The 2013 BCEC is the first edition of a series of annual conferences jointly organized by five leading research centers in Barcelona. These centers are the Institute of Predictive and Personalized Medicine of Cancer (IMPPC), the Biomedical Campus Bellvitge with its Program of Epigenetics and Cancer Biology (PEBC), the Centre for Genomic Regulation (CRG), the Institute for Biomedical Research (IRB), and the Molecular Biology Institute of Barcelona (IBMB). Manuel Perucho and Marcus Buschbeck from the Institute of Predictive and Personalized Medicine of Cancer put together the scientific program of the first conference broadly covering all aspects of epigenetic research ranging from fundamental molecular research to drug and biomarker development and clinical application. In one and a half days, 23 talks and 50 posters were presented to a completely booked out audience counting 270 participants.     

Perceived Quality of Care for Common Childhood Illnesses: Facility versus Community Based Providers in Uganda

Objective

To compare caretakers’ perceived quality of care (PQC) for under-fives treated for malaria, pneumonia and diarrhoea by community health workers (CHWs) and primary health facility workers (PHFWs).

Methods

Caretaker rated PQC for children aged (2-59) months treated by either CHWs or PHFWs for a bought of malaria, pneumonia or diarrhoea was cross-sectionally compared in quality domains of accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment and trust. Child samples were randomly drawn from CHW (419) and clinic (399) records from eight Midwestern Uganda districts. An overall PQC score was predicted through factor analysis. PQC scores were compared for CHWs and PHFWs using Wilcoxon rank-sum test. Multinomial logistic regression models were used to specify the association between categorized PQC and service providers for each quality domain. Finally, overall PQC was dichotomized into “high” and “low” based on median score and relative risks (RR) for PQC-service provider association were modeled in a “modified” Poisson regression model.

Results

Mean (SD) overall PQC was significantly higher for CHWs 0.58 (0 .66) compared to PHFWs -0.58 (0.94), p<0.0001. In “modified” Poisson regression, the proportion of caretakers reporting high PQC was higher for CHWS compared to PHFWs, RR=3.1, 95%CI(2.5-3.8). In multinomial models PQC was significantly higher for CHWs compared to PHFWs in all domains except for continuity.

Conclusion

PQC was significantly higher for CHWs compared to PHFWs in this resource constrained setting. CHWs should be tapped human resources for universal health coverage while scaling up basic child intervention as PQC might improve intervention utilization.     

Putting together the pieces of polio: how Dorothy Horstmann helped solve the puzzle

Dr. Dorothy Horstmann, epidemiologist, virologist, clinician, and educator, was the first woman appointed as a professor at the Yale School of Medicine. Horstmann made significant contributions to the fields of public health and virology, her most notable being the demonstration that poliovirus reached the central nervous system via the bloodstream, upsetting conventional wisdom and paving the way for polio vaccines. In 1961, she was appointed a professor at Yale School of Medicine, and in 1969, she became the first woman at Yale to receive an endowed chair, which was named in honor of her mentor, Dr. John Rodman Paul. In this review, the major scientific contributions of Dr. Dorothy Horstmann will be highlighted from her more than 50-year tenure at Yale School of Medicine.     

An Open Source Business Model for Malaria

Greater investment is required in developing new drugs and vaccines against malaria in order to eradicate malaria. These precious funds must be carefully managed to achieve the greatest impact. We evaluate existing efforts to discover and develop new drugs and vaccines for malaria to determine how best malaria R&D can benefit from an enhanced open source approach and how such a business model may operate. We assess research articles, patents, clinical trials and conducted a smaller survey among malaria researchers. Our results demonstrate that the public and philanthropic sectors are financing and performing the majority of malaria drug/vaccine discovery and development, but are then restricting access through patents, ‘closed’ publications and hidden away physical specimens. This makes little sense since it is also the public and philanthropic sector that purchases the drugs and vaccines. We recommend that a more “open source” approach is taken by making the entire value chain more efficient through greater transparency which may lead to more extensive collaborations. This can, for example, be achieved by empowering an existing organization like the Medicines for Malaria Venture (MMV) to act as a clearing house for malaria-related data. The malaria researchers that we surveyed indicated that they would utilize such registry data to increase collaboration. Finally, we question the utility of publicly or philanthropically funded patents for malaria medicines, where little to no profits are available. Malaria R&D benefits from a publicly and philanthropically funded architecture, which starts with academic research institutions, product development partnerships, commercialization assistance through UNITAID and finally procurement through mechanisms like The Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S.’ President’s Malaria Initiative. We believe that a fresh look should be taken at the cost/benefit of patents particularly related to new malaria medicines and consider alternative incentives, like WHO prequalification.     

Do Physical Proximity and Availability of Adequate Infrastructure at Public Health Facility Increase Institutional Delivery? A Three Level Hierarchical Model Approach

This study aims to examine the inter-district and inter-village variation of utilization of health services for institutional births in EAG states in presence of rural health program and availability of infrastructures. District Level Household Survey-III (2007–08) data on delivery care and facility information was used for the purpose. Bivariate results examined the utilization pattern by states in presence of correlates of women related while a three-level hierarchical multilevel model illustrates the effect of accessibility, availability of health facility and community health program variables on the utilization of health services for institutional births. The study found a satisfactory improvement in state Rajasthan, Madhya Pradesh and Orissa, importantly, in Bihar and Uttaranchal. The study showed that increasing distance from health facility discouraged institutional births and there was a rapid decline of more than 50% for institutional delivery as the distance to public health facility exceeded 10 km. Additionally, skilled female health worker (ANM) and observed improved public health facility led to significantly increase the probability of utilization as compared to non-skilled ANM and not-improved health centers. Adequacy of essential equipment/laboratory services required for maternal care significantly encouraged deliveries at public health facility. District/village variables neighborhood poverty was negatively related to institutional delivery while higher education levels in the village and women’s residing in more urbanized districts increased the utilization. “Inter-district” variation was 14 percent whereas “between-villages” variation for the utilization was 11 percent variation once controlled for all the three-level variables in the model. This study suggests that the mere availability of health facilities is necessary but not sufficient condition to promote utilization until the quality of service is inadequate and inaccessible considering the inter-districts variation for the program implementation.     

"C.-E.A. Winslow and the early years of public health at Yale, 1915-1925"

C.-E.A. Winslow was the first chairman of the Department of Public Health at the Yale University School of Medicine. This paper considers the development and changing agenda of his department, the structure of Yale University, and the maturation of public health as a discipline. Winslow's successes and failures are discussed as they relate to Yale and external societal influences.     

Injections,Cocktails and Diviners: Therapeutic Flexibility in the Context of Malaria Elimination and Drug Resistance in Northeast Cambodia

Background

Adherence to effective malaria medication is extremely important in the context of Cambodia’s elimination targets and drug resistance containment. Although the public sector health facilities are accessible to the local ethnic minorities of Ratanakiri province (Northeast Cambodia), their illness itineraries often lead them to private pharmacies selling “cocktails” and artemether injections, or to local diviners prescribing animal sacrifices to appease the spirits.

Methods

The research design consisted of a mixed methods study, combining qualitative (in-depth interviews and participant observation) and quantitative methods (household and cross-sectional survey).

Results

Three broad options for malaria treatment were identified: i) the public sector; ii) the private sector; iii) traditional treatment based on divination and ceremonial sacrifice. Treatment choice was influenced by the availability of treatment and provider, perceived side effects and efficacy of treatments, perceived etiology of symptoms, and patient-health provider encounters. Moreover, treatment paths proved to be highly flexible, changing mostly in relation to the perceived efficacy of a chosen treatment.

Conclusions

Despite good availability of anti-malarial treatment in the public health sector, attendance remained low due to both structural and human behavioral factors. The common use and under-dosage of anti-malaria monotherapy in the private sector (single-dose injections, single-day drug cocktails) represents a threat not only for individual case management, but also for the regional plan of drug resistance containment and malaria elimination.     

2009 Society for Medical Anthropology Conference: Global Public Health through the Eyes of Medical Anthropologist Didier Fassin

At the 2009 Society for Medical Anthropology Conference at Yale University, anthropologist Didier Fassin discussed social inequality and the politicization of health in the context of global public health.U.S. Rep. Joe Wilson shouted, “You lie!” during President Obama’s denial that the proposed health care reform bill would cover illegal immigrants, and anthropologist Didier Fassin used that antagonistic stance toward what the 1978 Declaration of Alma-Ata [1] had called a fundamental human right to best illustrate the issues of social inequality and the politicization of health.Global public health was one focus of the 2009 Society for Medical Anthropology Conference at Yale University in September. Since its inception in 1948, the World Health Organization (WHO) has striven to provide health assistance to the world population, especially those in developing countries. But Fassin, professor of social science at the Institute for Advanced Study at Princeton, professor of sociology at the Université de Paris, Nord, and director of studies in political and moral anthropology at the Ecole des Hautes Études en Sciences Sociales, argued that the concept of global health, albeit well-meaning, is problematic. Its utopian nature is clearly apparent in the rhetoric of politicians, he said, adding that health as a gift of nature, a common good, and the core of the WHO, quickly becomes an object of politics and the coverage in times of sickness of a select few is akin to entitlement and privilege.The present age of globalization certainly makes health threats such as epidemics a threat to all, and nations are in it together to take preventive measures or put up a concerted fight. However, threats like bioterrorism or predicted consequences of global warming such as population migration may be viewed, particularly by Western countries, as security issues that menace national interests and state sovereignties. The consequence being that new policies are implemented that may directly or indirectly affect the rest of the world population.And then there is the issue of humanitarian intervention, which Fassin refers to as “politics of life” [2]. How can we view humanitarianism with the eye of a cynic when it is, in essence, the effort to demonstrate the very best of our nature? Yet the transformation of some humanitarian interventions into military operations and the decision to intervene (Iraq, Kosovo, Bosnia) or not (Rwanda, Ethiopia, Cambodia), politicize this notion. Additionally, Fassin believes that the key nation-states integrate their own cultural and political biases during interventions in troubled regions.Nowhere is this subjectivity more apparent than in the image of suffering as depicted by psychologists and psychiatrists working for non-government organizations (NGOs). NGOs compile testimonies of traumatized people in war and conflict zones, but their subjective narratives enmeshed in the diagnosis reports are increasingly supplanting faithful witness accounts. Fassin sees this trauma as “political expression of the world” [3]. The experts, in trying to raise awareness on issues that need immediate attention, may dramatize certain situations or get emotionally involved during their missions and take sides. They become the new voice of the conflict and their efforts may throw the victims into a state of confusion.It’s no surprise then that some nations view with distrust Western practices and their portrayal of aggressors and victims [4]. In 2000, Thabo Mbeki, then president of South Africa, convened an advisory panel that aimed to collect scientific data to prove that HIV does not cause AIDS. In return, he received the Durban Declaration with the signatures of more than 5,000 scientists and doctors who unilaterally declared the opposite to be scientifically true.Fassin brings up the abovementioned issues in order to shift attention to the difficulties that face our common efforts for better health services. It is truly challenging for Western leaders to mend the rift between their political agendas and accessible health for all, and as long as that continues to be the case, health care will elude millions.