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Lecture Notes

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Rhan- Ju Song

WEEK 1 - Biological perspective – looking at biological and cultural factors - Ecological perspective – counting for ecology; separate from human behaviour but links to a cultural factor o i.e. global warming - Evolutionary perspective – accounts for historical contingency; time depth; looks at disease patterns today that are results of long term changes over thousands of years - Anthropogenesis means that we recognize human made factors - Pathogens take advantage of the social conditions created by man - The way we deal w/HIV and AIDS today has changed only since the ‘80s – this is has to do with the visibility of the disease o White men from Europe or North America o Relative visibility plays a role in whether we recognize a disease as an epidemic or endemic because of the publicity provided - Epidemic is a human made word and how we will classify something as an epidemic - ADHD o Dominant western approach to kids with ADHD is to give them drugs (Ritalin) - Some ppl argue the anti-viral drugs for AIDS is making it worse and causing more mortality than the actual disease itself - Pharmaceutical companies play a role in why we still have diseases today – some drugs are too expensive for ppl to buy - Epidemiology o Mostly quantitative info o Looking at patterns of disease within a population instead of an individual o Also looks at behaviour of humans, animals who could be hosts, as well as pathogens o Epidemiological triad of the host, agent, and environment - Paleoepidemiology o Ancient times o Looks at the past o Limited in trying to look at prevalence and incidence rates - Hippocrates o Considered founding father of medicine o The 4 humors - Balance between hot and cold foods is similar to Hippocrates’ 4 humors - John Snow o Founding father of modern epidemiology o Discovered the cholera bacteria - Disease as a Selection Force in Human Evolution o Some would consider the human kind as a product of disease o Even in our DNA, we have foreign sections of DNA picked out by other animals o Have to think about disease as a factor of selection in human evolution and change in population over time - Proximate Causes of Variation in Mortality - Ultimate Causes o i.e. TB o Social, political, economic factors would put a person at risk for TB o Interested in upstream causes - Anthopology’s Contribution o Emphasizing qualitative data o Recognizes individuals o Science is something we consider objective, quantitative, something we can replicate o Anthropology is not as objective, quite a lot of subjectivity, bias o Recognizes why epidemics are in one area and not another - Ethnopgraphy is just a case study – the anthropologist talks to 1-5 ppl about their life/community o Anthropologist writes a narrative o Narrative is an important methodological way to get qualitative data - Culture and Health - Study of epidemics is a scientific approach but is not “value-free” o Biases that exist in us also exist in doctors and nurses WEEK 2 - Epidemiological questions o Epidemiology is the predominant paradigm that we have of epidemics o Ppl are interested in generally patterns in a population - Anthropology is interested in cultural factors and in disease control - Medical anthropologists play a role alongside doctors in disease control but they bring a much more biocultural perspective to the table - Anthropologists are usually interested in the individual, or one family or one group of ppl in a community - Knowledge should lead to behavioural changes and this is the belief of the health belief model o i.e. advising that condoms can prevent HIV, so ppl use condoms more o Even though we have certain knowledge, it doesn’t always lead to a change in behaviour (ppl are still acquiring HIV) o Why doesn’t this model work 100%? Social scientists try to figure out why behaviour doesn’t follow certain knowledge - Important challenge o Some behavioural changes are not practical o Lack of political support - Rapid anthropological assessments o Anthropologists can provide methodological data (such as ethnographies) o Allows an anthropologist much more flexibility to just drop into a society and leave o Quick way to collect data about a community - Biocultural anthropology and epidemics o Essentially we have to think about epidemics (when they occur) o Recognize disease as a product of social rather than just natural settings o Think about the adaptive mechanisms in society that have deteriorated to allow that disease to occur/spike - Environment o We have to increasingly realize it is not just the physical environment but also the living environment and the social environment o Epidemics arise from an unbalance in the social environment  Structural violence Epidemics and consequences - Infectious disease and human history o As much as we’ve evolved, all of it has been accompanied by the pathogens we’ve been exposed to o The experience of the diseases we had 200,000 years ago were not a lot o Isolated, small communities restricted the transfer of disease o In terms of the evolutionary success of a pathogen in a small community, you want a low lethality instead of just wiping out the entire community so you can reproduce and pass on the pathogens o Hunter-gatherers were always on the move, followed animals and resources for food but that moving around keeps them small and less afflicted with infectious disease o 10-15,000 years ago there was a change - The first epidemiological transition o Happened when we first stopped hunting and gathering o First time this shift happened was in the middle east (Turkey, Iraq) o Shift from being mobile, small, groups to becoming a village and domesticating animals o At this time the population began to increase as well, but it’s hard to tell what came first, increase in population or agriculture? o Domesticated plants and animals and reliance on those food sources as a majority of our diet instead of foraging o If you go from moving every 3 months to sedentary, things happen  You meet pathogens and insects you didn’t have contact with before o The transition lead to change in disease that is marked by an epidemiological landscape o The age of pestilence o Ppl started doing specific jobs – lead to stratification and social inequality o Hunter-gatherer/foragers lived in egalitarian societies (everybody was equal) - Dental teeth o Shift to agriculture didn’t necessarily lead to better advantages o Nutritionally humans are better off as hunter-gatherers than farmers o Farmers eat a lot of ONE thing that are essentially just carbohydrates, they fill your stomach but are not nutritionally something you can subsist on o Constant carbohydrates from wheat and rice and porridge leads to poor dental health - Farming – malnutrition o Food all year round but it isn’t the best nutritional quality - Anemia o Low iron in the body o Chronic anemia leads to thinning of the bones of the skull o Many more cases of these conditions in farming communities than in foraging communities o Chronic anemia is a result of two things:  Diet deficient in iron  You can become anemic not because your diet is low in iron but because you suffer from an infectious disease - Disturbances in enamel development o Wilson bands reflect disruptive growth o If there is some sort of stress, the rate of that enamel development and can slow down o Where there is a depression is where there wasn’t enough enamel o A lot more noticeable in farming societies/agricultural societies o Red flag for poor nutrition or infectious disease o Generalized indicator of poor health - Urbanization - Notable epidemics in the past o Bubonic plague o Cholera o Influenza o Smallpox o Tuberculosis - The second epidemiological transition o Decline in infectious disease mortality o Rise in chronic non-infectious diseases o Declining because of improvements in sanitation, living  Development of antibiotics o 3 features of this transition  Replacing infectious diseases with non-communicable diseases/injuries  Morbidity/mortality transitioning from youth to elderly  Change from mortality majority to morbidity majority - Diseases of modernization o Cancer - The third epidemiological transition o The transition we are currently living in o Persistence of chronic non-infectious diseases o Newly emergent diseases and emergence of diseases that were declining in the second transition - Deliberately emerging infectious diseases o Bioterror agents o These agents exist in labs - Emergence of disease with contact o 4 ways health can be impacted  Changes in patterns of survivability  Changes in nutrition  Changes in types of health care - With contact/culture change o Marked by inequality - The Columbian exchange o Two way exchange o 1492 AD o Transoceanic contact - Important host factors o Genotype – leading to greater risk for certain diseases o Nutrition o Pre-existing factors o Previous disease experience – for a group of ppl to be met by sailors who carried highly lethal diseases with them was devastating to the communities  Complete lack of immunity - Crowd diseases o These are acute diseases – if you get them and you have no immunity, you die quickly and there is no effect on your skeleton (so no evidence that smallpox/measles killed a lot of ppl) - Smallpox o Air borne disease o Eradication of smallpox one of the greatest successes of modern science/medicine o Had a lot of social consequences - Pre-Columbian population o Majority of populations getting wiped out by smallpox o Urban areas suffered greatly rather than hunter-gatherers that lived on the edges of societies - Paleopathology o We can infer quite a lot of things from the bones and teeth of individuals - Sources of info o Art o Written sources o Human remains - Cemetery in Rouen, France, is just for plague victims - Challenges o Limited by the evidence - Hard tissue evidence o Skeleton reflects TB o TB effects lung tissue and goes to areas where red blood cells are produced o Suffer from Pott’s spines or hump backs o The spine essentially disintegrates and collapses on itself WEEK 4 - cholera - Surat, India – when the plague broke out, there was panic/chaos o Doctors, nurses, frontline medical professionals fled - Extent of cultural and social reaction to new disease depends on o Virulence and pathogenecity of the agent o Pathway of transmission o Disease manifestations o Repercussions on cultural and societal norms o Culturally specific beliefs that surround the epidemic/disease o Representations are not static, they can change over time o Not based on a true reality, perception is a significant factor in how we respond - Factors in the poor success of public health interventions in an epidemic o Anthropology plays a role in overcoming the ignorance of culturally specific beliefs - Public health interventions, esp. health education, need to consider o Group priorities and risk perceptions o Local belief systems and practices in their social and cultural, as well as economic contexts o Health educational measures that inform populations at risk of how behaviour change is feasible within existing social, economic and cultural constraints - Interdisciplinarity and methodological triangulation between epidemiologists, virologists and social scientists o Linking different pieces of data to see how they may affect each other, to see what is common and what is different o Optimal way we can approach disease and epidemic disease if the goal is to control the disease - Epidemics are happening within the social context of cultures - Epidemics are socially constructed as well as scientifically - Miasma and cholera o John Snow played a role in trying to figure out the cause of cholera beyond the society’s perception o Prior to epidemiology, a lot of diseases perceived to be caused by environmental factors o Snow tried to identify the source of the disease, he walked the neighbourhoods and went to the houses and saw a geographic distribution of the disease o Linked it to certain water pumps that he hypothesized was the source of the disease o Germ theory - Medical geography o Subset of medicine that is interested in the geographic distribution of disease - Cholera o It is a disease that causes rapid deterioration and rapid death via dehydration o Patients suffer extreme vomiting and extreme diarrhea o A lot of ppl can live with cholera, most cases are mild o And most ppl who have no symptoms can be carriers of cholera o In the case of severe symptoms – 2-5% get severe form and potentially die o In terms of protecting against it today, there is a vaccine or antibiotics, but in most cases it’s hoping you don’t get it and if you don’t get it hopefully you can pull through and deal with the dehydration and keep yourself alive/overcome it o Many ppl today still get cholera, different nutritional levels are a factor o Someone who is better nourished will more likely survive cholera o It takes a lot more of the vibrio to cause disease in a healthy person o Cholera is in areas where social living conditions allow for the vibrio to survive  Lack of portable, clean water & sanitation - Origins? o Probably from agriculture, water became contaminated with animal and human fecal waste - ORT and RIT Cholera in Peru - 400000+ cases in Peru in ’91-‘92 - The public perception of the disease was an ecological reason - Warmer temperatures allowed zooplankton to thrive and that is the element that vibrio attach on and thrive on - A critical medical anthropological analysis o Ultimate root cause is usually a political/economical cause - Social and economic factors o Cost of living kept rising from 70s to 90s o Large level of unemployment because gov’t had no money and fired many ppl o Borrowed money from IMF but there were conditions – spend the money on corporations and banks instead of the health sector o Cholera is really a result of poverty, economic globalization and environmental change - Cholera is a product of social rather than natural circumstances - Scapegoating o Another way to blame certain groups within a society, usually minorities - Scapegoating in Gibraltar o Contagionists versus localists o Miasma is a localist belief – “bad air” o By ’85, a lot of policies enforced by the government controlled the Maltese o The Spaniards were dying vastly of cholera but they were not scapegoated because they were an important trading partner o The Maltese were picked on because they spoke a different language, were typically less civilized o Scapegoating is problematic because it leads to stigmatizing WEEK 5 - influenza - It is a disease that effects other animals as well as humans - particularly wild birds are significant reservoirs of the influenza virus and are significant in the story of human influence on influenza - Lower respiratory infections are the number one cause of mortality due to infectious diseases Spanish flu - Mortality rates ranged from 2 to 20 percent, variation depended on the location in the world - 1918-1919 mortality pattern which was a W pattern in USA - Most diseases are a U shaped pattern, effecting the really young and really old - There are theories trying to explain the W pattern o If you had prior exposure or a prior experience, a second exposure may be more detrimental o Those who lived in rural areas didn't progress to secondary symptoms because they were already used to it o In urban settings, you have more novel bacteria and viruses coming at you so your exposure to bacteria is different  You get the infection but then die from a secondary infection - Historical "Siting" o Foreign soldiers living in poor conditions of the battlefield and suffering from poor nutrition o Ineffective medical intervention o Lack of adequate medical professionals and support staff o Increased urbanization which led to crowding - America's Forgotten Pandemic o Reported among soldiers stationed in the midwest o In terms of the mortality impact, it was not huge - Cause and Source of 1918 Pandemic? o H1N1 - swine flu o It has slightly mutated since 1918 but same virus Avian Flu - Population density is one of the highest in the world in Java, Indonesia - Avian flu attributed to the H5N1 - known for its lethality - Killed more than 50% of confirmed cases, only good thing you can say about H5N1 was it was difficult to transmit, in terms of number of cases, it was quite low and most cases were animal-human contact - Only a few cases were documented to be human to human - Have to be thankful in that sense - A lot chicken farming done close to home, probably another room in the house - In a lot of parts of the world, coming into contact with domesticated animals is very common o The animals are in constant contact with the ppl’s resources - In parts of southeast Asia, ppl drink chicken blood type of soup – put as a possible cause for Avian flu but in terms of actually proving that, there is none o Example of trying to find a scapegoat - Indonesia and the Avian Flu o Chickens and ducks in backyards provided extra income o Also provided extra food – eggs o If you had a sick chicken, you had to report it and so if that’s going on and if you have these requirements at a national level, but at a local level it wasn’t being put into practise – long, complex process o Chicken manure was also sold to other ppl, its a byproduct o So there is a lot of ppl involved in chicken farming – literally the whole chicken is used o There are hygiene issues – picking up the poop once a week instead of daily - Commercial Poultry Farming o Distributors sometimes made the decision if they should report a chicken illness o Scapegoating of non-Muslims in Indonesia o A lot of doubted the disease existed within humans, that it was just a disease of the birds o Ethnic tensions always flare up during these situations - Responses to Reports of Flu o Ppl more concerned with other things o In Indonesia – ppl more concerned with dengue fever - Public health Measures and Poultry Farming o Can’t expect everybody to report having a sick chick o It’s risky because if your chicken gets tested and it is sick then they kill all your chickens o Also risked ruining other ppl’s business because if your farm was positive than other farmers within a 5 km radius were tested and if they were positive their chickens were slaughtered too o Self-reporting was basically a failure o Very low compensation - Fear o There was a fear not necessarily in Indonesia but globally o Fear that was tied to the epidemic that was due to its high mortality - Media Representations o International press used war-like metaphors and overhyped it o Local press downplayed the danger - Rumours and Repercussions o One conspiracy theory that was common was that the west was trying to destabilize the poultry industry in Indonesia o Stigma o Stigma associated with chicken and chicken farming o If you associate a certain behaviour with a fact, it can be problematic  Negative association can prevent you from seeking further help or seeking to report  Can lead to poverty and neglect, or MORE poverty and neglect if you’re already in that boat  Distrust health authorities and killing their chickens themselves instead of reporting them  Mass panic among citizens - Indonesia Case Study: Solutions o Horizontal approach rather than vertical approach o Horizontal approach would be looking at access to health care, public education, other qualities of life o The best way to approach an epidemic of disease to look at the whole o What we want to achieve a community that can be self-sustaining and can address the concern themselves and improve public trust in gov’t and health officials - Economic Consequences of Stigma o Why would you want the stigma associated with the disease, lose all your chickens, make your neighbouring farmers lose their chickens, and receive no compensation for all your lost chickens? o In Surat, India – stigma itself can be an epidemic  Everybody fleeing in fear of the disease - H1N1 Swine Flu Pandemic o Define as being pandemic because  It was quite novel  Very highly transmissible  It was a mutated virus  Highly virulent - In terms of epidemics, how do we balance between mass hysteria and prevention - Really need to consider the global demands for animal products – meat has been cheaper than ever WEEK 6 REVIEW CLASS SAMPLE QUESTIONS The third epidemiological transition is most notable for: - Replacement of infectious disease-related mortality by non-infectious disease causes - Re-emergence of infectious diseases due to the interaction of ecology and technology - Global mortality rates predominantly attributed to infectious disease factors - Land encroachment making zoonotic infections the leading cause of mortality Greater contact of human populations with animals did not have the effect of - Lowering population due to competition - Changing human settlement locations - Increasing the quantity of infections - Affecting the etiology of diseases Which of the following is NOT a consequence of stigma described by Barrett and Brown? - Stigmatized individuals are less likely to leave their homes, leading to reduced transmission - Stigma causes social marginalization of the poor, leading to poverty and increased susceptibility - Stigma distorts risk perceptions, leading to mass panic and misallocation of health care spending - Stigma creates barriers against health-care seeking, leading to delayed treatment Which of the following statements is incorrect with respect to cholera? - The disease is caused by a bacteria - The disease emerged in human populations with the advent of urbanization - Oral rehydration therapy consists of a combination of salts and sugars - Vaccines and quarantines are not as effective as sanitation measures in preventing it A Holoendemic level of malaria refers to a population’s parasite rate in 2-9 year olds: - Constantly above 25% - “ 50% - “ 75% - “ 90% STUDENT QUESTIONS - Connection between chicken influenza and humans o It is contact with the carcass o Consumption is not heard of at all as the connection between influenza and ppl o Contact with the mucous, feces, etc. - Do we need to know statistics from the articles? o Only if prof went into detail on statistics within the slides - Do we need to know dates and places? o No. Only 1918 regarding the Spanish flu, but not the other pandemics that were not discusses o FYI the highlighted stuff is the more important stuff to study - For MC questions, should we focus on lecture slides or articles? o Lecture slides are based on articles, so read articles! o If you don’t read the articles, rely on outlines and lecture notes, but better to read articles o FYI do the review questions - What do you mean by conspiracy of cholera? o Important point from article from Monte o In terms of why there was non-compliance – ppl were not cooperating and the authors wanted to figure out WHY o Belief by the habitants that in terms of the public health interventions, they stopped complying because the msgs they were getting were implying there was a campaign by the government that was fortified by the military and police to not to treat the disease but to identify the disease and the ppl who have it and then lead to the killings of the ppl with the disease o The poster sent the msg to the poor that if they have cholera they should be blindfolded and shot (the X indicating execution) o The poor ppl were scared because of their past lived experiences, they faced police brutality and military oppression o Non-compliance was tied to misinterpretation of imagery - The extra slides about epidemiological principles? o Expect you to know the basics, not the specifics o Not going to ask you to compare between different epidemiological studies o But know which one each one is o Read the stattenfiel and strong article - WATCH THE CHOLERA FILM ON YOUTUBE o Understand the significant aspects of that film - ABOUT THE OPTIONAL ESSAY o Proximate versus ultimate factors  Proximate factors are immediate causation factors  Why do you have TB? You have the mycobacterium in your body. Or someone was coughing in your face for SO LONG who has TB.  Ultimate factors  You are in a overcrowded prison and now you’re exposed to it because prisons are particularly filthy, ultimate factor is the Russian structural society, social injustice, police brutality  Ultimate factors are more social factors, what put you in that situation that led to be exposed to TB?  Structural violence factors  Political, economic, inequality factors o Know the public health predictions o Note social consequences o Marks for content and style – 5 and 5, 1% of 15% is for proper referencing o 2/3 is marked for content, 1/3 for style WEEK 7 TUBERCULOSIS - The third epidemiological transition o These re-emergent diseases are stronger, drug resistant strains so they obviously have evolved over tie - Re-emergence of disease o Increasingly we see a trend of ppl moving from rural to urban areas o Ore biological aspects which as to do with pathogens ability to evolve but there is also the issue of medical malpractice that enabled pathogens to evolve - “Structural violence is one way of describing social arrangements that put individuals and populations in harm way... the arrangements are structural because they are embedded in the political and economic organization of our social world’ they are violent because they cause injury to ppl  Gender inequality, racism, socioeconomic status - Tuberculosis o Airborne transmission is why you should be concerned about TB, it is a much more efficient way to spread disease compared to sexual transmission o Primarily effects the lungs but does affect other parts of the body o Ppl can live with it for a long time in the latent form and also in the active form o TB is a chronic condition of bacterial infection o Probably originated with agriculturalism  When humans started to live in one settlement o Only 5-10% of those infected will develop the active form of TB, so most ppl have the latent form because of a good immune system o Majority of adults are getting active TB as a result from re-activation of earlier latent exposure even despite the vaccine o Can be reactivated with acquisition of another disease like HIV o Affects areas of red blood cell production - Hard tissue evidence o Affects vertebra, hip, knee o Bone destruction, not formation o Pott’s spine – collapsed bones; form a wedge that gives you a bent spine which leads to mobility issues - Old world vs. New world o Thought to be brought over with the Spanish when Columbus came o Been with us for thousands of years – shift to agricultural change and then with increased urbanization (population crowding) - A disease that was called “consumption” because it literally consumed ppl’s bodies from the inside out - Historical perspectives on TB? o All populations were equally at risk in the 19th century o In Europe and America, the approach to dealing with TB included public health campaigns (i.e. posters) o A lot of effort put in to contain the disease o Sanatoriums were built that were almost like spas  Get proper food/nutrition, feel like you’re on a holiday but at the same time you’re recovering  Typically catered to the wealthy  Was not perceived too much as a stigmatized disease because everyone had it o Known as “white plague” because so many white ppl infected o Under privileged populations suffered from a significantly higher rate  They were not offered the same resources  There was differential treatment - TB and Minority/Immigrant Groups o Aboriginals o Efforts to contain it, denying entrance into Canada to anyone with TB o Even the ones who are negative for TB and enter Canada are at a higher risk for acquiring TB, usually a reactivation  Could be due to immigration stress, or where they decide to live in Canada (impoverished populations) - A Critical Epistemology of Re-/Emerging Infectious Diseases o TB has particularly come back after the 1980s o Critical epistemology is basically “How do we know what we know?” o In terms of TB, did it emerge, completely disappear, and then show up again? No o After WWII it was much better contained, and considered “gone” by the 1960s o 20 years later after the 60s (as in the 80s), TB rates skyrocketed in north American populations, namely New York - What is emerging? - What is re-emerging? o This is misleading because it wasn’t actually eradicated o Even before the 80s in New York, TB was still around in New York o It is not so much a re-emerging disease as it is a disease that now became visible because it affected a popular location o It has always existed and was endemic in many populations - Social construction of epidemics o It’s been made to be re-emergent, made to be visible, because of the population it effects - Rhetoric of Immediacy o Andrew Speaker – lawyer who contracted TB  Had a form of TB that could not be treated and was advised not to go to Europe to get married but he disregarded that advice and went away  He turned himself in after but he knew he was in trouble  He came back to Montreal and then drove to the USA  It became a disease of immediacy because he was a rich, white, American male o There is social construction between what we consider emergent and re-emergent o TB is becoming more visible now because it’s showing up in affluent locations/populations - TB Today o Continues to effect ppl o Fortunately we see that the overall rate is declining o This decline is happening alongside the bacteria becoming drug resistant o Estimated that a third of the world’s population in infected with mycobacterium  Not necessarily the active one, can be latent OR active o Highest rates are in Africa o TB is second to HIV to be a disease of single infectious agent to cause death - Symptoms o Latent phase has no symptoms o Drug resistance is the major concern with TB - Drug Resistance o Two officially recognized strains of drug resistant TB o MDR-TB o XDR-TB  Increasingly more cases of this TB - TB and Medical Mismanagement o MM has played a big role o We don’t have MDR and XDR because the pathogen decided to evolve  It’s purely a result of MM --> doctors prescribing the wrong drug; not enough drugs  Maybe the ppl couldn’t afford the drugs  Sometimes the quality of the drugs are terrible, they don’t even work  There can be under prescription of the drugs OR the person can only afford only 1 out of 3 of the required drugs  A lot of ppl stop taking the drug ahead of time with prescription left over; get the symptoms again and then go back to the doctor; the doctor prescribes the SAME drugs even though the pathogen has now slightly changed --> doctor’s biggest mistake and is committed so often - Marginalized and Invisible - Disease, Risk Groups and Stigma o Being included in a risk group have social consequences o TB is highly stigmatized, whether you’re white/black, rich/poor o Back in the day it was not marginalized but today it is because it’s more visible and the poorer populations have higher rates o So is it ethical to highlight risk groups and focus public health efforts that way? - Blame and Non-Compliance o Not attending checkups o The favelas – ppl not drinking the chlorinated water o Not doing the full course of prescription treatment o Non-compliance is written down in your medical records o Once you’re considered non-compliant, you’re file is labeled with a big, red X --> doctors won’t want to deal with you, when making patient cuts, the non-compliant ppl are let go first (they add stress to doctors)  But as we know, there are generally underlying social reasons for non-compliance o Patient compliance is the biggest challenge with TB - DOTS o Most effective o Government commitment – including both political will at all levels, and establishing a centralized and prioritized system of TB monitoring, recording and training o Case detection by sputum smear microscopy o Standardized treatment regimen directly observed by a healthcare worker or community health worker for at least the first two months  Some doctors would have an issue with that  What they’re finding today is that the best way to approach TB is thru individualized approach  Identify what type of TB YOU have, what types of drugs would be best for YOU o A regular drug supply o A standardized recording and reporting system that allows assessment of treatment results o Doctors/health workers personally giving you the drugs and observing you taking them - Syndemic o Issues with TB:  1/3 of world having it  Issue of drug resistance  Issue of simple screening/recognition of the disease o Reason why it’s become so pandemic is because of its syndemic relation with HIV o 20-37X more susceptible to TB if you have HIV - WHO’s 3 I’s for Controlling HIV/TB Co-Infection o Intensified TB case finding o Isoniazid preventive therapy o Infection control for TB - TB in Peru, 1990s WEEK 8 - HIV/AIDS - HIv/AIDS o Risk for later infections that kill them because they have a suppressed immune system
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