Ariel Pablos-Mendez

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA (A Pablos-Mendez MD); Public Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Human resources for health: overcoming the crisis

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the worlds poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

The Emergence of Drug-Resistant Tuberculosis in New York City

BACKGROUND In the past decade the incidence of tuberculosis has increased nationwide and more than doubled in New York City, where there have been recent nosocomial outbreaks of multidrug-resistant tuberculosis. METHODS We collected information on every patient in New York City with a positive culture for Mycobacterium tuberculosis during April 1991. Drug-susceptibility testing was performed at the Centers for Disease Control and Prevention. RESULTS Of the 518 patients with positive cultures, 466 (90 percent) had isolates available for testing. Overall, 33 percent of these patients had isolates resistant to one or more antituberculosis drugs, 26 percent had isolates resistant to at least isoniazid, and 19 percent had isolates resistant to both isoniazid and rifampin. Of the 239 patients who had received antituberculosis therapy, 44 percent had isolates resistant to one or more drugs and 30 percent had isolates resistant to both isoniazid and rifampin. Among the patients who had never been treated, the proportion with resistance to one or more drugs increased from 10 percent in 1982 through 1984 to 23 percent in 1991 (P = 0.003). Patients who had never been treated and who were infected with the human immunodeficiency virus (HIV) or reported injection-drug use were more likely to have resistant isolates. Among patients with the acquired immunodeficiency syndrome, those with resistant isolates were more likely to die during follow-up through January 1992 (80 percent vs. 47 percent, P = 0.02). A history of antituberculosis therapy was the strongest predictor of the presence of resistant organisms (odds ratio, 2.7; P < 0.001). CONCLUSIONS There has been a marked increase in drug-resistant tuberculosis in New York City. Previously treated patients, those infected with HIV, and injection-drug users are at increased risk for drug resistance. Measures to control and prevent drug-resistant tuberculosis are urgently needed.

Global health 2035: a world converging within a generation

Prompted by the 20th anniversary of the 1993 World Development Report a Lancet Commission revisited the case for investment in health and developed a new investment frame work to achieve dramatic health gains by 2035. The report has four key messages each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. Conclusion 1: there is a very large payoff from investing in health. Conclusion 2: a grand convergence is achievable within our lifetime. Conclusion 3: scale-up of low-cost packages of interventions can enable major progress in NCDs and injuries within a generation. Conclusion 4: progressive universalism is an effi cient way to achieve health and fi nancial protection.

Antimicrobial resistance in developing countries. Part I: recent trends and current status.

The global problem of antimicrobial resistance is particularly pressing in developing countries, where the infectious disease burden is high and cost constraints prevent the widespread application of newer, more expensive agents. Gastrointestinal, respiratory, sexually transmitted, and nosocomial infections are leading causes of disease and death in the developing world, and management of all these conditions has been critically compromised by the appearance and rapid spread of resistance. In this first part of the review, we have summarised the present state of resistance in these infections from the available data. Even though surveillance of resistance in many developing countries is suboptimal, the general picture is one of accelerating rates of resistance spurred by antimicrobial misuse and shortfalls in infection control and public health. Reservoirs for resistance may be present in healthy human and animal populations. Considerable economic and health burdens emanate from bacterial resistance, and research is needed to accurately quantify the problem and propose and evaluate practicable solutions. In part II, to be published next month, we will review potential containment strategies that could address this burgeoning problem.

Responding to the global human resources crisis.

The global community is in the midst of a growing response to health crises in developing countries, which is focused on mobilising financial resources and increasing access to essential medicines. However, the response has yet to tackle the most important aspect of health-care systems--the people that make them work. Human resources for health--the personnel that deliver public-health, clinical, and environmental services--are in disarray and decline in much of the developing world, particularly in sub-Saharan Africa. The reasons behind this disorder are complex. For decades, efforts have focused on building training institutions. What is becoming increasingly clear, however, is that issues of supply, demand, and mobility (transnational, regional, and local) are central to the human-resource problem. Without substantial improvements in workforces, newly mobilised funds and commodities will not deliver on their promise. The global community needs to engage in four core strategies: raise the profile of the issue of human resources; improve the conceptual base and statistical evidence available to decision makers; collect, share, and learn from country experiences; and begin to formulate and enact policies at the country level that affect all aspects of the crisis.

Antimicrobial resistance in developing countries. Part II: strategies for containment.

The growing threat from resistant organisms calls for concerted action to prevent the emergence of new resistant strains and the spread of existing ones. Developing countries have experienced unfavourable trends in resistance-as detailed in part I, published last month--and implementation of many of the containment strategies recommended by WHO is complicated by universal, as well as developing country-specific, factors. The control of selective pressure for resistance could potentially be addressed through educational and other interventions for orthodox and unorthodox prescribers, distributors, and consumers of antimicrobials. At national levels, the implementation of drug use strategies--eg, combination therapy or cycling--may prove useful to lengthen the lifespan of existing and future agents. Programmes such as the Integrated Management of Childhood Illnesses (IMCI) and directly observed short-course therapy (DOTS) for tuberculosis are prescriber-focused and patient-focused, respectively, and have both been shown to positively influence factors that contribute to the selective pressure that affects resistance. The institution of interventions to prevent the transmission of infectious diseases could also lead to beneficial effects on the prevalence of resistance, as has vaccination against Haemophilus influenzae type B and Streptococcus pneumoniae. There has been an upsurge in the number of organisations and programmes that directly address issues of resistance, and collaboration could be one way to stem the dire trend. Additional factors such as unregulated drug availability, inadequate antimicrobial drug quality assurance, inadequate surveillance, and cultures of antimicrobial abuse must be addressed to permit a holistic strategy for resistance control.

The role of diabetes mellitus in the higher prevalence of tuberculosis among Hispanics.

OBJECTIVES This research studied the relative contribution of diabetes mellitus to the increased prevalence of tuberculosis in Hispanics. METHODS A case-control study was conducted involving all 5290 discharges from civilian hospitals in California during 1991 who had a diagnosis of tuberculosis, and 37,366 control subjects who had a primary discharge diagnosis of deep venous thrombosis, pulmonary embolism, or acute appendicitis. Risk of tuberculosis was estimated as the odds ratio (OR) across race/ethnicity, with adjustment for other factors. RESULTS Diabetes mellitus was found to be an independent risk factor for tuberculosis. The association of diabetes and tuberculosis was higher among Hispanics (adjusted OR [ORadj] = 2.95: 95% confidence interval [CI] = 2.61, 3.33) than among non-Hispanic Whites (ORadj = 1.31: 95% CI = 1.19. 1.45): among non-Hispanic Blacks, diabetes was not found to be associated with tuberculosis (ORadj = 0.93: 95% CI = 0.78, 1.09). Among Hispanics aged 25 to 54, the estimated risk of tuberculosis attributable to diabetes (25.2%) was equivalent to that attributable to HIV infection (25.5%). CONCLUSIONS Diabetes mellitus remains a significant risk factor for tuberculosis in the United States. The association is especially notable in middle-aged Hispanics.

Neighborhood Poverty and the Resurgence of Tuberculosis in New York City, 1984–1992

OBJECTIVES The resurgence of tuberculosis (TB) in NewYork City has been attributed to AIDS and immigration; however, the role of poverty in the epidemic is unclear. We assessed the relation between neighborhood poverty and TB at the height of the epidemic and longitudinally from 1984 through 1992. METHODS Census block groups were used as proxies for neighborhoods. For each neighborhood, we calculated TB and AIDS incidence in 1984 and 1992 with data from the Bureaus of Tuberculosis Control and AIDS Surveillance and obtained poverty rates from the census. RESULTS For 1992, 3,343 TB cases were mapped to 5,482 neighborhoods, yielding a mean incidence of 46.5 per 100,000. Neighborhood poverty was associated with TB (relative risk = 1.33; 95% confidence interval = 1.30, 1.36 per 10% increase in poverty). This association persisted after adjustment for AIDS, proportion foreign born, and race/ethnicity. Neighborhoods with declining income from 1980 to 1990 had larger increases in TB incidence than did neighborhoods with increasing income. CONCLUSIONS Leading up to and at the height of the TB epidemic in New York City, neighborhood poverty was strongly associated with TB incidence. Public health interventions should target impoverished areas.

Association of Apo E Polymorphism With Plasma Lipid Levels in a Multiethnic Elderly Population

Apolipoprotein E polymorphisms are important determinants of blood lipid levels and have been associated with longevity and atherosclerosis. However, information is limited on the effects of apo E variation on the lipids of nonwhite and elderly individuals. We tested the hypothesis that apo E polymorphisms are associated with plasma lipid levels in an elderly, multiethnic population. Cross-sectional data from 1068 noninstitutionalized individuals from northern Manhattan over the age of 64 who were not on a lipid-lowering diet or drug were analyzed. The ethnic distribution was 34% African-Americans, 47% Hispanics, and 19% non-Hispanic Caucasians. In the entire group, the most prevalent apo E allele was epsilon 3 (76%), followed by epsilon 4 (16%) and epsilon 2 (8%); epsilon 4 was more prevalent in African-Americans (21%) than in non-Hispanic Caucasians (12%) or Hispanics (14%). The apo epsilon 2 allele was the most important correlate of plasma lipids, but association varied across ethnoracial groups. After being adjusted for age, sex, obesity, diabetes mellitus, and alcohol intake, LDL cholesterol levels declined with each apo epsilon 2 allele by 8.8 mg/dL in Hispanics and by 25.6 and 18.1 mg/dL in non-Hispanic Caucasians and African-Americans, respectively (P < .001). No significant independent effect was noted for any apo E genotype on HDL cholesterol. Overall, there was a reduction in the total/HDL cholesterol ratio, per apo epsilon 2 allele, of 0.82 in non-Hispanic Caucasians and 0.43 and 0.48 in African-American and Hispanic individuals, respectively (P < .05). In a multivariate model, apo epsilon 4 did not significantly affect plasma lipid levels. Plasma triglyceride levels were inversely correlated with the number of apo epsilon 4 alleles (175, 159, and 143 mg/dL with 0, 1, and 2 alleles, respectively; P =.002), and this effect increased with age. Thus, in an elderly, multiethnic population, apolipoprotein E polymorphisms were important determinants of blood lipids, with differing effects depending on ethnicity. The presence of apo epsilon 2 was associated with lower LDL cholesterol levels and total/HDL cholesterol ratio, although apo epsilon genotype did not influence HDL cholesterol levels. Prospective studies are needed to test whether apo epsilon 2 protects against incident cardiovascular disease in the elderly.