Gregg Gonsalves

Panic, Paranoia, and Public Health — The AIDS Epidemic's Lessons for Ebola

The scientific ignorance and paranoia on display in the reaction to the return of health care workers from the front lines of the Ebola fight and the fear-driven suspicion and shunning of whole classes of people echo the response to the emergence of AIDS in the 1980s.

The production of consumption: addressing the impact of mineral mining on tuberculosis in southern Africa

BackgroundMiners in southern Africa experience incident rates of tuberculosis up to ten times greater than the general population. Migration to and from mines may be amplifying tuberculosis epidemics in the general population.DiscussionMigration to and from mineral mines contributes to HIV risks and associated tuberculosis incidence. Health and safety conditions within mines also promote the risk of silicosis (a tuberculosis risk factor) and transmission of tuberculosis bacilli in close quarters. In the context of migration, current tuberculosis prevention and treatment strategies often fail to provide sufficient continuity of care to ensure appropriate tuberculosis detection and treatment. Reports from Lesotho and South Africa suggest that miners pose transmission risks to other household or community members as they travel home undetected or inadequately treated, particularly with drug-resistant forms of tuberculosis. Reducing risky exposures on the mines, enhancing the continuity of primary care services, and improving the enforcement of occupational health codes may mitigate the harmful association between mineral mining activities and tuberculosis incidence among affected communities.SummaryTuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may critically mitigate the negative association between mineral mining and tuberculosis.

AIDS Funds: Undervalued

In their Policy Forum “Global HIV/AIDS policy in transition” (11 June, p. [1359][1]), J. Bongaarts and M. Over argue that the costs of AIDS funding—especially for antiretroviral treatment (ART)—are excessive and imply that funding should be redirected to other health priorities. Their

Time for zero deaths from tuberculosis

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Commentary: Will 20th century patient safeguards be reversed in the 21st century?

Most physicians and patients assume that medications are proved safe and effective. This hasn’t always been the case. The US Food and Drug Administration was born out of a series of 20th century tragedies: contamination of vaccines at the turn of that century; dangerous substances found in commonly sold medicines in the 1900s; deaths of over 100 children and adults in 1937 from a sulfa drug dissolved in diethylene glycol (antifreeze); extensive birth defects caused by thalidomide in the early 1960s; and infertility and deaths caused by the Dalkon Shield intrauterine device in the 1970s.1 Those tragedies all inspired laws that strengthened the criteria used to allow medical products on the market. Subsequently, the first effective challenge to the FDA’s growing authority came from an unlikely source: people with HIV/AIDS. In the 1980s, as people with AIDS faced certain death, they criticized the FDA’s drug approval process as too slow and unresponsive to their needs. AIDS activists pressed for expedited drug approval and making experimental therapies widely available, demonstrating at FDA headquarters, and speaking out to FDA officials, the media, and Congress. They were remarkably successful, helping shape FDA reforms, including pathways for accelerated drug approval and expanded access programs for experimental medicines. AIDS activists quickly learnt, however, that speedier approval …

Strategies to Prevent Cholera Introduction during International Personnel Deployments: A Computational Modeling Analysis Based on the 2010 Haiti Outbreak

Background Introduction of Vibrio cholerae to Haiti during the deployment of United Nations (UN) peacekeepers in 2010 resulted in one of the largest cholera epidemics of the modern era. Following the outbreak, a UN-commissioned independent panel recommended three pre-deployment intervention strategies to minimize the risk of cholera introduction in future peacekeeping operations: screening for V. cholerae carriage, administering prophylactic antimicrobial chemotherapies, or immunizing with oral cholera vaccines. However, uncertainty regarding the effectiveness of these approaches has forestalled their implementation by the UN. We assessed how the interventions would have impacted the likelihood of the Haiti cholera epidemic. Methods and Findings We developed a stochastic model for cholera importation and transmission, fitted to reported cases during the first weeks of the 2010 outbreak in Haiti. Using this model, we estimated that diagnostic screening reduces the probability of cases occurring by 82% (95% credible interval: 75%, 85%); however, false-positive test outcomes may hamper this approach. Antimicrobial chemoprophylaxis at time of departure and oral cholera vaccination reduce the probability of cases by 50% (41%, 57%) and by up to 61% (58%, 63%), respectively. Chemoprophylaxis beginning 1 wk before departure confers a 91% (78%, 96%) reduction independently, and up to a 98% reduction (94%, 99%) if coupled with vaccination. These results are not sensitive to assumptions about the background cholera incidence rate in the endemic troop-sending country. Further research is needed to (1) validate the sensitivity and specificity of rapid test approaches for detecting asymptomatic carriage, (2) compare prophylactic efficacy across antimicrobial regimens, and (3) quantify the impact of oral cholera vaccine on transmission from asymptomatic carriers. Conclusions Screening, chemoprophylaxis, and vaccination are all effective strategies to prevent cholera introduction during large-scale personnel deployments such as that precipitating the 2010 Haiti outbreak. Antimicrobial chemoprophylaxis was estimated to provide the greatest protection at the lowest cost among the approaches recently evaluated by the UN.

An inter-professional ‘advocacy and activism in global health’: module for the training of physician-advocates

Medical students typically learn about the role of physicians as health advocates through a component of the health professionalism curriculum. Recently, there has been a call for increased exposure to health advocacy in undergraduate medical education so that students can develop the interest, knowledge, skills, and attitudes that they will utilize throughout their careers as physician-advocates. We developed a four-session Advocacy and Activism training module that consisted of formal didactic teaching, training in basic skills, debate and discussion, and the development and presentation of advocacy projects. There were several uniquely innovative aspects of this module, including its structure, content, and inter-professional approach that included students of medicine, nursing, and public health. However, this approach also resulted in some important and unexpected limitations. We were encouraged by the quality of student participation during the module, as well as specific feedback regarding the format and content. The module was a low-cost, easy-to-implement, and academically rigorous model that can be implemented by interested students and faculty at other schools. We plan to continue to develop this program in the future, and we believe that other medical institutions should consider a similar model for introducing students to their future role as health advocates.

Research, Regulatory and Clinical Decision-Making: The Importance of Scientific Integrity

• There have been growing concerns about the reliability and validity of the underlying research that supports regulatory and clinical decision-making

Reducing sexual violence by increasing the supply of toilets in Khayelitsha, South Africa: a mathematical model.

Background Sexual violence is a major public health issue, affecting 35% of women worldwide. Major risk factors for sexual assault include inadequate indoor sanitation and the need to travel to outdoor toilet facilities. We estimated how increasing the number of toilets in an urban township (Khayelitsha, South Africa) might reduce both economic costs and the incidence and social burden of sexual assault. Methods We developed a mathematical model that links risk of sexual assault to the number of sanitation facilities and the time a woman must spend walking to a toilet. We defined a composite societal cost function, comprising both the burden of sexual assault and the costs of installing and maintaining public chemical toilets. By expressing total social costs as a function of the number of available toilets, we were able to identify an optimal (i.e., cost-minimizing) social investment in toilet facilities. Findings There are currently an estimated 5600 toilets in Khayelitsha. This results in 635 sexual assaults and US

Public health implications of changing patterns of recruitment into the South African mining industry, 1973–2012: a database analysis

40 million in combined social costs each year. Increasing the number of toilets to 11300 would minimize total costs (