Justin List

High acceptance of home-based HIV counseling and testing in an urban community setting in Uganda

BackgroundHIV testing is a key component of prevention and an entry point into HIV/AIDS treatment and care however, coverage and access to testing remains low in Uganda. Home-Based HIV Counseling and Testing (HBHCT) has potential to increase access and early identification of unknown HIV/AIDS disease. This study investigated the level of acceptance of Home-Based HIV Counseling and Testing (HBHCT), the HIV sero-prevalence and the factors associated with acceptance of HBHCT in an urban setting.MethodsA cross-sectional house-to-house survey was conducted in Rubaga division of Kampala from January-June 2009. Residents aged ≥ 15 years were interviewed and tested for HIV by trained nurse-counselors using the national standard guidelines. Acceptance of HBHCT was defined as consenting, taking the HIV test and receipt of results offered during the home visit. Multivariable logistic regression analysis was performed to determine significant factors associated with acceptance of HBHCT.ResultsWe enrolled 588 participants, 408 (69%, 95% CI: 66%-73%) accepted testing. After adjusting for confounding, being male (adj. OR 1.65; 95%CI 1.03, 2.73), age 25-34 (adj. OR 0.63; 95% CI 0.40, 0.94) and ≥35 years (adj. OR 0.30; 95%CI 0.17, 0.56), being previously married (adj. OR 3.22; 95%CI 1.49, 6.98) and previous HIV testing (adj. OR 0.50; 95%CI 0.30, 0.74) were significantly associated with HBHCT acceptance. Of 408 who took the test, 30 (7.4%, 95% CI: 4.8%- 9.9%) previously unknown HIV positive individuals were identified and linked to HIV care.ConclusionsAcceptance of home-based counseling and testing was relatively high in this urban setting. This strategy provided access to HIV testing for previously untested and unknown HIV-infected individuals in the community. Age, sex, marital status and previous HIV test history are important factors that may be considered when designing programs for home-based HIV testing in urban settings in Uganda.

Histories of Mistrust and Protectionism: Disadvantaged Minority Groups and Human-Subject Research Policies

court suggested hospitals establish ethics committees. (Although some have pointed out that the court may have intended only a prognosis committee, they certainly chose a term that encouraged a broader scope.) My conclusion is this: Many groups with power to protect have felt threatened by any implication that they should receive guidance from ethics. Ethics has too often been seen as usurping the rights of professionals to determine their own agenda. Our research ethics committees should have a name that includes rather than excludes the word “ethics,” and should have a membership that will focus on that goal. The members should include about 50% scientists, much like most successful ethics committees in hospitals include about 50% doctors. But it should also include at least one ethicist, and should not be institutionally based, but regional. The committee might have 20 members, including 10 scientists from 10 different research centers. Each would be asked to recuse himself or herself from any proposal from his or her home institution. Would this be more costly than the current system? If so, where might the extra funds be found? I suggest we learn from Bayh-Dole, and make the ethics review process part and parcel of the profit and patent-driven system. Just as universities quite fairly get 40–60% in overhead costs recovered, the regional research ethics committees should be funded by a charge to every grant that is funded, which would most likely add no more than 1–2% to the cost of grants. This would allow service on the research ethics committees to be reimbursed modestly, encouraging the member’s employer’s or universities to free up some of their time for the activity. The second new principle we need is federal guidance on the focus of research, something that has also been largely replaced by what turns out to be more the blind eye than the invisible hand of capitalism. Let the funding sources develop explicit ethical goals for research: the betterment of the health of the society, sensitivity to social justice, giving greater weight to potentially beneficial research than to the development of me-too drugs. Physics stopped being a cottage industry sixty years ago, and biology and medicine have since followed. The time of scientists as professionals who are allowed to set research agendas by personal interest alone is passé. Now the research agenda is often set by the patent office of the researcher’s university or the R&D department of her company. I believe a society which pays to support research has the right to regulate it, and more stringently than it has to date. This is the one contract with society which Americans are likely to be willing to endorse.5

Beyond Charity: Social Justice and Health Care

Though it is sorely needed, charity care may in some ways perpetuate the unjust system that makes it necessary in the first place. True social justice in medicine, on the other hand, demands that physicians take the lead in advocating for systemic change.

Medical Neutrality and Political Activism: Physicians' Roles in Conflict Situations

Physicians in conflict situations juggle myriad duties and experience many ethical dilemmas in caring for the sick and wounded. Issues of how to triage care, allocate resources, and knowledge of injustices committed against patients by warring parties are among these concerns. Medical neutrality—care given based on criteria of medical need and urgency—has been strongly instantiated as a core value in the moral fabric of medicine and international medical ethics. Yet, physician political neutrality or activism regarding war crimes and injustices against people wartime physicians serve has been met with controversy. Medical neutrality, political neutrality, and political activism can be construed as types of moral goods in the practice of medicine. I argue that medical neutrality in the provision of care and political neutrality in conflict situations are not equivalent goods. Physicians have duties to provide care on the basis of medical neutrality, but they also have an obligation to be politically active in certain conflict situations and report allegations and abuses revealed during either the clinical encounter or in the field. First, I review a short history of medical neutrality in medical ethics as well as offer a defense of it. Next, I discuss political neutrality, and I argue that there exists the obligation for physician political activism (e.g., reporting human rights abuses). At the same time, I argue that physicians must practice medical neutrality using ethical and public health-based arguments that combine physicians’ duties to preserve equal respect for all persons (clinical role) while maximizing the protection of individuals living in communities (public health role). I conclude by examining

The Dread Disease: Cancer in the Developing World

The triumvirate of HIV/AIDS, tuberculosis, and malaria have dominated our public health focus in the developing world. Having claimed millions of lives, these infectious diseases have prompted a large-scale response. Concomitant with these efforts has been a burgeoning bioethics literature examining global health and distributive justice. A scholarly wasteland only a decade ago, there is now a growing and rich literature that aims to unpack our moral obligations when it comes to diseases that affect the majority of the world (many living in absolute poverty). Now, added to the persistent challenges posed by infectious diseases is the growing burden of diseases such as cancer, which disproportionately affect developing nations. The rates of noncommunicable chronic diseases, including cancer, continue to increase in low-income countries. (1) Recent estimates suggest that the case fatality from cancer may be as high as 74.5 percent in low-income countries, compared to 46.3 percent in high-income countries. (2) Survival rates for some cancers, such as testicular and breast cancers, have been positively related to country income. (3) Additionally, low education levels, poor health literacy, and advanced presentation of different cancers lead to further difficulties for people in developing countries. The disparity between cancer resource allocation in lower and higher income countries is stark--about 5 percent of total global funds dedicated to cancer are spent in developing countries. (4) Together with an estimate that 80 percent of disability-adjusted life years lost to cancer worldwide occur in developing countries, (5) a renewed focus on solutions to cancer care in resource-poor settings is past due. Disparities in treatment and survival outcomes are perpetuated by a lack of adequate evidence-based guidelines and treatment algorithms for cost-effective cancer care in developing countries. (6) Most countries have not implemented effective national control strategies that can save lives. (7) Promising models of cancer control in lower- and middle-income country health systems exist, however, and there has already been some discussion of established models in Mexico and Colombia, which both have national insurance plans, and of nascent scale-up efforts ongoing in Rwanda, Malawi, and Haiti. (8) At the heart of scaling up cancer care in resource-poor settings is the pervading assumption that cancer care cannot be provided efficiently or equitably. There are least two problems with this assumption. First, a more generalized version of this assumption has been disproved; there are examples of successfully scaled-up HIV/AIDS and tuberculosis treatment programs in resource-poor settings. (9) Second, the assumption that meaningful cancer care is not feasible in lower-income countries imparts a particular view of reality that reinforces inequity. As John Seffrin of the American Cancer Society has forcefully pointed out, global cancer disparities illustrate a collective failure to actualize the universal human right to access an adequate standard of health, and these disparities in cancer care and mortality demonstrate some of the most glaring social inequalities in health. (10) CanTreat International, also known as the Informal Working Group on Cancer Treatment in Developing Countries, recently highlighted three key lessons learned from the HIV/ AIDS movement that may be applicable to cancer care. (11) First, access to cancer treatment should be mandatory. The World Health Organizations current list of essential chemotherapies is a start in this direction. Second, cancer control needs to be mainstreamed into comprehensive health systems along with ways to provide high-quality care in order to detect and address cancer effectively. Third, advocacy and education are essential, including efforts to define public health priorities and treat cancers within the existing health system to continue to improve cancer interventions and the health system as a whole. …

Honesty and fairness in the residency match.

More prestigious placements for individual residency candidates does not justify turning a blind eye to dishonest behavior during the match.

Recruiting for military scholarship programs on medical school campuses.

Arguments are examined for and against the ethics of allowing U.S. armed services to attempt to recruit financially vulnerable students on medical school campuses. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Illness, Poverty, and the Invisible Patient

The editor introduces an issue on the relationship between poverty and illness by suggesting that children, men, and women from low socioeconomic backgrounds are often marginalized in the current health care system. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Clinical Issues and the Empirical Dimensions of the Religion and Health Connection

Three journal articles highlight difficulties in the interpretation of data relevant to religion, spirituality, and health. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

This wound is consistent with harm.

It could have happened anywhere. I knew crime having lived in Chicago, Washington, D.C., and New Haven. But I thought I was going to be ready for this moment in Kampala. As part of my characteristic risk-calculating analysis, I worked out what I thought would be a logical plan to diffuse an unexpected situation exactly like this months before I moved to Uganda to conduct research. I would calmly give the perpetrator a strategic amount of money, and then offer to connect him with a local organization to address whatever need he would identify. He would be disarmed by my reaction. I would feel some control while having “turned the other cheek.” I was aware that this would sound naïve and idealistic at best, so I practiced street smarts religiously, often in a paranoid fashion, to avoid undesirable encounters. On this day, though, I didn’t turn around when I heard running footsteps behind me. When my assailant runs away, I do not think fast enough to register that he is running down a street that ends at an intersection with a police station. I fail to chase him, standing in place, stunned and defeated. An opportunity to rectify the emasculation I feel after giving into his demands passes. Somewhere nearby, a woman shouts from her window “Ooo, sorry, sorry!” The tears flow, but I tell myself to hold it together. Don’t miss this conference. I feebly compose myself and pass through a small squatter settlement on Mulago hill. I wave, force a smile and give the Ugandan greeting oli otya to the folks I know here, crying all the while. No one says anything more than the expected bulungi in response. Only then do I realize that my back continues to sting and now itch. I touch my back. Blood covers my hand, and I realize for the first time that I have been stabbed. Thoughts race: I wonder if I need a tetanus injection. Did he recently use the handsaw on someone else? Could I get infected with an awful illness? Minutes later, I arrive at the clinic where I work and greet two staff members. Noting my disheveled appearance, they ask if I am okay.It could have happened anywhere. I knew crime having lived in Chicago, Washington, D.C., and New Haven. But I thought I was going to be ready for this moment in Kampala. As part of my characteristic risk-calculating analysis, I worked out what I thought would be a logical plan to diffuse an unexpected situation exactly like this months before I moved to Uganda to conduct research. I would calmly give the perpetrator a strategic amount of money, and then offer to connect him with a local organization to address whatever need he would identify. He would be disarmed by my reaction. I would feel some control while having “turned the other cheek.” I was aware that this would sound naive and idealistic at best, so I practiced street smarts religiously, often in a paranoid fashion, to avoid undesirable encounters. On this day, though, I didn’t turn around when I heard running footsteps behind me. When my assailant runs away, I do not think fast enough to register that he is running down a street that ends at an intersection with a police station. I fail to chase him, standing in place, stunned and defeated. An opportunity to rectify the emasculation I feel after giving into his demands passes. Somewhere nearby, a woman shouts from her window “Ooo, sorry, sorry!” The tears flow, but I tell myself to hold it together. Don’t miss this conference. I feebly compose myself and pass through a small squatter settlement on Mulago hill. I wave, force a smile and give the Ugandan greeting oli otya to the folks I know here, crying all the while. No one says anything more than the expected bulungi in response. Only then do I realize that my back continues to sting and now itch. I touch my back. Blood covers my hand, and I realize for the first time that I have been stabbed. Thoughts race: I wonder if I need a tetanus injection. Did he recently use the handsaw on someone else? Could I get infected with an awful illness? Minutes later, I arrive at the clinic where I work and greet two staff members. Noting my disheveled appearance, they ask if I am okay.