Michael Westerhaus

How Do Intellectual Property Law and International Trade Agreements Affect Access to Antiretroviral Therapy

Westerhaus and Castro argue that US-negotiated bilateral, regional, and multilateral trade agreements are hindering access to essential HIV medicines in poor countries.

Poverty, Global Health and Infectious Disease: Lessons from Haiti and Rwanda

Poverty and infectious diseases interact in complex ways. Casting destitution as intractable, or epidemics that afflict the poor as accidental, erroneously exonerates us from responsibility for caring for those most in need. Adequately addressing communicable diseases requires a biosocial appreciation of the structural forces that shape disease patterns. Most health interventions in resource-poor settings could garner support based on cost/benefit ratios with appropriately lengthy time horizons to capture the return on health investments and an adequate accounting of externalities; however, such a calculus masks the suffering of inaction and risks eroding the most powerful incentive to act: redressing inequality.

The necessity of social medicine in medical education.

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMeds monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical Schools semester-long, required social medicine course; and the Lebanese American Universitys curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.

Framing HIV Prevention Discourse to Encompass the Complexities of War in Northern Uganda

In northern Uganda, physical and structural violence (political repression, economic inequality, and gender-based discrimination) increase vulnerability to HIV infection. In settings of war, traditional HIV prevention that solely promotes risk avoidance and risk reduction and assumes the existence of personal choice inadequately addresses the realities of HIV transmission. The design of HIV prevention strategies in northern Uganda must recognize how HIV transmission occurs and the factors that put people at risk for infection. A human rights approach provides a viable model for achieving this aim.

Linking anthropological analysis and epidemiological evidence: formulating a narrative of HIV transmission in Acholiland of northern Uganda.

For twenty years, a region of northern Uganda known as Acholiland has been heavily affected by war, leading to the formation of internally displaced peoples camps, rape, transactional sex and child abductions. While it is clear that the war has had onerous consequences for the health of the Acholi people, the specific impact of the war on HIV transmission remains unclear, as the epidemiological evidence presents an ambiguous picture of HIV prevalence patterns. Other than a few non-governmental organization reports, very little qualitative data exists about the impact of HIV on the Acholi population. Attempting to formulate a clearer narrative of HIV transmission in Acholiland, this paper jointly analyses the historical and political context of the Acholi people and the war, the epidemiologic evidence of HIV prevalence patterns, and the ethnographic perspectives of Acholi healthcare workers and patients living with HIV/AIDS. Juxtaposing these sources of information allows for the emergence of a rich understanding of HIV in Acholiland. It is argued that three specific forms of violence – physical, symbolic and structural – create vulnerability to HIV infection in Acholiland, although to variable degrees dependent on location. The ethnographic evidence presented regarding HIVs impact on Acholiland suggests that an incorporation of historical, political, cultural and social factors must form the backbone of efforts both to understand HIV transmission and design strategies for curbing the epidemic in war settings.

Of ‘microbes’ and ‘millet’: the practice of tea tea in northern Uganda

SUMMARY In northern Uganda, incisions called tea tea are commonly placed on the chests of children outside of the biomedical setting to relieve respiratory distress. To better characterize tea tea, we administered a questionnaire to 224 caretakers, whose children had evidence tea tea cuts. In 148 cases (66.4%), the grandparents made the decision to have the cuts performed, at times against the wishes of the caretakers. One seventy-six (80.0%) of the patients were seen by a medical professional just prior to receiving the cuts. Traditional healers and grandmothers, respectively, performed the cuts in 164 (73.5%) and 42 (18.8%) cases. Caretakers paid at least 500 USh (US

Violence and the role of illness narratives

0.29) for tea tea in 129 cases (57.8%) and nothing in 71 cases (31.4%). This study shows that tea tea is a healing practice with associated costs that is regularly advocated for and performed by grandmothers and traditional healers.

Where We Fall Down: Tensions in Teaching Social Medicine and Global Health

www.thelancet.com Vol 372 August 30, 2008 699 at radiation doses lower than amounts tradition ally considered inducible by direct changes in the exposed cells. Such fi ndings suggest non-targeted mechanisms could be associated with the development of radiation-related health eff ects. Atherosclerosis is a multifactorial disease, resulting from a lifelong interplay between genetic, environmental, and behavioural factors, which might be modifi ed by radiation exposure. The relative risk of cardiovascular disease associated with radiation dose is much smaller than that of radiation-associated cancer, which would have substantial public-health implications in view of the high background rates of cardiovascular disease. Because of the uncertainty in the magnitude and nature of cardiovascular disease risk at a low dose of radiation, estimation of the excess number of patients in an exposed population is premature. Further investigations are needed to sort out eff ects of radiation and confounders in existing and planned studies of radiation-exposed cohorts, and new laboratory studies are needed to explore biological mechanisms for low-dose radiation-related cardiovascular eff ects. The low-dose radiation eff ects on cardiovascular disease risk are likely to remain challenging and controversial—even more so than the linear no-threshold arguments for cancer risk that are debated to this day—but should not be dismissed. After writing this Comment, we learned about the recent death of Dave McGeoghegan. We are saddened by this news. The scientifi c community will miss this

Access to generic antiretrovirals: inequality, intellectual property law, and international trade agreements

BACKGROUND As global health interest has risen, so too has the relevance of education on the social determinants of health and health equity. Social medicine offers a particularly salient framework for educating on the social determinants of health, health disparities, and health equity. SocMed and EqualHealth, 2 unique but related organizations, offer annual global health courses in Uganda, Haiti, and the United States, which train students to understand and respond to the social determinants of health through praxis, self-reflection and self-awareness, and building collaborative partnerships across difference. OBJECTIVES The aim of this paper is to describe an innovative pedagogical approach to teaching social medicine and global health. We draw on the notion of praxis, which illuminates the value of iterative reflection and action, to critically examine our points of weakness as educators in order to derive lessons with broad applicability for those engaged in global health work. METHODS The data for this paper were collected through an autoethnography of teaching 10 global health social medicine courses in Uganda and Haiti since 2010. It draws on revealing descriptions from participant observation, student feedback collected in anonymous course evaluations, and ongoing relationships with alumni. FINDINGS Critical analysis reveals 3 significant and complicated tensions raised by our courses. The first point of weakness pertains to issues of course ownership by North American outsiders. The second tension emerges from explicit acknowledgment of social and economic inequities among our students and faculty. Finally, there are ongoing challenges of sustaining positive momentum toward social change after transformative course experiences. CONCLUSIONS Although successful in generating transformative learning experiences, these courses expose significant fracture points worth interrogating as educators, activists, and global health practitioners. Ultimately, we have identified a need for building equitable partnerships and intentional community, embracing discomfort, and moving beyond reflection to praxis in global health education.