S. Jody Heymann

Orphan Care in Botswana’s Working Households: Growing Responsibilities in the Absence of Adequate Support

OBJECTIVES Botswana has one of the worlds highest HIV-prevalence rates and the worlds highest percentages of orphaned children among its population. We assessed the ability of income-earning households in Botswana to adequately care for orphans. METHODS We used data from the Botswana Family Health Needs Study (2002), a sample of 1033 working adults with caregiving responsibilities who used public services, to assess whether households with orphan-care responsibilities encountered financial and other difficulties. Thirty-seven percent of respondents provided orphan care, usually to extended family members. We applied logistic regression models to determine the factors associated with experiencing problems related to orphan caregiving. RESULTS Nearly half of working households with orphan-care responsibilities reported experiencing financial and other difficulties because of orphan care. Issues of concern included caring for multiple orphans, caring for sick adults and orphans simultaneously, receiving no assistance, and low income. CONCLUSIONS The orphan crisis is impoverishing even working households, where caregivers lack sufficient resources to provide basic needs. Neither the public sector nor communities provide adequate safety nets. International assistance is critical to build capacity within the social welfare infrastructure and to fund community-level activities that support households. Lessons from Botswanas orphan crisis can provide valuable insights to policymakers throughout sub-Saharan Africa.

Modelling the efficacy of prophylactic and curative therapies for preventing the spread of tuberculosis in Africa

Concerns have been raised about whether the interaction between tuberculosis and human immunodeficiency virus (HIV) may lead worldwide to a recrudescent tuberculosis pandemic. These concerns are particularly grave in Africa which has a high prevalence of both tuberculosis and HIV. This study used a computer simulation model to examine the effect of tuberculosis-HIV interactions on tuberculosis prevalence and mortality in Africa. The model then assessed the impact of expanding treatment and chemoprophylaxis programmes on tuberculosis prevalence and mortality over the next decade. In communities where 20% of the population is infected with HIV and 25% receive treatment for tuberculosis, deaths from tuberculosis would be 100% higher than in communities where none of the population is HIV-infected. In a population the size of Ugandas, during one decade there would be approximately an additional 530,000 deaths from tuberculosis. When 50% of patients with active tuberculosis receive treatment, one death will be averted for every 2.5 people who receive treatment. The prevalence of active tuberculosis could be cut by over 90% in a decade by providing effective chemoprophylaxis to 30% of individuals with inactive TB. In conclusion, TB is only one example of a preventable and treatable infectious disease which can be spread through casual contact and which, because of its higher prevalence among the HIV positive population, may lead to a preventable increase in incidence of infection among the general population.

Working HIV care-givers in Botswana: Spill-over effects on work and family well-being

Families provide most of the care to the tens of millions of HIV-infected and -affected in Africa. Little research exists on how care-givers balance the demands of holding a job with providing care for those who have become ill or orphaned by HIV/AIDS. Using data from a large survey administered to 1,077 working care-givers in Botswana, we compared the experience of HIV care-givers with non-HIV care-givers. Compared to non-HIV care-givers, HIV care-givers were more likely to worry about routine childcare (44% vs. 31%) and sick childcare (64% vs. 49%). Amongst those working far from home, more HIV care-givers were concerned that their children were not receiving adequate academic support (39% vs. 20%) and emotional support (57% vs. 33%). Parents who were HIV care-givers were less able to spend time with their own children. Children of HIV care-givers were more likely to have physical, mental and academic problems. While HIV care-givers were more likely to take leave from work for care-giving (53% vs. 39%), and for longer periods of time (13 vs. 7.6 days), this leave is more likely to be unpaid. Strategies to support those directly and indirectly affected by HIV and to avoid economic responsibility are discussed.

Meeting Children's Needs: How Does the United States Measure Up?

The majority of parents in the United States today must balance work and caregiving responsibilities. Workplace policies and community supports markedly influence the ability of parents to care for their childrens health and education while obtaining, retaining, and advancing in their jobs. The goal of this article is to analyze the dilemmas faced by working parents in general and by low-income families in particular, to present new data on how public policies in the United States compare to policies in over 150 other countries in addressing these dilemmas, and to suggest what more can be done to meet the needs of all working parents and their children across social class and residence.

Self-reported risks for multiple-drug resistance among new tuberculosis cases: implications for drug susceptibility screening and treatment.

Background Multiple drug-resistance in new tuberculosis (TB) cases accounts for the majority of all multiple drug-resistant TB (MDR-TB) worldwide. Effective control requires determining which new TB patients should be tested for MDR disease, yet the effectiveness of global screening recommendations of high-risk groups is unknown. Methods Sixty MDR-TB cases with no history of previous TB treatment, 80 drug-sensitive TB and 80 community-based controls were recruited in Lima, Peru between August and December, 2008 to investigate whether recommended screening practices identify individuals presenting with MDR-TB. Odd ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression to study the association of potential risk factors with case/control variables. Results MDR-TB cases did not differ from drug-sensitive TB and community controls in rates of human immunodeficiency virus infection, reported hospital or prison visits in the 3 years prior to diagnosis. MDR-TB cases were more likely than drug-sensitive TB controls to have had a recent MDR-TB household contact (OR 4.66, (95% CI 1.56–13.87)); however, only 15 cases (28.3%) reported this exposure. In multivariate modeling, recent TB household contact, but not contact with an MDR-TB case, remained predictive of MDR-TB, OR 7.47, (95% CI 1.91–29.3). Living with a partner rather than parents was associated with a lower risk of MDR-TB, OR 0.15, (95% CI 0.04–0.51). Conclusion Targeted drug susceptibility testing (DST) linked to reported MDR-TB contact or other high-risk exposures does not identify the majority of new TB cases with MDR disease in Lima where it is endemic. All new TB cases should be screened with DST to identify MDR patients. These findings are likely applicable to other regions with endemic MDR-TB.

WORKING TO EXIT POVERTY WHILE CARING FOR CHILDREN'S HEALTH AND DEVELOPMENT IN VIETNAM

Since the implementation of economic reforms in 1986, levels of urbanization, industrialization, and womens labour force participation have increased in Vietnam. This article focuses on the experiences of parents in Vietnam and how labour and social conditions affect their ability to work and exit poverty while caring for their childrens health and development. We interviewed a sample of 147 parents in Ho Chi Minh City using in-depth, semi-structured questionnaires. Sixty-three percent of parents had faced loss of income or promotions or had difficulty retaining jobs because they had to care for children. Fifty-eight percent of parents lost income while caring for their sick children because they had to take unpaid leave from work to care for their children or because they had to decrease productivity if they were able to continue working. Fifty percent of parents with school-age children experienced barriers to helping with homework, to attending meetings, or to participating in other aspects of their childrens education. The aftermath of the Vietnamese – American War affected parents through loss of extended family members, limiting access to a major traditional source of support. The war had affected other parents by preventing them from completing their education, which left them with job choices that offer little or no work benefits. Although Vietnam has made significant progress in providing early childhood care and education and legislating labour laws, working families’ experiences demonstrate the need to ensure that paid leave and work flexibility policies are available and implemented in all work sectors and to expand affordable, quality child care in order to help low-income working parents in Vietnam meet work demands and exit poverty while meeting their childrens needs.

How Safe Is Safe Enough? New Infections and the U.S. Blood Supply

Excerpt Recently, 14 patients who were negative for human immunodeficiency virus (HIV) types 1 and 2 were found to have T-lymphocytopenia. The possibility has been raised that at least one of the c...

Child Care Providers' Experiences Caring For Sick Children: Implications For Public Policy

This study examines the experiences of preschool and school-age child care providers regarding sick child care. In-depth, semi-structured interviews were conducted of child care providers at every city-sponsored preschool and afterschool program in an urban area in the United States. In addition, random sampling was used to identify home-based child care providers from a list obtained through a child care resources center. In spite of rules requiring that sick children be kept home, child care providers repeatedly described sick children whose health problems made it impossible to provide adequate care for the sick child at the same time as caring for the well children in their care. Problems arose for a range of reasons, including inability to provide sufficient attention to the sick child-s needs, inability to keep a sick child clean and well hydrated in the case of vomiting and diarrhea, spread of infectious diseases, and inability to care for healthy children adequately when meeting the needs of sick children. International public health policy implications for child care and paid family leave are discussed.

A Call to Action: Training Public Health Students to Be Effective Agents for Social Change

In the 21st century, we face enormous public health challenges that differ fundamentally from those of the last century, because these challenges involve widespread societal change and complexity. To address these challenges, public health professionals need to be able to place their work in a larger social context, understand local and global perspectives on a deeper level, and effectively engage a wide variety of stakeholders. To confer these skills, we need to change the way we train our students. We present two examples of low-cost innovative approaches to teaching public health that promote active engagement with individuals across a wide range of backgrounds and fields and that train students to be effective agents for change.

The infectious risks of transfusions in the United States: A decision-analytic approach

INTRODUCTION The development of AIDS as a result of HIV transmission and of cirrhosis as a result of chronic non-A, non-B hepatitis are the greatest infectious risks associated with transfusion in the United States. The goal of this study is to provide explicit quantitative guidelines to determine when the risk of death from all causes associated with transfusion exceeds the risk associated with anemia. METHODS This study uses a decision-analytic model. RESULTS On the basis of reported transfusion complication rates and an independent worst-case calculation of the risk of AIDS and non-A, non-B hepatitis, transfusion with red blood cells should be recommended as long as each unit received reduces the patients risk of dying from anemia by at least 1/1100. DISCUSSION Because of the relative safety of the blood supply as a result of universal screening and donor deferral, the overestimation in practice of fatal infectious complications, and the possible underestimation of the risk of anemia, undertransfusion has the potential to be as serious a problem in the United States as is overtransfusion. Although caution should be exercised not to undertransfuse when a patient has an appreciable risk of anemia-associated death, we must be wary not to overtransfuse for temporary relief of morbidity.