USDA Fails to Proactively Remove Dangerous “Downer Cows” from Human Food Source – Punit Patel

The Committee chairwomen and Democratic Representative from Connecticut aggressively claimed that the United States Department of Agriculture (USDA) needs to take the issue of Mad Cow Disease seriously and take more stringent measures to ensure the safety of the American people. She pointed out that 5,000 Americans die each year due to insufficient inspection of food based on current regulations and compared their deaths to the 3,000 American lives lost in the World Trade Center attacks and vehemently stated, “This Nation went to war because of those deaths. We have 5,000 people every single year in this nation who die from food-borne illness. Do we not believe we should go to war against the system that allows that to happen?”(1) Of the 5,000 people accounted for about 250 die each year from Mad Cow Disease that was ingested from the processed meat of a “downer cow” on American soil(2). Downer Cows are sick and weak cows that are not able to stand on their own feet any longer and have a very high chance of having Mad Cow Disease.

Although the actual percentage of deaths from downer ingested meat is relatively low, it is important to note that symptoms from Mad Cow Disease appear years after meat ingestion has occurred. (3)The nature of such a prion disease is that it constantly is changing so it is difficult to contain and has the potential to incorporate itself into a part of the DNA passed down to the next generation.(4) Hence, we can only know of the past prevalence of the disease from how many people have currently died. However, epidemiologists predict a steady increase in deaths from downer ingested meat once the current infected population begins to show symptoms (5).

Since the USDA is the federal agency in charge of providing “leadership in food, agriculture, natural resources, and related issues based on a sound public policy, the best available science, and efficient management,”(6) the responsibility to make “sound public policy” lies in their hands and that is what is currently lacking. In March 2004 US legislation passed a law banning all downer cows from entering into slaughterhouses for the use of meat for human consumption. (7)In July 2007 the USDA removed this ban, and once again allowed USDA policy to include downer cows.(7) There was a stipulation to this ban lift stating that downer cows would be considered and included in the human food supply, only after the downer cow in question was re-inspected by a USDA certified veterinarian. (8) The USDA felt that a certified veterinarian would be qualified enough to understand the health implications of allowing a downer cow to pass USDA inspection. (8) The USDA’s policy allowing downer cows to be used as processed meat and re-enter the American food supply is irresponsible and unsafe taking into account the flawed foundation behind the policy, the lack of responsible and consistent implementation of it, and the dire consequences to the overall American Public Health.

Political Foundation
The political drive behind this policy is evident in that there are a series of obvious assumptions regarding the meat packers and convenient loopholes within the policy that allow the USDA to “look the other way” when certain regulations aren’t followed all the time. The USDA has two major responsibilities as an organization, one is to promote the agricultural industry via its Agricultural Marketing Service (AMS) and the other is to maintain the safety of food quality for the American public via its Food Safety and Inspection Service (FSIS).(6)

Though the intention of this paper is to critique the intervention or lack thereof via the policy and not the USDA or the federal organizational issues regarding overall food safety, it goes without saying that they go hand in hand as their is an inherent conflict of interest that cannot be overlooked. The USDA is expected to crack down on safety measures while maintaining the growth of the agricultural industry placing them in a political catch 22 situation.(2) Unfortunately, they choose not to enact seriously needed strict policies because they are influenced by the lobbyists from the meat industry and thus safety loses at the hands of marketing because of the meat industry’s strong political power over the USDA.(2)

Secondly, this policy is based on unreliable data and flawed laws from previous years which fall short of full proofing the food supply. For example, the 2006 USDA Inspector General Report stated that all annual inspections of Mad Cow Disease after the initial outbreak were voluntary and not random which misrepresented the actual sample size of potential cows with Mad Cow Disease. (11)This annual inspection is what the USDA uses when formulating the relative risk of the disease in the cow population of the United States which meets the 40,000 cows to be tested goal but ends up testing mainly healthy cows and not ambulatory downer cows.(9) This system works for the USDA as well as the meat industry since meatpackers who utilize a higher number of downer cows into their food source would not want to reveal themselves to the USDA and the USDA can fulfill their quota of testing without doing any serious damage to meat packers. Countries like England and Japan test all of its cows for Mad Cow Disease while the United States only tests .1% of its cows breeding a false sense of security from inadequate testing. (9)Though it might seem that there is no need for this, the Japanese originally had no cases of the disease but once they started testing they found 31 cases so the trend seems to be the more you test the more you find. (2) In the United States, testing isn’t even proportional to the number of cows slaughtered per state and in no way reflects the current risk in cattle.

The USDA relies heavily on the 1997 law stating the cattle feed cannot be fed to other cattle and spinal cord and brains of cows 30 months or older cannot be utilized as food but blood from cows can be incorporated in cattle feed.(7) The problem here is that prions can still travel via blood and what about the risk of a downer cow with Mad Cow Disease of 29 months?(8) Such laws with numerous loopholes cannot be considered the fundamental basis of safety from Mad Cow Disease in general or specifically from downer cows.

Finally, this new policy is a continuation of past mismanagement of food quality and safety as a result of basing the approach to safety solely on the Health Belief Model causing the responsibility and decision making to fall in the hands of the distributor of the processed meat and not the regulator, the USDA. (10)It is based on the idea that if the meat packers feel that a downer cow is susceptible to Mad Cow Disease and if they are informed of the seriousness of the disease, the industry will automatically choose the perceived benefit of public safety and accept the cost of the downer cow as lost revenue for the sake of the public’s health. It is also assumed that their intention of protecting the meat supply from disease will lead to responsible and safe behavior on the part of the meat packers. The assumptions this model makes are not only unrealistic but they are dangerous because they give so much power to an industry whose key incentive is profit and this one major fact automatically alters the outcome from this model. This is something the USDA has failed to realize allowing them to claim that according to their new policy, derived from this model, food safety is accounted for but the real question here is if the individual factories and their employees that makeup the industry are following through on that model?

Unsatisfactory Implementation of the Policy

The only way this policy would be able to successfully promote the interests of the meatpackers while still maintaining the safety of food quality from diseased downer cows is, if the state level implementation was carried out impeccably and if every single division and subdivision of this hierarchical ladder would honestly and carefully carry out his or her duties. Unfortunately, there are organizational deficiencies in staffing and training within the FSIS (the body that handles state-wide inspections and enforces regulations) as well the individual meat packing factories that have lead to a high level of inconsistencies confirming the risk of increased Mad Cow Disease prevalence in future years.

Training Issues

There is a serious lack of quality training being offered to both USDA officials and none is offered to the managers or their employees who are the ones assessing the on-site status of downer cows. A USDA Training and Development Consortium has been established “to provide coordination and consistency to the training function within USDA. The Consortium is authorized and empowered to direct mission areas and agencies to comply with its programs, procedures, and guidance” but one of the major goals as stated within their priorities is to “eliminate duplication of effort” so this is clearly training that is geared towards efficiency and conservative budgeting schemes than to genuinely train the employees for safe and tedious inspection of unsafe cattle. (6)

The FSIS deals mainly with managers of meat factories and rarely interacts with employees so no specific training is given to any employee by the government regarding state and federal regulations and that responsibility lies with the individual managers. (6) Though, it may seem fair and cost effective to not train private employees, there is no standard test or license or even certificate of completion or any document that states that the particular necessary training has been provided for the proper treatment and exclusion of downer cows. Every manager will train his or her employees and this is where the inconsistency occurs in quality of meat because though the policy requires a USDA certified veterinarian to inspect the downer cows for safety, before used as meat, the person making that decision is the ill trained employee whose expected to observe the downer cows on a federal standard of safety but works for a biased employer who would benefit from incorporating as much meat as possible. (2) Therefore, the employees may be “encouraged” to overlook certain regulations in an attempt to increase output causing the employees to not inform the USDA veterinarian and the potentially diseased downer cow ends up in the American food supply being distributed to various companies to be incorporated in hundreds of products.

The issue of inconsistency does not stop with the ill trained employees of the factories, but spills over into the main body enforcing the regulations, the FSIS. Staffing is limited requiring a higher level of “efficiency” which results in inconsistent implementations of policy. This allows for an ambiguous gray area where managers tend to use their own “discretion” and that is where the enactment of the policy fails.

Staffing Issues

There are 7,800 inspectors working for the USDA for 6,200 facilities, though this may seem adequate, each facility on average slaughters 500 cows which leaves approximately 1 inspector to every 400 cows for inspection per day. (6) Of that, there is an average vacancy of 500 inspectors which creates a 7%-21% lack of much needed inspectors within the districts. (6) The actual ratio should be of inspectors to number of cows within a facility since it clarifies the immense amount of responsibility for every inspector. Not only do they have to check the downer cows for injuries and disease, they also have to sample butchered meat for E. coli and various other bureaucratic tasks as well which leaves little time for actual thorough inspection.

Even if the inspectors manage to find regulations not being followed within factories, there seems to be an inherent inconsistency in the inspection process showing a dangerous level of leniency in some states. For example, the state of Pennsylvania has 139 meat plants but only 4 citations were written least year whereas in a more stringent and safer state like California there were 15 citations written where there are only 32 plants. (5) Though, it is a fair argument that the number of citations do not have to be proportional to the number of plants, there is a serious number of discrepancies in the above two states and the disheartening thing is that inspectors of both states receive the same federal and state level training. (6)

Finally, if inspectors do stay on there toes and actively issue citations when needed, there may be piles of citations before anything is done about the plant in terms of closing it down for violations or increasing on site inspections. There is no written rule of “x number of strikes and your out” so each violation amounts to a fine and tends to stop there. (7) For example, the Westland Meat Company in Chino, California was recently closed down and the largest meat recall in the history of the USDA was done amounting to 147 million pounds of meat after having received numerous violations from the USDA for the last 10 years. (2) This shows how long the meat company has been able to freely pass on dangerous meat into the food supply enhancing the argument of the increase in future deaths and current prevalence of Mad Cow Disease.

Consequences
Along with the medical dangers of this policy, there are a series of social consequences that prove to be detrimental to society psychologically, through the inhuman treatment of downer cows, and financially through the numerous recalls that occur in increasing numbers annually. The way in which the USDA has formulated this policy it seems that the only loophole to utilizing the maximum amount of downer cows is either to get the cows to stand by forceful means or injure the downer cows so that they may pass the inspection as “injured” rather than automatically excluded as “diseased.” (12) Though, downer cows are segregated for inspection separately, the sheer number of downers to inspect per day causes the quality of inspection to suffer. Here is where meat packers take advantage of the situation and through inhumane treatment inflict injury on the cows while trying to force them to stand.(12) And if an injury is found on a downer cow, the chances of it passing inspection as “injured” is much higher, taking advantage of the USDA’s Chairman, Ed Schafer’s argument that “injured downer cows are not a threat to the food supply and should be allowed.”(2) A key thing to remember here is that a downer cow with Mad Cow Disease can also get an injury and end up passing the test because of the nature of the disease. Veterinarians have trouble deciphering between the actual disease and an injury because the disease causes similar external symptoms of weakness as does an injury. (8)

Inhumane Treatment

Unfortunately, this policy harbors and instigates meat packers to employ inhuman methods of electrical prodding of downer cows, power hosing them, or simply pushing them with a fork lift until they stand up and walk into the slaughter house assembly line or get injured in the process and end up inspected and labeled as “injured” and then forced into the assembly line. (12) In fact, the Westland and Company factory was even cited for “too much electrical prodding” but was allowed to continue there slaughtering after a fine. (12) The Humane Society of the United States has clearly agreed that this policy is “dangerous and deplorable taking into account the large economic incentive the meat packers have to force downer cows into slaughter lines and the risk that even those cows with broken limbs and weak muscles are 49 to 58 times more likely to have Mad Cow Disease as the disease weakens muscles.”(12)

A major danger of this mistreatment is the greater impact on the industry as a whole as this creates a type of Meat Plant Culture of abuse and mistreatment of downer cows that is passed on as some sort of tradition to each new generation of employees. The entrance of a new employee into the meat factory and the training one receives as a result is based on the Social Learning Theory (10) where an employee will do what he sees his fellow workers doing and in this case it will be the illegal and inhumane attempts at trying the get downer cows to stand or pulling them with chains to the slaughter line. There is no question of any Reasoned Action () as the concept of self efficacy does not exist for most of these workers who are poor immigrants who are living pay check to pay check and are afraid of losing their job if they voice any sort of opposition to existing methods. As time goes on, the employee that initially entered the work force and learned this behavior of mistreatment through modeling has become a member of that very Social Network as in the Theory of Social Networking (10) and his or her behavior is a result of belonging to that Social Network which forms the “Plant Culture” of inhumane treatment and maintains this tradition through the Theory of Social Learning and a cyclical series of events occur over generations and the tradition of force and abuse continues as the next wave of employees arrive.

Recalls

In an effort to correct their wrongs of this policy, the USDA issues recalls whenever proof is presented of mistreatment of animals or risky entrance of un-inspected downer cows into the human food source as an attempt to protect the public from products containing the risky meat via the loopholes of this policy. (12) Unfortunately, recalls are a voluntary procedure and the USDA does not have the power to force any plant to comply and as the Consumer Federation of America’s Food Policy Institute points out “critical time can be lost in negotiating between the USDA and the company over the terms of the recall” prolonging the risk of Mad Cow Disease from the downer ingested meat. (13) Recalls cause the public to go under a scare and paranoia infiltrates members of society causing mistrust of food products and as a result the economy is effecting when United States quality of meat is questioned when other countries like France refuse American beef and revenue is lost. (1) Also, as was the case for 220 employees of the Westland and Company, hundreds of employees lose their jobs when a recall occurs as the loss of credibility leads distributors to pull out of their contracts with the plants. (2)

Finally, the meat from these factories which have recalls does not remain in a concentrated geographic area, but travels across the nation to millions of people as the meat is first sent to distributors and companies which process the meat for different products, 466 in the case of Westland and Company, so containing the potentially diseased meat is close to impossible. (2) In fact, the meat from the Westland and Company was distributed to the National School Lunch Program as well as to needy families with low income and that is a serious risk. (2) Most children who are approved to be a part of a school lunch program are required to be from medium to low income households and those very children’s parents might be ones receiving a part of the quota of meat distributed to needy families so that child is at risk two times more than the average person. (2) Children in general have lower immunity but coming from a low income household, whether child or adult, it is clear in the literature that healthcare options are limited if at all available. (12)

Conclusion
This policy is a threat in itself to the safety and well being of millions of Americans and needs to be changed immediately. The USDA is inherently not able to and lacks incentive to prevent downer cows from entering the human food supply and that needs to change. If nothing is done, we will have to watch an entire generation of beef consumers becoming infected with Mad Cow Disease and there will be nothing that can be done for them. One of public health’s main goals is prevention and we might have missed the current population but we can surely save the next one if action is taken now.

The ethical implications of allowing such a small group of people, in the industry, to control the health status and health outcome for millions of people is disturbing and unsafe. The fact that our world today is becoming smaller and smaller is a haunting fact when thinking of meat from downer cows and the increasing geographic area in which such meat is consumed. The factory owners in the industry weigh the chances of higher profits against the future sickness of the public and choose the immediate profit. One of the main reasons for this is that this is a decision for which the consequences will occur in the long run and by that time it will be nearly impossible to trace the meat to the original factory. Hence, the industry sees utilizing downer cows as a crime without a consequence and it is the current policy which gives them this security and causes such discomfort within the field of public health as well as the masses that may be at risk as of now.

REFERENCES
1. Lee, Christopher. Washington Post. USDA Rejects “Downer Cow Ban”. February 29, 2008.
2. http://www.pe.com/reports/2008/cattle/vitindex.html
3.http://www.usda.gov/wps/portal/usdahome
4. Zimmerman, Janet. United States Department of Agriculture Handbook of Laws. Washington, DC: Penguin Press, 2007 Edition
5.CJD deaths 'may have peaked'. BBC News (2001-11-23). Retrieved on 2008-04-08.
6."BSE: Disease control & eradication - Causes of BSE", Department for Environment, Food, and Rural Affairs, March 2007.
7."The BSE Inquiry", led by Lord Phillips of Worth Matravers, report published October 2000.
8. Harden, Blaine (2003-12-28). Supplements used in factory farming can spread disease. The Washington Post. Retrieved on 2008-04-08.
9.Bovine Spongiform Encephalopaphy: An Overview (PDF). Animal and Plant Health Inspection Service, United States Department of Agriculture (December 2006).
10. Association of Health Practitioners. List of Health Behavior Models. Washington, DC. Association of Health Practitioners. http://www.aph.org/health.
11. United States Department of Agriculture. 2006 USDA Inspector General Report. Washington, DC.
12. Humane Society of the United States. Westland and Co. Surveillance Report. New York, NY.

Refugee Women's Health Screening in Massachusetts one Shot Deal-Paroma Mitra

Although women and children face the maximum brunt of war and strife, they are a small part of the overall picture of refugee health. Approximately 80% of the refugees are women or children. Refugees are persons who are outside their country of nationality and who are unable or unwilling to return to that country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.(5) The current system does not emphasize on the specific needs of health care in female refugees. Female refugees are at maximum risk since in countries of conflict, they play more traditional roles and are dependent on their families for all types of support, namely physical, monetary, mental and emotional support. During times of conflict, losing or being separated from their families’ leaves them susceptible to all forms of injuries. Female refugees are also extremely vulnerable to sexual violence in the form of rape, genital mutilation and violation of other reproductive rights due to racial and ethnic discrimination Also, they tend to be overcrowded in camps which are unsanitary and hence they are extremely vulnerable to multiple diseases. When they enter a new country of refuge, they come with special needs of their own namely human needs namely physiological, psychological, social and spiritual.

Currently, the Massachusetts Department of Public Health carries out a basic physical examination of refugees. The primary aim of this physical check up is to ensure that refugees don not have any diseases that would prevent them from entering the United States. These exclusions would include certain communicable diseases and mental health associated with violence. The refugees are further divided into Class A and Class B where Class A deals with communicable diseases and Class B deals with physical deformity and violence leading to Mental Health (5). Whereas, there is provision for treatment including follow up for Class A there is no provision for help for Class B refugees. The current refugee and immigrant program is currently conducted under the Department of Public Health in Massachusetts effective since July 1995. According to the current figures, the number of immigrants entering the state is 1100 annually primarily from Africa and central and east Europe especially from regions of strife. (5) Looking at the background these women come from, a physical examination seems inadequate, real emphasis must be paid on issues like mental health, malnutrition, gynecologic health which forms the bulk of the needs of refugee women.

Current Refugee Physiological Care in Massachusetts
Physiological issues like access to health care and diet and nutrition are overlooked in the current Massachusetts outline. Physiology concerns the normal functioning of the human body hence correct physiological care essential to the well being of these women. When refugee women come in for their first physical examination in most of the cases an interpreter is provided to explain the procedure. An interpreter could also help explain the new health care system they are to become a part of. There are language barriers, limitations regarding transportation, the refugee health finances which women traditionally are not trained to understand in their country of origin. Most women are taught not seek formal care but culturally are expected to treat themselves at home.(1) Therefore, an effort must be made to set up interpreters who not only speak the language but understand the cultural background these women come from and provide with tools to access health care. Interpreters can also counsel about topics like diet and nutrition to women as in a study looking a refugee camps it was reported that particularly prone to diet related malnutrition therefore they must be counseled and given correct diet in regard to their status as women who are menstruating or women at child bearing age as current data shows in a lot of refugee camps there is food shortage hence countries of second asylum must make arrangements for adequate nutrition.(3) Mostly women in refugee camps suffer from some form of malnutrition as during times of conflict there is shortage of food supplies and males tend to be fed first. Also, the food supplies often land up being inadequate in essential nutrients leading to large number of diseases. Dehydration is also another common occurrence seen in women as the water shortage is quite common and lack of clean water is very frequent resulting in a lot of cases of dehydration and diarrhea. Efforts must be made to ensure correct nutrition which does not lead to further exacerbation of disease and pre- existing dehydration must be treated with adequately.

Mental Health as a Vital Factor
Mental Health problems are a part and parcel of every group of society but particularly seen in refugee women. Pre-existing mental disorder may already be present in women which may be triggered by stress due to their surroundings. Other women may be stressed due to what happened in their home country, their flight to a new one and relocation. A study measuring health variables of refugee women for resettlement (10) included biopsychosocial factors such as depression and anxiety as important primary variables as they are seen in about 58% and 24% of women refugees .The most common disorder seen is PTSD (post traumatic stress disorder). (3)In a Yugoslavia study 65% women developed post traumatic stress disorder due to physical and sexual torture. (Kang et all 1965) .Separation from their families leads to additional stress which may exacerbate PTSD. Mental health examination carried out in detail must be mandatory while dealing with refugees and they have special needs that must be addressed adequately to ensure their well- being and they must be followed up on as well by specialists who can deal with the particular sort of stress disorders seen in refugees.

Refugee Women and History of Sexual Abuse and Rape

There is a high prevalence of sexual abuse and rape in refugee women. (1) Especially seen in third world countries, women are traditionally expected to submit to the needs of men and men may take advantage of women already weakened by war for personal abuse and pleasure. It is often reported that soldiers are at the fore front of sexual abuse and often use it as a tool for controlling a population already weakened by war and strife. A study investigating basic women’s right has shown that limitation of sexual and reproductive rights may affect health. (7) It has also been reported that men in second country of asylum may take advantage of frightened and susceptible immigrant women.

Adequate measures must be taken to address this part of mental health and a country or a state granting asylum must provide adequate counseling and support in regard to this. Also health care providers must understand privacy issues and the question of chastity in these women; they may not be able to trust male health care providers completely. It is also important to understand that seeing violence towards others or seeing acts of violence increases sense of vulnerability amongst women.

Refugee Women and Gynecological Issues
Refugee women suffer genital trauma in terms of various degrees of female circumcision which lead to various gynecological and obstetric problems later. (3) There are three different kinds of circumcision, Type 1(seen in Niger, Eritrea, Uganda) which is removal of the clitoris and prepuce, Type 2(seen in Kenya, Somalia, Egypt) deals with excision of clitoris and prepuce along with part of labia minora and type 3(Northern Sudan, Somalia) deals with removal of clitoris and prepuce and sewing up the labia minora with thread and leaving a little gap for urine and menstrual blood. (3)

A lot of countries in Africa namely Somalia and northern Kenya both currently involved in internal strife have high prevalence rates of type 2 & 3 type of circumcision. A large concern of female genital cutting (FGC) is the environment in which it is done in. A lot of the time, a non- sterile blade is used to perform the procedure on young girls by a mid- wife. There is high incidence of hemorrhage and septicemia (3) leading to death. Also a major concern in women who have undergone a type 3 FGC, urinary system infections are very common due to stagnation of urine and they face a large number of urologic as well as gynecological problems. In older women who have undergone the procedure, increased cases of pyometritis, dysmenorrhea, dysparenuia, pelvic inflammatory disease and chronic cervicitis are seen.(3) There is also increased aversion regarding sexual activity leading to different psychological problems from ones discussed above. In addition to this, there is increased incidence of HIV and HBV transmission.

Gynecologic care must be provided to prevent these diseases as far as possible. Women must be regularly checked for gynecologic diseases, regular pap smears and health care surrounding care of the genital region must be given. Also, refugee women have a higher incidence of parity leading to increased cervical prolapse and stress urinary incontinence. Also, special prenatal care must be given to women who have undergone FGC. These concerns if raised by women must be addressed correctly and health care providers must be able to respect the values and needs of women.

Refugee Women and Social Interaction and Expectations
Women are expected to fulfill the “family role” and expected to recreate an atmosphere equivalent to the old home and country putting additional stress on them. (3) They have to adjust to a foreign country and society and are expected to adhere to the ways of the old society as well as cultural traditions in their homeland casting them into particular roles. Role strain occurs when individuals are expected to conform to a form of behavior expected of them which leads to increased amount of stress. (3) It is commonly known that foreign ways are rarely valued by the larger society. This causes excessive strain and burden on women. According to the social networking theory, the surroundings influence the behavior however a new environment does not always necessarily assure of change of behavior. To address this role strain, support groups consisting of members of the same background & society nay help new immigrants to adjust to the ways of a new country and life style. Women should be encouraged to mingle and work in the new society they are in. They are also expected to adjust to a new system in terms of facilities new home and away from parts of their family. The concept of resettling is not addressed currently a high- quality tools are required to measure relevant concepts required for resettling like education. (10)

In other states, the Baylor nursing home ( near Dallas, Texas) uses community outreach services and centers that is driven by human needs and serves the refugee communities nears Dallas, Texas that comprises of many different societies of refugees such as South- east Asians, refugees from Central America , refugees from Mexico and Saudi Arabia. 70% of the people serving in these communities speak the language of the refugee community and it gradually introduces concepts of all forms of health care. (4) Students are encouraged to mingle in the community they serve and teach basic health care prevention. Massachusetts may also incorporate a similar method of care. In another state, Ohio, the system talks about interlinking between various departments to provide for physical, mental and social care of refugees. (2) It has also paid some emphasis on different needs of women refugees and talks about coordinators that not only address physical examination but set up agencies to help refugees to understand the new system they are now a part of. . It can serve as a basic framework for a revised model of the current Massachusetts system. Based on the Social Learning Theory where modeling may cause behavioral change, having other refugee women to help counsel the incoming women may cause a change in their behavior and attitude towards a new system.

A simple electrical system which we take for granted may seem new and foreign to refugee women. Language too becomes a burden. Electrical appliances, laundry and other things we take for granted may not be as prevalent in third world countries. Women particularly may be overwhelmed as children tend to pick up these modes faster and hence they must be specially taught to use the facilities available in the new country. Women in particular according to a study(9) reveal themes of leaving the good life behind, worrying about their children, feeling ambivalent about marriage and lacking hope in the future. These concerns must be addressed to ensure their well-being.

There is a role change that is seen in refugees as in women may get jobs before their husbands and become the primary bread- winner of their families creating a new gender role. If this causes a strain on familial ties, it leads to additional stress on the women concerned. A way to deal with the stress may be via prayer and worship for many. Religion is a key part of life for many women and religious practices may be a part of everyday living for many. It may be a source of strength for many and religious beliefs must be respected in every aspect of care. A new society may not always compliment the old hence the well-being of the individual is compromised. A social advocacy approach is needed with both individual and collective strategies for responding to the lack of sensitivity shown many times. (8)

Conclusion

Refugee women deserve to be treated with special sensitivity and careThe more we learn and study about them the better we can address their issues. (9) They each have varying needs that must even be assessed at an individual level if possible. Women form the back bone of the family in most places and can become contributors to society if given the opportunity to do so. The best way to address the needs of female refugees is to increase the knowledge and sensitivity regarding special health care. One must understand that these women come from often a tragic and violent past to an unknown and uncertain future. The feeling of being degraded, dismissed or ignored may have serious repercussions on these fragile lives. Massachusetts has a large number of refugees many of whom come from violent pasts and it is in integral part of society’s responsibility to ensure their well being. The Commonwealth could modify their clinical program on a more needs based assessment and follow up rather than a purely physical assessment. This must also contain special assessments of women’s needs separately. New proposals are being made currently to incorporate women’s health into the main framework of the current refugee and immigrant health program. The Massachusetts government and Department of Public Health must look into providing health care as well as addressing the other issues describe above. It is imperative and urgent that the community act to provide basic needs to refugees (6). One routine physical examination is not enough to assess the needs of many of these women, mental, psychological and spiritual health must also be addressed simultaneously.


REFERENCES:-
1 http://www.theirc.org/special-report/rape-in-congo.html
2http://jfs.ohio.gov/refugee/docs/NEW%20HEALTH%20SCREENING%20PROTOCOL.pdf
3 http://www3.baylor.edu/~Charles_Kemp/refugee_health_problems.htm
4http://www3.baylor.edu/~Charles_Kemp/refugee_health_models.htm
5 http://www.mass.gov/dph/cdc/rhip/wwwrihp.htm
6. http://refugees.org/uploadedFiles/Investigate/Publications_&_Archives/WRS_Archives/2007/SilentSurge.pdf

7. Basic health, women’s health, and mental health among internally, displaced persons in Nyala Province, South Africa, Sudan. Kim G, Torbay R, LawryL. Massachusetts Veterans Epidemiology Research and Information center, Veterans Affairs Boston Health Care System, Boston, MA.Jan, 2005.
8. Listening to different voices. Hrycak N, Jakubec SL. Faculty of Nursing, University of Calgary, Calgary, Alberta, Jun 2006.
9. Pavlish C. Narrative inquiry into life experiences of refugee women and men. International Nursing Review. 54(1):28-34, 2007 March
10. Gagnon AJ. Tuck J. Barzun L. A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International.25 (2): 111-49, 2004 Feb.

Needle Exchange Programs: An Unrealistic Approach to Decreasing Rates of HIV/AIDS – Elyssa Pesin

The HIV/AIDS Epidemic
Human Immunodeficiency Virus (HIV), the virus that causes AIDS, attacks the immune system, leaving the body vulnerable to a variety of life-threatening infections and cancers [1]. This devastating disease is the focus of many public health interventions in the United States, especially among intravenous drug users (IDUs), a recognized risk group. Nevertheless, current efforts are inadequate to address the complex risks associated with injection drug use, particularly among disadvantaged populations [2]. The nature of intravenous drug use, specifically the process of preparing and injecting drugs, is conducive to the spread of HIV. As the CDC reports, “many opportunities for contamination with and transmission of HIV or other blood-borne viruses” exist among IDUs, due to the mechanics of drug injection [3].

Introduction: A Public Health Intervention
Needle Exchange Programs (NEPs), in which IDUs exchange dirty needles for clean replacement needles, are intended to be a critical strategy for containing the spread of HIV and other blood-borne diseases within this population. However, issues relating to social and behavioral sciences, differences in socioeconomic stratum and sociopolitical issues contribute to the failure of implementation in the United States. Contrary to the 1980’s United States Drug Campaign known as the “war on drugs,” using the slogan “Just say no,” the NEPs’ ideology is based on “Just say yes,” as these programs prioritize HIV/AIDS prevention over reducing drug use.
In a social and behavioral context, the Health Belief Model (HBM) was developed to explain health-related behavior at the individual, decision-maker level. The focus of this model is preventative health behavior of individuals, assuming that human behavior is determined by an objective, logical thought process. HBM includes four concepts: “perceived susceptibility,” “perceived severity,” “perceived barriers to taking that action,” and “perceived benefits of an action” [4]. With regard to NEPs, the former three concepts are skewed and lead to NEP failures. First, instead of realizing that the perceived susceptibility of drug use is the chance IDUs will overdose, develop neurological problems, or acquire multiple chronic and acute illnesses, the perceived susceptibility is the realization that IDUs could only contract HIV/AIDS through dirty needles. Second, IDUs overlook the perceived severity, that is, how severe the effects of transmitted diseases might be, as they continue to use drugs and reject other ways blood borne diseases are transmitted - through sexual contact [5]. Lastly, the perceived barriers and costs of emotionally and financially supporting drug use are overlooked by NEP creators and supports. Interestingly, NEPs use an HBM limitation to their advantage – that is, if drug users have the intent to do a particular behavior, they will do it. Thus, NEPs are structured around the susceptibility to HIV/AIDS and the perceived benefits of preventing the transmission of the disease through shared needles.
By expecting drug-users to seek out these programs on their own using undersupplied and underprovided distribution methods and providing limited geographic locations, needle exchange programs fail to decrease HIV/AIDS through shared needles within the IDU population. More specifically, failures of NEPs can be seen in their inability to reach many drug users due to geographic disparities, broad target populations, and limited distribution strategies.

Reason for Failure #1 – Geographic Disparities
Failures of NEPs are attributed to several different models of social and behavioral science. First, the Stages-of-Change model applies to IDUs who utilize NEPs, who realize they engaged in drug use, who contemplated the risks of intravenous use, and who decided to address those risks by participating in a needle exchange program. Nevertheless, the “action” and “maintenance” stages of change in NEPs, where individuals begin to engage in a new behavior and attempt keep that pattern going or sustain the new behavior respectively, is flawed [6]. This relates to an IDUs use of NEPs, as research shows there are inconsistencies in location, equal distribution of supplies, and accessibility [7]. As a result, IDUs are not able to engage in and maintain this new behavior consistently. Herein lies the first problem: NEP geographic disparities.
Geographic disparities in access to NEPs present clear difficulties to program utilization. Indeed, NEP locations do not always correspond to a demand for such a program in the area. In 1999, a study reported the existence of NEPs in 81 cities and 31 states as well as the District of Columbia. The study concluded that many of these programs were heavily concentrated in four states: California, New York, Washington, and New Mexico. Yet, data suggest that New Jersey – a state with high demand for NEPs –disproportionately lacks in access to these programs [8]. As Barbara Tempalski reports, “injection drug use is the most frequent reported risk behavior among HIV-positive individuals” in New Jersey, and in Jersey City, Newark, and Bergen-Passaic have some of the highest rates of IDU related AIDS in the country [9].
Even within existing NEPs, inequalities in supplies inhibit the efficacy of these programs; twelve of the largest programs, for example, receive 62 percent of available syringes, leaving other NEPs without adequate supplies [10]. The unequal distribution of NEPs and NEP-related resources do not address disparities in HIV prevalence among socially disadvantaged groups or the geographical distribution of IDUs.
One last social and behavioral theory can be attributed to the first reason for NEP failure. The last several stages of the Diffusion of Innovations (DOI) theory are interrupted, as the NEP geographic and inventory shortages prohibit the success, wider implementation, and unrestrained use of this public health intervention. Within the DOI theory, the “adoption process,” is affected by insufficient locations, supplies, and geographic representation, prohibiting the “uptake” of the behavior by IDUs. According to this principle, “uptake” requires movement through knowledge of NEPs, persuasion or attitude development (about adopting behavior), decision (to adopt behavior), implementation, and confirmation, and none of these steps can occur, as NEPs fail to be equally accessible or sufficiently equipped [11].

Reason for Failure #2 – Broad Focus
Two additional social and behavioral principles can be applied to a second reason for NEP failure. On one hand, the success of NEPs relies largely on selecting a target population, where IDUs among different socioeconomic strata are the targets. The widespread use of the intervention relies on these social groups or networks to communicate the benefits of the program. On the other hand, failure to account for the “political economy,” which has an important bearing on why and how people do what they do, and consequently, how people change what they do, affects the efficacy of NEPs [12]. Both political economy and behavior are factors that must be addressed when assessing the inadequate and very broad focus of NEP interventions as it contributes to the crisis of HIV/AIDS in poor, urban communities. Because HIV/AIDS has such a disproportionate effect on poor, minority, and urban communities, NEPs are suffering because they frame HIV/AIDS as just a health problem, rather than the product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender [13]. Consequently, the NEP failure is rooted in its very broad focus, as they do not take into account the aforesaid larger set of social and political relationships.
Despite drug regulation, illegal drug use continues among the underserved and the needs of those who seek prevention or treatment have not been met. As Dr. Adewale Troutman states in his on-line tutorial Creating Health Equity Through Social Justice, “the existence of social injustice typified by the continued growth of the gap between the have and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral” [14]. This inequality is ever-present among IDUs. According to Richard Hofricter, although overall life expectancy has increased and mortality rates have decreased in the twentieth century, “an increasing level of inequality in the health status and mortality of those with less material resources in relation to their social class, particularly in ‘communities of color’ persists” [15]. Moreover, disadvantaged groups do not benefit equally from advances in HIV and AIDS intervention, treatment and prevention.
While the HIV/AIDS epidemic has had a disproportionate impact on certain populations, particularly racial and gender minorities, NEPs do not effectively narrow their focus among these groups. Within the IDU population, disadvantaged groups are especially vulnerable to HIV infection. In certain racial and ethnic groups, half of the deaths due to HIV in both African American and Latino populations can be attributed to injections with contaminated needles. Furthermore, African American IDUs are 5 times as likely, and Latinos are 1.5 times as likely as white IDUs to develop AIDS [16]. These statistics highlight the limitations in the breadth of NEP, as programs do not have specific strategic plans to reach each group.
The African American experience portrays an obstacle that NEPs do not address or overcome with regard to ethnicity. African Americans are increasingly vulnerable to the transmission of HIV/AIDS. With this, another social and behavioral principle accounts for the larger HIV/AIDS cases in this group: the Social/Environmental Context, and more specifically within this context, the Historical Context. Historically, African American communities have greatly opposed NEPs as a consequence of their distrust of the government and medical trials in general. According to Stephen Thomas, African Americans’ adverse response to NEPs is connected to the “persistent neglect of the drug abuse epidemic, mistrust of public health authorities, and fear that the broader society may consider large segments of the black population expendable consumers of scarce human and economic resources” [17]. Many of these opponents worry that needle exchange programs will ultimately lead to Tuskegee-like abuse of research subjects [18]. Within many African American communities, NEP initiatives are held in high suspicion due to historic exploitation and discrimination [19]. With these factors, one can observe that throughout various segments of the American public, NEPs prove controversial. This Social/Environmental Context is relevant, as the Tuskegee-mentality is shared across this group, contributing to an African American experience made up of historical influence and personal experience interacting with the environment that inhibits this group from utilizing NEPs [20]. The failure of NEPs in this group is rooted in the history of the African American experience for which NEPs do not account.

Reason for Failure #3 – Methods of Distribution and Legal Implications
A third reason for the failure of NEPs lies in their distribution strategies, which are neither private nor anonymous. When using NEPs, IDUs must make themselves publicly available to the needle “exchanger” and must make behavioral changes through regular needle exchanges. For this reason, there is a great deal of social and personal responsibility, motivation and social and personal acceptance of help. The two primary methods of delivery are fixed NEPs located in pharmacies or health and community centers and NEP vans that drive through areas with known groups of IDUs [21][22]. Both of these methods of delivering exchange services require IDUs to seek out needle-exchange programs, which deter many from utilizing them. For this reason, drug-users typically refrain from using NEPs, consequently transmitting disease.
Many states have opted to utilize pharmacies in addition to local community centers to allow IDUs to obtain sterile syringes if businesses choose to participate. Nevertheless, while the pharmacy model has been shown to dramatically reduce the risk associated with IDU, not all geographic areas have benefited from these programs. For example, in New York, it is legal for pharmacies and other organizations to register and to provide up to ten syringes to individuals over the age of eighteen without prescriptions [23]. However, many pharmacists have refrained from participating in such services due to personal beliefs of fear that the presence of IDUs are detrimental to their businesses [24]. Moreover, the exchange of syringes in this model is not necessarily free, so many IDUs are unwilling or unable to participate [25]. For this reason, implementation of the pharmacy exchange model has been piecemeal and inadequate, contributing to the failure of NEPs in pharmacies.
Mobile exchange services are the second method of distribution which intend to reach more drug users. These mobile programs, which have predetermined van routes, are interventions for including hard-to-reach individuals and those who do not typically access mainstream services. For instance, an analysis of a 1997 Baltimore program revealed that mobile services attracted twice as many high-frequency injectors as pharmacy programs [26]. Furthermore, a study of the Vancouver program, which consisted of a variety of different facilities, reported that 65 percent of participants obtained some of their needles from the van and 17 percent used the van as their main needle source. Typically, users of this mobile exchange injected more frequently, were younger, more likely to engage in prostitution, and less likely to enroll in a drug treatment plan [27].
The mobile exchange model, whose intention is to reach those who are unable to access participating pharmacies, has several limitations [28]. First, the mobile programs offer fewer opportunities for counseling and other educational service, as the mobile programs do not afford lengthy time intervals during which the staff and clients can interact. Second, in the case of the San Diego, California NEP, IDUs refrained from visiting this site because legislation fails to protect IDUs from state laws prohibiting the transport of drug paraphernalia. In fact, reports confirm that law enforcement officers wait outside NEPs and arrest individuals suspected of carrying syringes [29]. Two social and behavioral theories, the Social Cognitive Theory and more specifically the Social/Environmental Context applies to the existing laws pertaining to drug paraphernalia in each state [30]. Drug paraphernalia laws, which exist in all states except Alaska, hinder the sale, distribution, purchase, and possession of syringes. In fact, 20 states have drug paraphernalia laws that are used against IDUs who possess a syringe [31]. Additionally, pharmacies may implement their own requirements and regulations that inhibit access [32]. The fear that this regulatory environment and existingpolicies instill in IDUs prevents them from accessing either method of distribution, even though the presence of these programs is acceptable. A third theory known as Political-Economic Space - a space that is governed by a specific political system, with regulations, values, and procedures –applies to the existing regulations and laws that affect health [33]. In this framework, many states, even those that support NEPs, continue to restrict the sale of syringes to pharmacies and require IDUs to have a prescription, provide valid identification, or disclose their reasons for purchasing the syringe [34]. This barrier to access is associated with the Political Economy, as NEPs encompass a wide range of theory and history about the links between politics and behavior, and their functions in society [35]. While NEPs focus on reducing disease transmission through sharing needles among IDUs, NEPs have failed to address the legal implications of the program such that the legal framework and Political Economy deter users for fear of identification and police harassment.
The lack of anonymity in these two methods of distribution makes IDUs vulnerable to the ever-present legal and regulatory barriers to access and to possess sterile syringes. Barriers include: drug paraphernalia laws, syringe prescription laws (both of which place restrictions on syringe exchange programs), pharmacy regulations and practice guidelines, fear of identification and police harassment - presenting obstacles to participation and decreased disease transmission. Further, the fear instilled in IDUs is largely derived from a Social Cognitive Theory known as Reciprocal Determinism, in which a person acts based on individual factors and social environment cues, receiving a response from that environment, and adjusting behavior accordingly [36]. In this fashion, IDUs act based on their personal responsibility and motivation to use NEPs, but ultimately react to the negative “cues,” that is regulation and punishment for attempting to use this intervention. Lastly, the concept of Self-Efficacy applies, as IDUs’ past experiences with NEPs will affect whether they are motivated to use this intervention. IDUs with low Self-Efficacy regarding NEP use may feel more hesitation, and when they actually use the program, may be reluctant to use it for fear of being punished. Once IDUs feel comfortable and confident in their chosen NEPs, this sense of Self-Efficacy may help the IDU continue this intervention and spread the word about NEPs in their networks [37].

Conclusion
NEP programs, meant to decrease HIV/AIDS transmission, are unsuccessful not only structurally, but also for reasons surrounding social and behavioral sciences, socioeconomic strata, and sociopolitical issues. More specifically, NEPs fail to address their geographic disparities, political patterns, and relationships of ethnicity that contribute to the efficacy of this intervention. This intervention fails to identify groups of IDUs on which to focus their strategies, as the target population is much too large to see positive results, that is, a decrease in HIV/AIDS transmission. After this assessment, it is clear that HIV/AIDS affects a wide-ranging population of potential NEP users who, in one form or another experience barriers to access.

References
1. Centers for Disease Control and Prevention. Prevention Among Injection Drug Users. US Department of Health and Human Services, January 2007. http://www.cdc.gov/idu/default.htm. Date accessed: 27 Mar 2008
2. Ibid.
3. Ibid.
4. Rosenstock, Irwin M. Ph.D. Historical Origins of the Health Belief Model. Health Education Monographs 2 (4): 328-335, 1974.
5. Centers for Disease Control. op.cit.
6. Prochaska JO, Reding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education, 3rd ed. San Francisco, CA: John Wiley & Sons; 2002.
7. Centers for Disease Control and Prevention. Epidemiology of HIV/AIDS—Unites States, 1981- 2005. Morbidity and Mortality Weekly, 55(21):589–592, June 2006.
8. Robert E. Fullilove and Mindy Thompson Fullilove. HIV/AIDS in the African American Community: The Legacy of Urban Abandonment.
9. B. Tempalski, P.L. Flom, S.R. Friedman, D.C. Des Jarlais, J.J. Friedman, C. McKnight, and R. Friedman. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. American Journal of Public Health, 97(3):437, 2007.
10. M.P. Singh, C.A. McKnight, D. Paone, S. Titus, D.C. Des Jarlais, M. Krim, D. Purchase, J. Rustad, and A. Solberg. Update: Syringe Exchange Programs–United States, 1998. Morbidity and Mortality Weekly Report, May, 18:384–87, 2001.
11. Rogers EM. Diffusion of Innovations, 4th ed. New York: Free Press; 1995.
12. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 72.
13. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall;
1977.
14. Adewale Troutman. Creating Health Equity Through Social Justice. Satellite broadcast originally aired February 20, 2003.
15. R. Hofrichter. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. Jossey-Bass, 2003.
16. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US Department of Health and Human Services, 2004.
17. S.B. Thomas and S.C. Quinn. The Burdens of Race and History on Black Americans’ Attitudes toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, 14(3):320–347, 1993.
18. Ibid., p337
19. Ibid., p343
20. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 52.
21. Institute of Medicine of the National Academies. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. The National Academies Press, 2006.
22. Riley E.D., M. Safaeian, S.A. Strathdee, M.A. Marx, S. Huettner, P. Beilenson, and D. Vlahov. Comparing New Participants of a Mobile Versus a Pharmacy-Based Needle Exchange Program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 24(1):57–61, 2000.
23. Institute of Medicine of the National Academis. op.cit.
24. Institute of Medicine of the National Academis. op.cit.
25. Institute of Medicine of the National Academis. op.cit.
26. Riley, E.D. op.cit. p59.
27. M.W. Tyndall, J. Bruneau, S. Brogly, P. Sptal, M.V. O’Shaughnessy, and M.T. Schechter. Satellite Needle Distribution Among Injection Drug Users: Policy and Practice in Two Canadian Cities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 31(1):98–105, 2002.
28. Riley, E.D. op.cit. p60.
29. Kaiser Family Foundation. Syringe Exchange and AB 136: The Dynamics of Consideration in Six California Communities, February 2002. Pub 6018.
30. Bandura A. Social Cognitive Theory: an agentic perspective. Ann Rev
Psychol. 2001;52:1-26.
31. T.S. Jones and P.O. Coffin. Preventing Blood-Borne Infections Through Pharmacy Syringe Sales and Safe Community Syringe Disposal. Journal of the American Pharmacists Association, 43:6–9, 2002.
32. Ibid., p 6-9.
33. Edberg, Mark. op. cit. p52.
34. Ibid., p52.
35. Ibid., 72.
36. Bandura A. The Self System in Reciprocal Determinism. Am Psychol. 1978; 33:344-358.
37. Bandura A. Social Learning Theory. op. cit.

TITLE: WHO'S ROLL BACK MALARIA: WHERE EXACTLY ARE WE ROLLING? SOME SAY NOWHERE – KATE DILLEY

Introduction
Malaria is the most common vector borne disease, meaning that malaria is transmitted through a bite from a mosquito. The most common vector for malaria is the anapholies mosquito. Malaria is an endemic disease, which means that there is a very distinct seasonal transmission or regular transmission of the disease. Malaria is the most common vector borne infectious disease impacting countries in Africa, Asia, South and Central America. Current estimates place the global burden between 350 to 650 million cases each year. In children under the age of five, malaria is one of the leading killers. Each year, approximately 1 million children die from malaria. Africa bears the greatest burden in the world, with 60-90% of all malaria illness and deaths occurring on the African continent, in Sub-Saharn Africa (1).
In 1998 the World Health Organization, UNICEF, the United Nations Development Programme (UNDP), and The World Bank came together to start the Roll Back Malaria (RBM) initiative. The goal of this partnership is to halve the global burden of malaria by 2010 (2).
The fight against malaria is a complicated one, with three major challenges facing the RBM initiative. The first and most important challenge is that of poverty. Malaria is an inexpensive disease to treat and prevent, but many of the countries with the greatest burden of disease lack the infrastructure to implement prevention and treatment programs without major subsidies or donations from governmental and non-governmental organizations. Additionally, citizens of these countries often lack the resources to protect and treat themselves on an individual level (3). The second challenge is that of resistance development among mosquitoes. Resistance has been developing to both the insecticides used to kill the mosquitoes as well as to the drugs to treat malaria (3). This developing resistance is changing the landscape in which the RBM initiative is working. Finally, conflicts and natural disasters often displace large numbers of people into areas with high malaria transmission.
These complex humanitarian emergencies are problematic for a number of reasons. By pushing people out of their homes and into refugee camps or other temporary living situations a variety of things can heighten the transmission of malaria. People who have not been living in malaria endemic areas (where malaria is present or heavily transmitted) can be pushed into malaria endemic areas and they have little or no immunity so are susceptible to malaria infection. Additionally, further breakdown in infrastructure and loss in wealth means that malaria falls lower on the priority scale for many affected populations. Any personal preventative or treatment measures that were being undertaken are no longer in place so individuals are now more susceptible to malaria infection.
The RBM initiative is a three tiered program, including personal protection, mosquito control, and appropriate use of medication. Insecticide treated mosquito nets (ITNs) are a simple and cost-effective way to prevent a bite from an infected mosquito, therefore are the first line of defense against malaria. The use of ITNs has been targeted mostly at children, pregnant women, and those with HIV/AIDS. RBM has used social marketing and educational campaigns in order to raise awareness about malaria prevention (4). The second component of the intervention is mosquito control. The insides of peoples homes are sprayed with insecticides to kill mosquitoes. This type of indoor residual spraying has been an effective measure to control mosquitoes in Central and South America, Asia, and southern Africa. However, indoor residual spraying is not a very widespread component of the initiative; instead it is used only in specific and targeted situations (4). The final component of the RBM initiative is access to appropriate medical care. The goals of this component of the intervention are for all persons to have immediate diagnosis followed by treatment with correct and effective medications. Persons ill with malaria must be diagnosed immediately and promptly treated with the appropriate medications. However, the increasing development of drug resistance is causing a range of problems from ineffective treatment in some cases to the inability to treat malaria at all (4).
Two years away from the culmination of this initiative there has been little or no substantial progress. The annual number of deaths from malaria in 2004, was higher than in 1998 (Yamey 2004). Many are saying that this initiative is clearly failing, and dealing ineffectively with an increasingly complex battle of reducing the global burden of malaria. One critic of the RBM initiative asserts that the campaign currently has all of the necessary tools to combat the growing malaria burden, but that those tools are not widely available due to geographic or economic barriers. He goes on to say that the last thing that the campaign needs is a lack of donors. There is still great work to be done, and the goals of the campaign are within reach, however, continued donor support will prove to be vital (5)
The Roll Back Malaria Initiative started by the WHO and UNICEF is failing to address the basic needs of malaria prevention and treatment by ignoring basic social and behavioral factors associated with the disease; socioeconomic and geographical barriers, as well as access to the resources that communities need in order to have success with the various components of the intervention.
Poor implementation of a promising tool: Insecticide Treated Bednets
While the campaign has been somewhat successful in communicating the importance of using ITNs, it is failing to increase the proper use of nets, because it ignores important socioeconomic factors of its target population such as family income, priority of disposable income, and willingness to pay.
Populations that suffer through endemic and seasonal malaria are well aware of its dangers as a disease. People know how serious of an illness that it is and that it is an illness that can have potentially devastating affects on a family and a community. That knowledge combined with the knowledge of ITNs has the potential to be a powerful tool in combating malaria around the world. ITNs can reduce malaria transmission in the general population as well as all cause mortality in children under the age of five by 15-33% in areas with low to high, although seasonal transmission (6). However, there are reasons why communities are not utilizing the ITNs at the rates the RBM initiative was hoping for. It is now necessary to understand and examine adherence and use of ITNs in malaria endemic areas. A major focus of these studies must be how community and individual level factors are impacting adherence.
Overall, uptake of ITNs in the general population is high, and often the result of successful social marketing and educational campaigns. These campaigns combine free distribution of ITNs and other active community education, and can result in bed net uptake as high as 83% (7). The high use of ITNs illustrated very clearly by the fact that families who participated in randomized control trials are more likely to have bed nets in their homes. When enrolled in a trial, families or heads of households receive extensive education regarding the proper use of bed nets, their advantages, and ways to make them more effective, including the use of insecticide treatment (8).
When community members talk about the ITN uptake and use in their villages, many cite the strengths of the educational campaigns and the social marketing. However, there are a number of barriers associated with not using ITNs, mostly focusing on issues of access and affordability. Bed nets are not always for sale in convenient locations, and if they are they are far too costly for families to purchase them. These access and financial barriers lead to people having to travel great distances to find a bed net at a cost they can afford. The same barriers exist when examining the failure to treat or retreat nets with the insecticide treatments. While the communities understand the importance of and have the skills to mix the insecticides and treat the nets, the chemicals are often not available for reasonable prices or within close proximity (8, 9, 10).
These various studies highlight one of the major problems with the Roll Back Malaria initiative. It is based on the Health Belief Model, assuming that when the target population is armed with all of the appropriate information, aware that they are at risk for something, and have the intent to make a change, that change will occur. The RBM partners are ignoring glaring limitations and barriers to actually achieving the behavior; the economic barriers and infrastructure limitations are preventing a large number of people from using ITNs.
Various problems with pharmaceutical access and administration
The second goal of RBM is that all people will get the right drugs, from the right place, at the right time. Currently, this appropriate medical treatment is not happening. The inappropriate medication of patients is creating complicated problems, including increasing drug and insecticide resistance. All of these factors are combining to make malaria control, let alone malaria eradication, difficult to achieve because the disease keeps changing. By ignoring key socioeconomic and geographic barriers to health care, the RBM initiative is failing to ensure that all individuals in malaria endemic countries receive fast and effective treatment (11).
Although baseline access to good and effective malaria treatment was low, in 2000 little progress had been made. In 2000 The African Summit on Malaria was held to address the current progress against malaria, what challenges remained, and what could be done to make progress against those challenges. This meeting included community and political leaders, WHO representatives, and public health officials from around the world (12). By 2008, treatment improvement was a major cornerstone of the Abuja Declaration made at the African Summit on Roll Back Malaria in 2000. The goal following the conclusion of the Summit was that by 2005, at least 60% of those suffering from malaria have access to affordable, appropriate and timely treatment (12).
The definition of appropriate treatment is complex. The factors that go into treatment include receiving a correct diagnosis of malaria, administration of an appropriate medication, in the correct dose, and taking that medication for the defined amount of time. Some estimates suggest that only 7% of children under the age of 5 years are being treated in compliance with the RBM initiatves goals and recommendations (13).
The most common anti-malarials given to patients in sub-Saharan Africa are chloroquine and pyrimethamine plus sulfadoxine. While chloroquine is currently almost completely ineffective in treating malaria in Africa, medical professionals are moving towards a more effective, but more expensive, treatment. That treatment is artemisinin-based combination therapies (ACTs) which are available for $0.75-$2.75 per treatment. Although this cost seems inexpensive, it is a much higher price to pay than individuals have been previously paying (2). Individuals’ willingness to pay for treatment of malaria decreases with decreasing socioeconomic status, meaning that the poorest people do not want to pay for treatment, or are less willing to pay, and when that transpires, it means that people with fewer resources are not accessing the care that they need when they are ill (14).
Other factors related to childrens’ access to medical care include the age of the child, perceived severity of illness, education level of the head of household, and socioeconomic status. Adults do not receive appropriate care for similar reasons, including availability of care in close proximity to the home, care must be given at a fair or reasonable price, and those administering the care must be capable of fostering a polite and enjoyable relationship with the patient (14, 15, 16).
Another issue related to inappropriate care is the dependence of many African communities on private sector drug distributors. This includes formal sources of drugs, like small pharmacies or merchandisers, but also informal drug dealers at small kiosks or nomadic dealers who move around from village to village. The reliance upon these distribution schemes is understandable when they are more numerous, closer to home, offer variable payment plans, are stocked with the desired drugs, and a friendlier atmosphere. They possess all of the qualities that the public sector venues lack (17). However, these drug outlets are increasingly problematic due to the fact that it is well known that they are poor care providers. They often do not provide proper advice, complete or correct doses, and in too many cases, they do not provide the correct drug for the illness. These factors are all directly related to diagnosis of malaria, which is the crux of the problem. Because there is such poor infrastructure, diagnosis is generally made using only symptomatic criteria. This leads to all fevers being diagnosed, and treated, as malaria (17).
Poor implementation strategies of the major initiative components
Despite having realistic goals and sound strategies, the RBM initiative fails in its implementation. By employing traditional, or western, implementation techniques, the campaign fails to account for the unique needs of it's target population. The traditional, or western, mechanisms for employing the use of insecticide treated bed nets and appropriate treatment are clearly not working in these African communities. The success of this intervention rests on considering novel implementation techniques both for ITNs and medication.
The World Health Organization and other non-governmental organizations suggested that novel distribution techniques for bed nets and new ways to administer medical care may be part of the solution for malaria treatment and prevention. Some of these suggestions include using community health workers to distribute malaria treatment, training private sector drug distributors in the knowledge that they need to prescribe malaria medications, and distributing ITNs during the measles vaccination campaigns (18).
A study published in 2006, examined the preferences of community members for having community health workers (CHWs) provide malaria treatment. It is clear that one of the major obstacles in the treatment of malaria is distance that individuals must travel in order to receive care. CHWs work in local communities and are trained in the health problems of the community they are working in, which means that they have the medical knowledge to provide appropriate and effective treatment and are conveniently located. The study clearly demonstrated that CHWs can be used to effectively get appropriate treatment to the individuals who need it. Furthermore, using CHWs is a sustainable strategy, since community members preferred being treated by the CHWs (19).
A similar study conducted in 2007 found the same results, but also examined the costs associated with establishing such a program and some community factors that contribute to, or detract from, the success of these CHW programs. Start up costs were low, which means that these programs are these programs can be easily implemented in communities where financial resources are lacking. Other conditions that led to the success of the CHW model in this population included CHWs behaving as a bridge between the community and the formal health care system, bringing all of the appropriate medical care to the community because the CHWs were so well trained (20).
Novel distribution techniques have been suggested for the increased implementation of ITNs. Combining the distribution of free ITNs with national vaccine days has proven to be a successful and equitable way to distribute ITNs. A week long measles vaccination campaign in Ghana was utilized to target children aged 1 – 5 years to receive free ITNs. Baseline data were collected and indicated that only 4.1% of the children under the age of five were sleeping under bednets. After the campaign, that number increased to 60.2%. Additionally, 68.3% of people had a net hanging over beds in the home and 94.4% had an ITN in the home. The second major finding of this study was that taking out the cost of the net, it is a way to target all levels of socioeconomic status equally. Following the campaign, the coverage of ITNs in the poorest homes was ten times that of the wealthiest homes at baseline. This study suggests that linking bed net coverage and vaccination campaigns could be a successful way to ensure that all people have exposure to ITNs (17).
Conclusions – Steps we must take to roll forward
Collecting data in the places where the RBM initiative is working presents a series of challenges. This makes it difficult to determine what of the initiatives targets have been met. However, there is a clear indication that steps have been taken in the right direction. These steps include making treatment more widely available and changing national drug policies, forcing the effective ACT’s as the first line of treatment, instead of the traditional chloroquines. Organizations are also stepping up and subsidizing the cost of the treatments, helping to make it more available (2).

References
1. Olumese, P. Epidemiology and surveillance: Changing the global picture of malaria – myth or reality? Acta Tropica. 2005;95:265-269.
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Stop TB: Exploring Global Trends in TB Advocacy – Aishwarya Lakshmi Vidyasagaran

An estimated one-third of the world’s population is infected with Tuberculosis bacterium and nearly 9 million people get sick with TB every year (1). With the rise in the HIV epidemic, TB is the most common cause of death in HIV-infected individuals in developing countries and is threatening to re-emerge as a public health problem in developed countries as well (2). The emergence of Multi Drug Resistant TB (MDR – TB) and more recently, extensively drug resistant TB (XDR-TB) has compounded the burden of disease worldwide. The Stop TB strategy, launched by the World Health Organization is working to halve TB deaths and prevalence by 2015 (3) and one of six components of the strategy is to empower people with TB and communities through advocacy, communication and social mobilization (4).
Despite TB being a major public health problem worldwide, little effort has been made in sensitising the public about the disease and its symptoms, especially in rural areas (5). A practical guide for TB advocacy published by the WHO in 1999 states that despite the successful implementation of Directly Observed Treatment, Short-course (DOTS), TB is responsible for more deaths among the youth and adults than any other infectious disease (6). The disease has large social implications due to the stigma attached to it and its control remains a low political priority in many countries. All these support the need for greater TB advocacy worldwide.
However, advocacy for TB has failed as a public health intervention because of financial and political barriers, failure to involve the private health care sector and failure to include different need-based strategies for different target audiences.
Failure to address needs of different target audiences
There are two basic messages provided for most advocacy strategies – TB is a devastating disease and DOTS can control it (6,7). However different audiences have different concerns and advocates have to target messages accordingly. Audience segmentation is a basic principle of the social marketing theory, which addresses the issues of those those we are specifically trying to reach (8,9). Also, in McGuire’s communication/persuasion matrix, the first of the six steps to consumer decision-making is exposure to the information, where the importance of market segmentation is emphasized (10). The Human Face of TB is a video campaign launched by the WHO – Stop TB partnership (11). The campaign focuses on increasing awareness of the global TB prevalence and the success of DOTS worldwide. Although this campaign provides general information about TB in a very compelling manner, it is not tailored specifically to address concerns of different target audiences. While decision makers and politicians are concerned about budget implications, public opinions and the liabilities of their actions as leaders, health practitioners are concerned about the feasibility of implementing DOTS. Advocacy messages should be framed to address these concerns and those of corporations and businessmen, such as impact of the disease on workers and on the market (12). Framing theory also supports the importance of focusing the attention of people within a field of meaning. Contrary to the concept of making rational choices, framing theory suggests that the way in which something is presented will influence people’s choices (13).
Another important factor to consider is message development. Drawing from advertising theory, the message should be created in order to change the awareness, knowledge and attitude of decision makers (14). Although the film mentioned earlier clearly reinforces the two basic TB advocacy messages, this information by itself does not provide decision makers with any tools to address the problem of TB. These messages do not promote self-efficacy – they do not make the audiences believe that they are capable of attaining certain goals (15,16). The advocacy campaign will not succeed unless key policy makers are made to feel that their decisions will help control TB.
There is also a need for social mobilization as a type of grass-roots level advocacy, whereby the existing concerns among the public are explored, including stigma and gender issues and they are all incorporated in a collective effort of decision-making (17).
Failure to target the private health sector
Choosing the correct target audiences - the people, who can make changes to solve problems, plays a key role in the success of any advocacy campaign. The role of private medical practitioners cannot be underestimated, particularly in South-East Asia (18). It has been estimated that the first point of contact with health care services has been the private sector for over 50% of TB patients because of convenience and perceived quality of care (18,19). Other causes for concern include the treatment provided by the private practitioners, which does not always follow a standard regimen and is oftentimes different from the regimen provided by the National Tuberculosis Programme (NTP) and also the quality of care especially at the more informal end of traditional healers. These practices have implications not only for the individuals treated but also for disease transmission and development of drug resistance (18). Despite this, the NTP in many countries has been unprepared or even reluctant to involve the private sector.
Involving the private heath sector in private-public mix (PPM) health programmes has been successful in the treatment of STDs, malaria and family planning interventions (20,21). Social marketing is another method that has successfully been used to involve private sectors. This approach uses commercial marketing technique to address the lack of consumer information and stimulate a demand from the public for effective interventions, which are then sold through the private sector at subsidized rates to increase affordability (20). TB advocacy campaigns lack such innovative approaches in involving private practitioners.
TB advocacy campaigns have failed to target private pharmacists and pharmaceuticals and this has contributed to its failure as a public health intervention. With easy availability of ‘over-the-counter’ drugs in many developing countries (18,22), patients directly approach pharmacies for common symptoms such as cough and fever, which could be symptoms of TB and we could hence potentially be missing opportunities for early diagnosis of disease. In Asia and Latin America, anti-TB drugs are also available over the counter and self-medication is common (23). By not targeting pharmacists through advocacy, especially in these regions, the risk of primary resistance to anti-TB drugs increases. Yet another important target audience is pharmaceutical companies that manufacture TB drugs. With increasing reports of MDR-TB and XDR-TB, the urgency to discover novel compounds to treat tuberculosis cannot be sufficiently stressed.
Political and financial barriers
Advocacy denotes activities that are designed to place TB control high on the political agenda, foster political will, increase financial and other resources on a sustainable basis, and hold authorities accountable to ensure that pledges are fulfilled and results achieved (24). But TB advocacy has failed because of political and financial obstacles. There is a global indifference to tuberculosis, largely because it is considered to be a disease of the poor and destitute and so more of a social issue than a medical issue (25,26). But this is a fallacy because even in the some of the poorest areas in the world, a good TB control program has been successful in reducing the burden of disease. This is the case in Bangladesh, a country with a huge caseload and poor resources (6,25).
As tuberculosis is considered a disease of poverty, the solution proposed is general improvement in living standards worldwide. But Szreter argues that the concept that good health is a natural consequence of socio-economic improvement is naïve. It neglects the political actions that have resulted from public health advocacy and the impacts that these actions have had on health services (27).
A major challenge has been raising and sustaining financial support for TB advocacy and this arises in relation to insufficient political commitment. This could also be because the issue of TB is too big or too complex especially in the context of poverty. The Global TB control report (2007) estimates that the funding gap for TB worldwide in 2007 was about $1.1 billion (28). Such figures translated in terms of human lives shows the uphill struggle in addressing the current situation.
Conclusion
There are several adverse implications of failure of TB advocacy. The most serious of which is MDR-TB and XDR-TB, which render patients extremely difficult to treat. Lack of advocacy, resulting in misconceptions and lack of awareness among people in power would affect policy decisions and if they make harmful statements about TB more so in the setting of HIV/AIDS, then that would contribute to increased stigma and discrimination (29). On a global level, re-emergence of TB in developed countries in the setting of increased immigration needs to be considered (30) and one of the challenges to alter political will in the developed countries arises from the popular perception that tuberculosis is not a problem in these regions (31).
Another challenge in designing advocacy campaigns can be the difficulty in defining the concept in many languages and cultures, which may contribute to keeping people from participating in advocacy work and governance (29). However, in recent times, there have been advocacy campaigns that use the media as vehicles to promote messages with powerful language and imagery, keeping written information simple. Advocacy for TB control is at the core of the WHO Global plan and the goals are two fold. (I) To create political accountability and social pressure to shape policy agendas around the world; and (II) To mobilize US$ 56 billion from 2006 to 2015 for TB control and development (32). With such newer initiatives and promising trends in TB advocacy, it would certainly prove a valuable tool in the Global fight against TB.
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