User:Lorraine.meriner/sandbox

= Wikipedia Article Selection =

PE Org: PATH Mumbai
PATH, a Seattle-based global health nonprofit, focuses on developing low cost drugs, diagnostics, technologies, systems innovations (such as reforming the modes of healthcare delivery) and their implementation. At its Mumbai office, these innovations are centered about urban slums, where the prevalence of tuberculosis tends to be much higher. Indeed, India currently has the world’s highest burden of TB, and the poorest 20% of the population has 5 times the risk of developing tuberculosis relative to the population at large. PATH’s current two projects aim to facilitate early and accurate diagnosis of TB, TB case notification, appropriate and high quality care of TB cases, and treatment completion to improve cure rates of TB, all within the scope of a currently overburdened private sector. Given that the private sector (including the informal sector) is the fist point of contact for 50-80% of tuberculosis patients in India, and its insufficient size relative to its contribution to TB care, TB patients can expect high expenditures, diagnostic delays, and substandard treatments from the private sector. PATH Mumbai’s Joint Effort for Elimination of TB (JEET) focuses on capacity-building and engagement of the private sector; in training all actors involved in patients’ care and facilitating coordination between them, PATH has facilitated a scheme for less patients lost to follow up, more collaboration between respective actors, and overall increases in the amount of cases diagnosed and treated. I will be creating and distributing surveys for providers and health workers in the JEET scheme to map their pain points, questions, and concerns. I will report back to my colleagues about these qualitative findings, and develop a toolkit for addressing these gaps in the private sector for the remainder of the project. I will also be doing administrative tasks such as emailing and taking meeting notes for this project, opening up time for my colleagues to focus on their areas of expertise, and standing in solidarity with their mission in the capacity they have seen fit.

Area
Tuberculosis in India: This is a high important article rated at C class (so it contains a lot of irrelevant material or it's missing a lot of relevant material). I don't see much about the government's initiatives to deal with tuberculosis. I would love to add more about the RNTCP and why even though the government is seemingly doing so much to address TB, most people still seek treatment in the private sector. There's also not very much mention of the private sector in this article, and I would love to add more to that.

Sector
Public private partnership under RNTCP: This is a medium importance article at the starting stage. I am really curious to learn more about the public private partnership scheme. It is quite common in many high burden TB countries, according to WHO reports. I am curious about the history of the program, as well as if it does anything to build the capacity of public providers. I also wonder how informal providers (given India's large informal sector for example) play into this scheme.

Area
Chandra et. al have put forth a study (not literature review) on the intersection of social capital/ public services with urban tuberculosis in Delhi, India. While the article consists of statistical analysis that correlates growth of slum populations, growth in the number of single room dwellings, etc. with tuberculosis, I was primarily interested in this article for its discussion of collective action in the context of urban tuberculosis in India, and its promotion of solutions that address social infrastructure (such as housing, health, empowerment of women, participatory governance, citizen networks). It puts forth a very lovely schematic that shows how participatory governance and other methods of social infrastructure can feed into health outcomes. Notably, the RNTCP and DOTS frameworks put forward by the Indian government are very technical solutions that do not incorporate the methods suggested in this study. Given how closely correlated TB is with poor social determinants, it is surprising that neither the RNTCP/ DOTS or my PE organization (PATH Mumbai) have accounted for these social dimensions. My Area page does not discuss the social dimensions of TB at all, either. I hope to add some of the information presented in the analytical (correlational) portion of this study into the article, as well as more information from its suggested community development strategies (and the social inequities they address). Given that the article is open access, I would love to add their schematic to the Wikipedia article as well.

Kamineni et. al discusses various pro-poor strategies that have been incorporated into TB care and control in several states in India. Notable strategies included wage compensation for time lost to treatment, working with civil society organizations to link low income patients to social services, nutritional support, and offering local NGOs and committees a platform for engagement with the work done by private providers. In this way, the RNTCP (which was designed to benefit those who are most vulnerable to TB: the poor) is better able to meet its goals. Notably, these pro-poor programs have not been evaluated for effectiveness; if not for TB specifically, I am hopeful to find more information about pro-poor infectious disease interventions elsewhere. Under its description of the tuberculosis treatments, my Area page doesn’t include these social interventions or their impacts. Especially if I am able to learn more about their effects, I would like to add this information to the page.

Hargreaves et. al have discussed the role of social determinants in tuberculosis around the world (not specific to urban India). They state that TB incidence is correlated with human development indices than with the DOTS framework that the Indian government (RNTCP) has promoted. They cite poverty, hunger, overcrowding, etc. as increasing susceptibility to TB, and propose economic-oriented actions to promote health (“livelihood-strengthening”) and security. Fiscal support in the form of cash transfers, microfinance, and training/ skills development as well as slum upgrading projects are seen as viable means to alleviate the burdens of TB. This perspective is not accounted for in my Area article, nor is it utilized in my PE org. This article reminds me that we live in a market-based society where livelihood can be equated with incorporation into the market. I am generally skeptical about market-based solutions; to me, they are a signal of crumbled public infrastructure. Nonetheless, the market-based context is that which the organizations addressing TB operate in; therefore, economic inclusion AND private infrastructure are important for addressing urgent and immediate concerns such as infectious disease.

The Daftary et. al article is a call to action for policies and practices to mitigate the stigma surrounding TB. Daftary notes that stigma surrounding TB stems from its associations with social marginalization, poverty, and infectiousness. While the HIV movement has been successful in institutionalizing policies that affirm the dignity of folks who experience it, a similar movement/ policies cease to exist for TB. Daftary et. al notes that harsh language (referring to cases as ‘suspects’) and impersonal care (which is overly clinical and often involves punishing non adherence without understanding the social determinants that underly it) fuel the social exclusion of people with TB. They also highlight that there is some activism surrounding TB from organizations  referred to as “key actors in the TB community” - global-scale TB campaigns and NGOs. The article suggests many means of destigmatization along the entire pathway of TB care (from screening to notification to treatment) as well as for research & awareness surrounding TB. On the latter, suggestions include participatory research methods, focus groups that inform research (this reminded me of Duraiappah), public representation of folx who have experienced TB (humanizing the disease), and framing TB as a rights-based issue rather than one of disease control. This article was very informative to me — I was not cognizant of the stigma that surrounded TB. TB stigma really has the propensity to make people feel isolate and disempowered, and I think that this article suggests that this disempowerment leads to lacking collective action around TB. How did the HIV movement overcome stigma and move toward collective action? Also, it’s really interesting to me that stigma surrounding non adherence (verbally reprimanding or even incarcerating people who do not adhere to treatment) reproduces non adherence — care that is not understanding of why someone might not be ‘noncompliant’ in treatment and subsequently reprimands it doesn’t empower ‘suspects’ (I hate this word) to adhere any better. This makes me think about my PE a lot - non adherence is one of the issue PATH tries to address, but it does so in a very clinical way. It is hoping to increase adherence by training all professionals in the [very technical] RNTCP protocol, which should streamline care. While this is useful and has been shown to increase adherence, it doesn’t directly address the other underlying factors such as mistrust, low social protections for TB ‘suspects’ etc. that also contribute to TB non adherence. This article does a fabulous job of giving me some material to dream on — just as PATH is working on every step of the care pathway with their training program, the article has suggestions for every step in the care pathway on how TB care can be more sensitive, human, and affirming. Among my favorites are social support networks, auxiliary therapies that address mental health and nutrition, employment protections while receiving treatment, and the like. Also, I am a bit averse to the phrase “key actors in the TB community” because this referred to topdown organizations (global health NGOS such as PATH) — but reading this article has reminded how these topdown organizations, too, have the capacity to engage with communities and individuals meaningfully. Many of them just aren’t doing it yet. Lastly, with regards to my Wiki article - I think I'll add my thoughts on social stigma around non adherence to the section on "treatment" in the article.

The Dye et. al piece is not a lit review, but an original study that statistically analyzes how much particular sociobiological determinants are correlated with TB incidence TB (sociobiological in the sense that some of the specific determinants are biological [diabetes, nutrition, and the like] but are widely known to be preceded by social factors). The study essentially hopes to shed light  on how much of TB incidence can be attributed to particular social factors by correlating data of TB incidence with changing proportions of populations having high BMI, lacking nutrition, living in urban areas, and the like. There is a particular section on India that projects that the 30% increase in TB incidence between the years 1998 - 2008 was attributed mostly to changing overall BMI, increased prevalence of diabetes, urbanization, and the population’s aging, in order of decreasing impact. These factors need to be taken into consideration in TB control, and are not really addressed by the RNTCP (the national TB control protocol that my PE organization follows). Unlike in America, BMI in India is not necessarily correlated with low income; but lacking nutrition and living in overly crowded urban environments are. Given that PATH’s Mumbai projects specifically address TB in urban areas, I wonder how much they have thought about addressing the urban conditions and lacking nutrition in their work. Their work right now seems very clinical and downstream. I think that this will be really useful for my Wiki research - I’m creating a new section on the social determinants of TB in my Area (Tuberculosis in India) page and think that concrete examples such as “the annual risk of infection has been found to be 69% higher in urban than rural areas” are very compelling and reflective of the social conditions that produce TB, which were discussed in the Hargreaves article.

The Achmat article cites successes of South Africa’s Treatment Action campaign, and challenges the TB movement to take on some of the practices the TAC has enacted in HIV care. TAC is a grassroots HIV campaign (rooted in the anti-apartheid/ gay rights movements in South Africa) that has promoted research in the realm of HIV/AIDS as well as a treatment literacy program for HIV patients. The literacy program borne out of the notion that personal autonomy is often compromised in medical care, and that feeling in control of one’s own health is an empowering and important experience. The literacy program informs people not only about the science behind treatment, but also the political and social contexts in which treatment is situated. The article discussed how the DOTS (TB treatment course that is at the core of the RNTCP) relinquishes patients’ independence because of how closely they are monitored, and suggests treatment literacy efforts as an antidote to this phenomenon. I really like this approach of patient empowerment. Empowerment is such a nebulous concept and I’m not sure that its exact impacts on health can be quantified in the way that the impacts of the DOTS can be. It is nonetheless an important issue to address, especially as disempowerment is a barrier to collective action around TB. I had not previously seen the DOTS specifically through the lens of disempowerment, although I had understood it to be very impersonal. Can the DOTS be adapted to be more empowering (maybe through less surveillance of patients)? And what conditions would it take for organizations such as the TAC to arise and make large-scale change in the TB sphere? Could PATH uptake some of the tenets of TAC, or does an organization have to “have skin in the game” (i.e. be comprised of people who have been directly affected by TB) to be effective in outreaching to communities/ identifying what needs need to be addressed? Has PATH even thought about this? I wonder. For my Wiki research, this article will be going under my Sector page as I talk about pro-people and pro-poor treatment options for TB, under the “Treatment” section. I think it will complement the technical underpinnings of the RNTCP that this section currently focuses on.

The second chapter of Corburn’s book “Street Science” introduces the concept (and power) of local knowledge. Local knowledge, he explains, is that acquired by lived experience and culture, rather than through professional inquiry or academia (what Frasure might refer to as expert discourse). He cautions that this knowledge is often romanticized, or framed as antithetical to professional/ academic knowledge; he subsequently highlights several examples of how professional & local knowledge can overlap and intersect to create better health outcomes. Of particular interest to me was his section on activism around AIDS (as like TB, it is an infectious disease. The “AIDS movement” or organizing surrounding AIDS was very grassroots and interdisciplinary: POC, queer folx, activists, allies, artists, and many advocacy groups organized around AIDS policy/ research. Their resistance to scientists’ tendency to produce results that reproduced stigma (such as attributing etiology to a homophobic lifestyle), their construction of terms like “safe sex” that drew away from antigay sentiments, as well their presentation of alternative evidence (gathered from clinical trials they undertook themselves) changed the narrative surrounding AIDS for good. This was a super inspiring read; it made me think about why activism hadn’t spun off in this direction in the realm of TB, which ended up being one of my subsequent topics of focus in my Wiki research. It also gave me a sense of how local knowledge and professional knowledge can interact; these spheres are typically (sadly) very distinct and seeing how they overlapped helped me to move past my mental roadblocks to imagine what engagement with community knowledge might look like for my PE. There isn’t existing activism around TB (which I explore in my later wiki research), but looking to another example Corburn has cited about a West Harlem citizens’ involvement in addressing adolescent asthma (their use of citizen scientists sort of similar to PATH’s partnership with local organizations to train community providers to tackle TB) has given me some food for thought — do PATH’s training programs offer providers the space to adapt their protocol to local needs/ to incorporate local knowledge? I hope to learn more about this when in Mumbai.

The Macq et. al article is a survey of various patient empowerment schemes in TB care from around the world. From loans to TB families for increased financial autonomy in Cambodia, to patient-comprised health education committees that work to mitigate TB stigma in Zambia, to self help/ support groups in Mumbai, there are lots of ways needs outside of diagnosis and treatment have been addressed in the TB sphere. My favorite part of this article was that which explained how TB care can help enable advocacy skills in patients. In Nepal, for example, TB patients are invited to be on committees that figure out how to implement the DOTS (TB treatment regimen) in a way that is sensitive to patient needs. Similarly in Burkina Faso, patients meet with other stakeholders in the TB sphere to design treatment regimens that achieve not only better biological outcomes, but also better social and economic outcomes. This article really helps me to dream about a better version of my PE. I would love for PATH to include community input into the implementation of the DOTS protocol — I’ve been thinking about this for a while (since reading the Duraiappah reading), and dint’ think it possible till I read in this article that it’s already been done. I wonder what particular (social, or bureaucratic, going against the status quo, or something else) barriers are in the way of achieving a more participatory DOTS strategy in India. I’d love to learn more about this. This article is going into my Area section, when dreaming about what care that better addresses the social determinants of health might look like.

Sector
Amrith describes the nationalistic, political nature of the origins of post-colonial public health infrastructure in India. Public health discourses were rooted in scientific racism (eliminating inferior castes) and nation-building (having a greater physical capacity was equated to a greater economic capacity). Amrith argues that the Indian government alone could not shell out the resources to meet its ambitious goals (given colonial extraction), paving the way from the entrance of external and unreliable funding and resources, such as the WHO, UN, and USAID. He cites an example of malaria eradication programmes that were successful, but whose benefits were quickly lost when USAID divested in India’s efforts. The Sector article I have chosen doesn’t offer much of a reason for India’s choice to pursue a public-private mix in most subsets of public health; however, this article offers a historical and political perspective into why it is used: it was a matter of lacking resources. The malarial example sheds light on India’s inclination toward reliance on private schemes for public health matters; given this dependence, I understand better why my PE is working on capacity-building in the private sector.

Verma et. al discuss gaps in the implementation of the Revised National Tuberculosis Control Program (RNTCP), India’s state-run tuberculosis eradication program. A clinical treatment sequence called Directly Observed Treatment Short-course (DOTS) has been put forth as a highly successful means of controlling tuberculosis on the managerial level, but these practices have not been taken up almost at all in private practice (less than 1% compliance) to improve the quality of care, though over two third of doctors in India are private providers. The article cites that this is because of lacking training and coordination for private practitioners; I find this argument compelling because it pertains directly to the PE project I will be working with this summer, which is building capacity in the private sector. The quality of TB detection and care in the private sector are also cited as issues in this article, and are issues that my PE org is seeking to address. My sector page does not note that a lack of adherence to its rules in the private sector is an issue, and I feel that I could add to the page accordingly. I am curious about what RNTCP compliance looks like in public sector care, given the general consensus that public sector healthcare is lacking in India. I also wonder how the RNTCP holds both private and public healthcare providers accountable, given low compliance and quality of care in the private sector and low quality care in the public sector.

The Sachdeva article is useful for understanding the RNTCP’s most recent phase, which ambitiously aimed to universalize access to TB care  (“TB-free India”) through better diagnostic technologies, engagement with private care providers, treatment and diagnosis of multi drug resistant TB, research development, endogenous funding, alignment with rural health initiatives, and alignment with civil society organizations. I am surprised to see the latter in this list, and have so far found that articles eventuating the RNTCP do not discuss this objective at all. To see all of these objectives (which I should add to the Sector article) and where PATH fits in has been useful; the first four objectives listed above are definitely being addressed by PATH. Of course, to have too broad of a scope would make the achievement of these objectives quite difficult for one organization, and the ones PATH addresses seem to fall within a similar category of health systems management. I wonder if PATH has given any consideration to community-based organizations, and would be curious to find out more about this. On what organizations does the responsibility fall to engage with social mobilization and community outreach? Also, I am a bit disheartened that this goal only takes up about one sentence in the entire RNTCP scheme, and fear that it too ambiguous/ nebulous.

The Murrison et. al article is an original, analytic study that quantifies the variance in TB care offered by urban private providers in Chennai, in terms of how well they follow various protocols established by India’s [revised] national tuberculosis control program (RNTCP). The study population was only part of that which PATH works with: only private physicians in the informal and formal sectors were included in the study. Variance in practice was particularly pronounced when between practitioner types (general MD vs general allopathic vs chest specialist) and by patient volume (those who saw more patients tended to have different practices than those who saw less). The study found that adherence to RNTCP protocol was relatively poor - there are many criteria that only 25-30% of the surveyed providers met, including particular molecular tests, treatment monitoring, and case notification to public authorities. The study ultimately concluded that the quality of TB care is very variable across providers, and that adherence to RNTCP recommendations is quite low. ends on a call to action for better training on TB management protocols. My PE org follows the recommendations this paper makes by offering training to not only physicians, but many people along the TB care pathway (screening to diagnosis to treatment and beyond). PATH does the work of standardization that is in many senses necessary. However, I wonder if there are practices that ought to be more context-specific. Is enforcing all parts of the RNTCP protocol a financial burden? WHY is this variance the case - other than lacking standardized training? Is it possible to accomplish all its parts given how high demand TB care really is? Ie - could variance be a ‘good’ thing in terms of relieving financial/ time burdens on patients and providers? Also, this article conducts its analysis from the lens of following RNTCP protocol, which may be too narrow a scope. Are there practices that these providers do that the RNTCP doesn’t entail, but that still work quite well in the context of their clinic? So many questions. Anyways, for my Wikipedia article, I will be adding information about the variance in care as a predication to why “standardization” through training is important (through the PPIA model, which is what PATH follows to offer its trainings), preceding my discussion of the PPIA.

The Wells et. al article discusses in this article various methods through which the private sector for TB can be better ‘engaged.’ This phrase, “private sector engagement” is thrown around a lot in India’s TB discourse, and refers to the betterment of the private sector through working directly with in the form of training, financial support, etc. (since the private sector is the first point of contact for most TB patients’ care, but is also under equipped relative to this high demand). Wells + team explain that “PPIAs” (Private-Provider Interface Agencies) are a particular form of private sector engagement that are currently being piloted. These agencies offer a wide range of services, including vouchers that eliminate the cost of TB drug and tests, quick electronic notification of your car status, and information systems that make tracking many patients easy. PPIAs help make it possible to treat, track, and follow up with high volumes of patients, which is important for the overburdened private sector. The description is very short, but it was the most thorough I could find anywhere (other than in the RNTCP guidelines). Indeed - PPIAs are being piloted in a handful of locations India per RNTCP protocol, and PATH itself functions as a PPIA. This article helped me understand the full scope of my PE, which I had not been able to garner previously through the various articles my supervisor had sent me, or from the information I found on the internet about it. As I bring up in many of these annotations, I am a bit disappointed by the technical focus of many of the RNTCP’s guidelines (including those outlining PPIAs), and this article reinforces my perception of PATH as having a very technical (rather than social or rights-based) approach. Their role as a PPIA is marketed in a sort of humanized way, as publications about their PPIA work include stories of people who benefit from it, and about the grassroots organizations they partner with. Yet, this description of PPIAs doesn’t seem very grounded in community. I think that, given the lacking literature on this subject, I’ll need to learn more about this topic and how it works when I’m there. This article equipped me with a sense of curiosity about PPIAs! Regarding my Wikipedia article, I will bring this into my Sector article as it outlines various parts of the RNTCP. As PPIAs are not very well-known about, I would love to bring them into the public discourse surrounding TB control in India, embodied by the RNTCP Wikipedia article.

Goodchild et. al offers insights into the economical benefits of the RNTCP rollout, and praises the RNTCP for being a cost-effective means of improving health outcomes. The study estimates that following the RNTCP guidelines cuts disease duration by 2/3 (1.6 years less), has saved 1.3 million lives, and has a return of $115-155 per dollar spent. The RNTCP has, by the sounds of Goodchild + team, been a very successful effort. The only drawback, they mention, is that the RNTCP has not reduced the incidence rate of TB. As a public health student, I can see why — the RNTCP is not geared toward prevention, but toward clinical practice and downstream treatment. In this sense, it of course does not decrease the incidence of TB. To decrease incidence, one might need to look more upstream to address the social determinants that surround TB, of which there are many (as addressed by several other articles in my bibliography). I have no background in economics, but my public health training gives me a hunch that addressing these more upstream factors might result in even more costs averted, as if cases are prevented, treatment costs would be, too. Anyways, the article gives me a whole new appreciation of the work my PE does — although the economic impact is not as ideal as it could be if the RNTCP did a better job of addressing social factors that contribute to TB, the Program’s impact is nonetheless HUGE and extremely beneficial. Investments in the RNTCP have made quality care and better livelihoods more possible — 1.6 years less of disease is 1.6 years more of laughing, loving, and living free of disease. I am very appreciative of my org for helping make that happen. I plan to bring the ‘costs averted’ from this article into the RNTCP article (Sector), to shed more light on the economic benefits of the RNTCP as they are not yet presented. Although this knowledge is still quite ‘expert’ in nature it will complement the current [very biological] content quite nicely I feel.

This Daftary article, which is a call to action for care that better suits the sociomedical needs of patients, explains why the scope of care for HIV and TB is so different. Whereas HIV care equally weights adherence/ case detection and education/ empowerment, TB control has always taken in sole a very biomedical approach. Daftary notes that this may primarily be due to the two diseases’ distinct causes and disease courses. In the case of HIV, intimate human contact results in lifelong disease; its etiology is very distinctly behavioral, making it important to work closely with patients to understand and help change their behaviors. In contrast, TB is transmitted through less consciously in airborne particles and can be cured. TB’s clinical orientation, Daftary argues, stems from the fact that it can be cured at all (therefore treatment is more important than behavioral work), and from the fact that sustained behavioral change in patients wouldn’t necessarily preclude disease. Daftary frames HIV care as empowering and TB care as dispiriting; resources for the former are mobilized by activists, many of whom have HIV themselves, and the latter is very expert-driven. I had been wondering for a while why HIV activism had been so much greater than that for TB. I recently heard in a public health class that internalized racism undermines collective action, and I think that a similar dynamic is it play for TB — care that is impersonal and revolves around treatment and compliance (TB) moreso than humanness (HIV) can be very disempowering. The article primarily attributes this disempowerment to the DOTS (directly observed treatment, short-course) framework, but doesn’t really explore other aspects of TB care and how they might work toward or against patient empowerment (improved outreach to communities, for example, is an integral part of the RNTCP guidelines that is seemingly empowering, depending on how it is done). Capacity-building, which is something that my PE org does in the private sector per RNTCP, seems to be somewhat empowering — it devolves power into providers’ hands. However, none of my PE’s work seems to empower patients themselves to act collectively. Can any of the RNTCP guidelines be spun to promote patient empowerment? I speculate that, given the social determinants of disease that surround TB including overcrowding as a result of political marginalization, people who have/ have had TB have lots of room for organization. Empowerment is just the first step. For Wiki, I will be using this Daftary piece in my Sector section to explain why the TB protocol surrounding the RNTCP is so clinical/ biomedical, but also to briefly touch on how this leads to lacking political organization around TB (explaining how state-centric TB narratives are).

Summarizing & Synthesizing
I was surprised to find that community organization was a goal of the RNTCP. I feel that it is well known that community empowerment has beneficial impacts on health outcomes. One of the articles I read didn’t even mention that this was one of the main goals of the RNTCP; even the article I found it in did not discuss it at length.

Most articles evaluating the RNTCP don’t seem to include metrics evaluating community organization/ involvement, which makes me feel that it is undervalued. This makes me curious about what orgnizations are addressing this dimension, and how common these organizations are relative to those that address diagnostic gaps/ gaps in the quality of private care (such as PATH). I am curious about how the concerns of community organizations might align or clash with organizations such as PATH, and what impacts they have had on changing outcomes related to TB. I am hoping to explore this a bit more. It seems that PATH is addressing one of the biggest concern of the RNTCP: that protocols haven’t been followed by private providers. Their private-sector capacity-building/ training initiatives make it easier for private providers to follow these guidelines. Even though this seems to be one of the biggest issues with the RNTCP, there isn’t any discussion of this on my Sector page. I hope to add more about it.

The article on the political history of public health leaves me with a lot of questions: How reliant is the Indian government on outside resources today? Is the Indian government investing in rebuilding its public healthcare infrastructure? Given the growing economy in India (abundant resources relative to the era just post-colonial that this article discusses), is the government any more able to invest in public infrastructure? If so, has it? I understand why the private sector was able to flourish in the 50s, but would like to learn more about why that hasn’t changed, especially because reliance on external funding has proved to be unsustainable (the article cites an example of a failed malaria control scheme due to this). I am also interested in learning about the vestiges of scientific racism in the context of public health in India.

A lot of information on TB control programs is technical and acronym-prone (DOTS, RNTCP, PPM, etc.). This was especially true of my Sector articles. Therefore, I looked to other means of TB control, as well as the social determinants of TB in this section. One article hoped to address these social determinants through economic empowerment in the forms of cash transfers and microfinance, given that many susceptibilities to TB have to do with economic status (lacking nutrition, chronic stress, poor living conditions etc.). I am usually skeptical of these solutions, but given how closely linked TB and economic conditions, I am curious to learn more about TB efforts that have included these, if any at all. The Sachdeva et al. article made me hopeful about the existence of these “pro-poor” strategies to address TB. I was happy to see that the social dimension of the RNTCP is indeed being addressed, although the impacts of organizations acting in this capacity are not well-quantified. The Chandra et al. article also discusses theoretical ways to empower communities and simultaneously address TB. I would love to learn more about these methods, and to ask if PATH has partnered with any organizations implementing them, or if the community organizations it partners with primarily regard its provider capacity-building efforts.

Causes[edit]
'''There is a specific bacterium that evolves inside the body to result in tuberculosis, known as mycobacterium tuberculosis. This bacterium is only spread throughout the body when a person has an active TB infection. One of many causes of acquiring TB is living a life with a weak immune system; everything becomes fragile, and an easy target. That is why babies, children and senior adults have a higher risk of adapting TB. The bacterium spreads in the air sacs, and passes off into the lungs, resulting in an infected immune system.'''

'''In addition, coughing, sneezing, and even talking to someone can release the mycobacterium into the air, consequently affecting the people breathing this air. It has been stated that your chances of becoming infected are higher if you come from – or travel to – certain countries where TB is common, and where there is a big proportion of homeless people. India, having the most TB cases of any country  being the largest country with diagnosed patients, falls under this cause because it stands recognized as consuming a higher chance of gaining TB.'''

Socioeconomic Dimensions of TB [new subheading]

Those listed are all the bodily and personal causes of acquiring TB, but decreases in tuberculosis incidence are correlated with improvements in social and economic determinants of health moreso than with access to quality treatment. In India TB  is rich in its  occurs in '''high rates because of the pollution dispersed throughout the country. Pollution causes many effects in the air the people breathe there, and since TB can be gained through air, the chances of TB remain high and in a consistent movement going uphill for India.'''

'''Another major cause for the growth of TB in India has to do with it currently still standing as a developing country. Because its economy is still developing, the citizens are still fighting for their rights, and the structure of the country lies in poor evidence that it is not fit as other countries still.''' A study of Delhi slums has correlated higher scores on the Human Development Index and high proportions of one-room dwellings tended to incur TB at higher rates. Poor built environments, including hazards in the workplace, poor ventilation, and overcrowded homes have also been found to increase exposure to TB.

[insert Hargreaves Figure 1]

TB rises high in India because of the majority of people not being  patients are not '''able to afford the treatment drugs they are prescribed to diagnosed patients. “At present, only the 1.5 million patients already under the Indian government's care get free treatments for regular TB. That leaves patients who seek treatment in India's growing private sector to buy drugs for themselves, and most struggle to do that, government officials say.”''' Although the latest phase of state-run tuberculosis eradication program, the Revised National Tuberculosis Control Program, has focused on increasing access to TB care for poor people, the majority of poor people still cannot access TB care financially.

'Consequently, high priced treatment drugs and the struggles of “poor patients” also brawl through the poor treatment they receive in response to acquiring TB. “It is estimated that just 16% of patients with drug-resistant TB are receiving appropriate treatment”''. To combat this huge problem, India has instated a new program to try to provide free drugs to all those infected in the country.'''

While RNTCP has created schemes to offer free or subsidized, high quality TB care, less than 1% of private practitioners have taken up these practices. '''Lastly, as high pricing is linked to the economic standings of India, which is linked to poor treatment, it all underlines the lack of education and background information practitioners and professionals hold for prescribing drugs, or those private therapy sessions. A study conducted in Mumbai by Udwadia, Amale, Ajbani, and Rodrigues, showed that only 5 of 106 private practitioners practicing in a crowded area called Dharavi could prescribe a correct prescription for a hypothetical patient with MDR tuberculosis.''' Because the majority of TB cases are addressed by private providers, and because the majority of poor people access informal (private) providers, the RNTCP's goals for universal access to TB care have not been met.

Poverty and lacking financial resources are also associated with malnutrition, poor housing conditions, substance use, and HIV/AIDS incidence. These factors often cause immunosuppression, and are accordingly correlated with higher susceptibility to TB ; they also tend to have greater impacts on people from high incidence countries such as India than lower incidence countries. Indeed, addressing these factors may have a stronger correlation with decreased TB incidence than the decreasing financial burdens associated with care. Yet, the RNTCP's treatment protocols do not address these social determinants of health.

Disempowerment and stigma are often felt by TB patients as they are disproportionately impoverished or socially marginalized. The DOTS treatment regimen of the RNTCP is thought to deepen this sentiment, as its close monitoring of patients can decrease patient autonomy. To counteract disempowerment, some countries have engaged patients in the process of implementing the DOTS and in creating other treatment regimens that adhere to their nonclinical needs. Their knowledge can inform valuable complements the clinical care provided by the DOTS. Pro-poor strategies, including wage compensation for time lost to treatment, working with civil society organizations to link low income patients to social services, nutritional support, and offering local NGOs and committees a platform for engagement with the work done by private providers may reduce the burden of TB and leads to greater patient autonomy.

History[edit]
India has had an ongoing National TB Program (NTP) since 1962. At that time, the Indian government lacked the financial backing to meet its public health goals. Therefore, external sources of funding and administration, often from the WHO and UN, became common in the realm of public health. In 1992, the WHO and Swedish International Development Agency evaluated the NTP, finding that it lacked funding, information on health outcomes, consistency across management and treatment regimens, and efficient diagnostic techniques. In order to overcome these lacunae, the Government decided to give a new thrust to TB control activities by revitalising the NTP, with assistance from international agencies, in 199 3 7'''. The Revised National TB Control Programme (RNTCP) thus formulated, adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective approach to revitalise the TB control programme in India.'''

'''In order to overcome these lacunae, the Government decided to give a new thrust to TB control activities by revitalising the NTP, with assistance from international agencies, in 1993. The ''' Given TB's high curability rate 6-12 months after diagnosis, moving toward a clinical and treatment-based strategy was a sensible progression from the NTP. Revised National TB Control Programme (RNTCP) thus formulated, adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective '''approach to revitalise the TB control programme in India. DOTS was adopted as a strategy for provision of treatment to increase the treatment completion rates. Political and administrative commitment were some of its core strategies, to ensure the provision of organised and comprehensive TB control services was obtained. Adoption of smear microscopy for reliable and early diagnosis was introduced in a decentralized manner in the general health services. DOTS was adopted as a strategy for provision of treatment to increase the treatment completion rates. Supply of drugs was also strengthened to provide assured supply of drugs to meet the requirements of the system.[citation needed]'''

Program working[edit]
'''The program initially adopted the Directly observed treatment, short-course strategy which consisted of the five components of strong political will and administrative commitment, diagnosis by quality assured sputum smear microscopy, uninterrupted supply of quality assured Short Course chemotherapy drugs, Directly Observed Treatment (DOT) and systematic monitoring and Accountability. The DOTS strategy achieved and sustained the target detection rate of 70% of all estimated cases and a cure rate of 85% in new cases'''.The strategy is estimated to have saved 1.3 million lives since its implementation, and has cut the disease duration by nearly 70% (by 1.6 years). Although incidence and mortality remain quite large in magnitude, with 2 million incident cases and over 250,000 deaths from TB in 2009 alone, the DOTS has also  and led to the  a decrease in incidence of TB in the country.

Public private partnership under RNTCP[edit]
In India a sizable proportion of the people with symptoms suggestive of pulmonary tuberculosis approach the private sector for their immediate health care needs. However, the private sector is overburdened, and lacks the capacity to treat such high volumes of patients. RNTCP-recommended Private-Provider Interface Agencies (PPIAs) help treat and track high volumes of patients through offering treatment vouchers, electronic case notification, and information systems for patient tracking.

Due to lacking training and coordination amongst private providers, adherence to the RNTCP protocol is quite variable amongst private providers, and less than 1% of private providers comply with all RNTCP recommendations '''There is need for regularizing the varied anti-tubercular treatment regimens used by general practitioners and other private sector players. The treatment carried out by the private practitioners vary from that of the RNTCP treatment. Once treatment is started in the usual way for the private sector, it is difficult for the patient to change to the RNTCP panel. Studies have shown that faulty anti-TB prescriptions in the private sector in India ranges from 50% to 100% and this is a matter of concern for the healthcare services in TB currently being provided by the largely unregulated private sector in India.'''

Area
People's Park (Berkeley): history of the park, particularly the 1969 people's park protest! Also, proposed developments on the park. Could be cool to expand on the Bloody Thursday bit.

Homelessness in the San Francisco Bay Area: the history, causes, consequences, etc. of homelessness in the Bay (Berkeley, San Francisco, Richmond). There's a little bit about anti-homelessness ordinances; I think that there could be more added here.

Homelessness in the United States by state: surprisingly Suitcase has made it to this page! Would be interesting to compare what homelessness looks like in other cities (particularly in Boston, where there are, I have heard, many great services for folks experiencing homelessness).

Sector
Suitcase Clinic: there's a whole wikipedia page dedicated to where I'm doing my PE! Whoa! I would love to add more to this; for the PE I will be co-facilitating the class; I am wondering how I might be able to incorporate scholarly articles into this.

Anti-homelessness legislation: the selective enforcement of laws, the laws that specifically target people who are houseless, trends in how these laws have changed over time, and other information about how folks who experience homelessness are marginalized by the law.

Land-grabs by the university: I haven't found any articles on this yet, but I do hope to. Would love to add this to one of the Area pages.

* need to fix*

Principles of Public Health Practice

Safe space

Homelessness services

Article Evaluation (Suitcase Clinic page) [archived]
Evaluating content:

- The location of the Womxn's Clinic has not been updated (moved last year to a different location)

- The Womxn's Clinic underwent a change (formerly Women's Clinic) in recent years, and this is not reflected in the article.

- The history is short. There is not enough content about why we changed to a focus on public health, etc. or when. Also, the words "advocacy" and "solidarity" are not included in our Overview, though they are part of our mission.

- Lack of scholarly resources (although I am struggling to figure out where we could get more scholarly resources on our history and premise; we could talk more about the models of wellbeing we operate under, though, or cite them).

- The "Subdivisions" category doesn't really reflect the structure of our organization, this could be more clearly delineated as "Clinics" and a separate subsection for our unique services, and for the class itself. Also, we should add more services such as foot-washing and haircutting into the service section.

- the media coverage is not very up to date

- The locations of the clinics should be included here.

- We could add a section about our advocacy work and stances in the past and present with regards to the city.

Tone:

- Mostly objective in my opinion.

- There is some justified but opinionated tone in the YQT+ page, which says that there's a "reluctance amongst this population to deal with the bureaucratic intake and formal processing methods of traditional institutions" although I do believe this to be the truth.

Evaluating Sources:

- There are very few citations at all in this piece.

- The information comes from members of the organization most likely, and not outside sources.

- Although not scholarly, maybe they could cite more outside articles about the Suitcase Clinic, to increase the number of sources (including negative press). Otherwise this is largely biased by the opinions of people inside the organization. It would be interesting to get more perspectives from folks at the clinics on the Suitcase Clinic and add them to the article.

- There are no scholarly articles cited. I think that we could cite point and time counts on homelessness in this area which are created by the city, or other W.articles (such as Homelessness in the San Francisco Bay Area, for example). We could also cite research on criminalization of homelessness and the impacts of stigma on well-being, if there are any.

Talk Page:

- There was a conversation about the fact that the organization claimed to be "humanist" from 2006, which was disputed because this word wasn't found on their website. The critic seems to have taken issue with this because because it is a philosophical stance that should not be used lightly/ without proper sourcing.

- This seems to be a low-importance article at the moment.