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Farmer chapter 2. Rethinking emerging infectious diseases.
- He speaks about the multi factorial nature of disease and how there is a major difference in the amounts of deaths from infectious disease between the developed and undeveloped world

- He asks why this is, and why it is from diseases that have essentially been eradicated from the developed world.

- Many people believe it is because these diseases are reemerging but Farmer calls for a critical epistemology of infectious disease in this chapter

- Critical Epistomology of infectious disease is the being critical of the traditional view of disease by asking questions of who is being left out, are emerging infections new? Being critical of transitions. Risk of infection is based on the local not global.

- This is why Farmer and McMichael are different.

- Essentially the diseases have only been taken out of the developed world and been forgotten about because of their reduction but they are still around in other places.

- These diseases are not reemerging, they have always been with us, it is just that we do not see them.

Cohen. Changing patterns of infectious diseases.
- Infectious diseases once scarred us but later we believed vaccines, antibiotics would save us and we didn't have to worry about infectious diseases and it was not chronic diseases like cancer that we have to focus on

- But now new infectious diseases and microorganisms are being recognized and being recognized as causes of chronic disease

- We are not so safe after all

- Factors that decrease risk of catching one infectious disease lead to catching other different kinds

- Aging, IV drugs, unnecessary use of antibiotics, behavioural changes influence risk of catching infectious disease
Six factors decreasing infectious disease spread:

1. Better Housing
2. Nutrition
3. Antibiotics
4. Safe food and water
5. Immunizations
6. Hygiene and sanitation

Six factors increasing spread of infectious disease:

1. Changes in technology and industry - AC legionnaire's disease, fridges and listeria
2. Demographics and behaviour
3. Environment and land use - Rain, rodents and disease spread
4. Travel and commerce - global village, more contact with new diseases because diseases don't respect barriers
5. Microbial adaptation - toxins can combine with each other and cause more resistant diseases
6. Public health breakdown - leads to reemergence of diseases

McMichael. Environmental and social influences on emerging infections
- Defines emerging disease as: diseases undergoing increased incidence, newly discovered infections and newly evolving infection.

- Demographics and mobility, land use/environmental changes, consumption behaviours, other (sexual or drug behaviours), and host condition/immune status effect the process of emergence.

- Talks about 4 time periods of infectious disease

1. local (5000 - 10 000 years ago)
- Many mutant microbes originating from husbanded animals and urban pest species (rodents, flies, etc.) HIV, SARS would have survived and prospered.

2. Continental (1500 - 3000 years ago)
- Eurasian civilizations came into military and commercial contact therefore exchanging diseases such as the Justinian plague.

3. Intercontinental (1500 - present)
- European exploration and imperialism led to trans-oceanic spread of diseases. Darwin's observation on the aboriginals of Australia and states the Europeans brought over diseases and the aboriginals were dying from it.

4. Global (Present)
- We are destabilizing the ecosystem in favour of the pathogen species which are reproducing rapidly.

Farmer chapter 4. The exotic and the mundane.
- Critical epistemology had the power to reveal a great deal about infectious disease

- There was a lot of blame in Haiti

- The problem in Haiti was not physical or political geography, it was moral geography "The geography of blame" Blame linked to social inequality

- Unlike most other patients diagnosed with AIDS in the US, Haitians denied homosexuality and iv drug use, most never had a blood transfusion so it was a complete mystery for north american researchers. The Haitian men committed homosexual acts but didn't identify themselves as homosexual and htey would have sex with women and spread more.

- Americans said Haitians gave AIDS to the homosexual americans and that AIDS in Haiti was because of voodoo but this was not true.

- First AIDS related case of Kaposi's sarcoma in Haiti was in 1979 rare and found usually in europe.

- The type AIDS in the US was similar from the one in Haiti, but the opportunistic infections were different and their survival rates as well

- Rates of AIDS in Carrefoure were higher that of Port-Au-Prince because it is the site of male and female prostitution. None of the Haitians with AIDS have ever been to Africa. There was racism towards Haitians in other countries New York you are Haitian it is assume you have AIDS

- Rural areas had less cases of AIDS than urban areas and more prevalent in areas with lower SES

- Men spread AIDS better in Haiti because urban men have more partners than woman

- Shift in sexual tourism from Cuba to Haiti because of the revolution and male prostitution catering to homosexual men from north america led to the majority of AIDS being introduced to Haiti by homosexual men

- Men transmit HIV better than women because HIV in more concentrated in seminal fluid than in vaginal secretions

- Increasing numbers of Aids being reported around the Caribbean and rates doubled

Treichler. Aids, Africa and the Cultural theory.
- Data colleciton in developing countries is both over and underestimated

- Data is not well represented, a map of Aids in Africa only depicts sexually active people in urban areas.

- Stereotypes deeply entrenched in AIDS in Africans gender, race and class. Africans are animals, have crazy exotic sexual rituals, dry sex.

- In Africa they are trying to fight the epidemic but Western coverage does not show this so they are seen as passive, compliant and incapable of understanding messages from Western scientists

- Infants over estimated because pediatric AIDS doesn't exist yet so the child is diagnosed based on the mother.

- Prostitutes and homosexuality, no legal word for prostitution and homosexuality so if doctors ask them if they do this they won't understand or do not answer out of shame or because it is disrespectful for a man to come into a woman's home.

- We have a huge bias of quantifiable research which can only use surveys to get answers. The surveys are often skewed and we don't get the ethnographic view that reveals more about the epidemic in Africa.

- Without any information on AIDS we are forced to go with the inadequate data.

Packard. Post-Colonial Medicine.
- Packard’s theory was that socio-economic statuses matter and determine the level of countries health care.

- Packard outlines three time periods of health care which are

1. The colonial period up to World War II

- During the colonial period health care was specified to the colonial elites and the health care facilities were in urban areas where these elite lived. The society wasn’t helped because the solutions to health of the colonizers were technocratic, very narrow based on techniques or technology in order for them to maintain health and continue their economic venture.

2. The post-war period after World War II

- Health care was extending to help larger populations, not just European colonizers.

- Technological developments made the extensions of health intervention more affordable and easier to accomplish this task.

- The health and manpower of the free nations was the “most vital resource” against communism.

- Thus internationalization of health became important. International organizations like the WHO and UNICEF were created to try and get health care to a wider number of people and not just the elite, technological developments made this possible. Countries of power went on campaigns to eradicate malaria in third world countries with more technocratic medicinal care to eradicate communism for the reason of opening trade markets because industrialized countries are dependent on underdeveloped countries. We use their labour and take their goods and sell them our goods. These countries were economically hurt after the Vietnam war. By providing vaccines DDT for malaria and INH for smallpox and preaching that the free market is the way, win the hearts and minds of the population, communism was crumbling bad. Links between health and social and economic development were still ignored.

3. The Independence period when most countries were free

- During the independence period western countries took advantage of these newly independent countries. These newly independent countries had no resources due to colonization and the legacy of colonialism left them with their traditional policies which made it difficult to stimulate their economy. These countries became dependent on countries of power but in order to receive their help they had to allow the west to structure their countries. Super powers gave them grants to be used only on items that constituted to their donator’s as development. The leaders who gave the west control of their countries allowed the west to continue patterns of colonial health care. The local elites demanded the best health care near them, so the best health care was in the urban areas which left none for the rural areas once again and inequalities grew larger. The people that wanted the medical system to stay like this were the physicians themselves who feared learning locally specified medical for rural areas would devalue their degree and impede their progress in finding a job and they lobbied for work in urban areas.

Farmer. Chapter 1. The vitality of practice.
- There are preventable deaths from malaria, TB and postpartum infections in Haiti.

- Lack of access to effective biomedical services is the most salient feature of the Haitian health system.

- 5 physicians for 100 000 people.

- Haitians were asked what they wanted for health care and they said a hospital, not a clinic, health post or dispensary.

-The priest in Haiti says appropriate technology means good things for the rich and shit things for the poor.

- The hypocrisies of development are not only morally flimsy but in fact analytically shallow

- Unlike developed countries, there are limited funds available for “sustainable projects” in Haiti so doctors must choose between high tech and low tech

- World-systems theory

- Immodest claims of causality are created when blame is being put on patients rather than fixing the structural problems of the country they decided they show invest in educational programs.

- TB is the world’s most common AIDS opportunistic infection

- Gender inequality and poverty are great factors in the distribution of HIV

- Farmer learned how relative poverty has pathogenic effects

- Farmer and his friends build a community pharmacy but a bomb blew it up later his friend died from MDRTB

- Drug resistance must be diagnosed fast and treatment based on drug-susceptibility testing that use drugs with the ability to kill the strain infecting the human

- WHO and other organizations used a type of TB called Ebola with wings to scare countries into donating to give money for TB control.

- CDC said only aggressive contact tracing and prompt initiation of therapy would interrupt transmission of resistant strains and that it is cost-ineffective to treat MDRTB

- MDRTB is a public health emergency in certain countries but not in others, not important in Peru physicians say. It is also treatable in certain countries and not others

- Peru 20% of government outlays was going to finance external debt

- Western world doesn’t acknowledge that these are two different worlds that have social inequalities. It is like the Tuskegee experiment where women in the third world would not receive antiretroviral treatment and investigators were not there to help them, only to see their infants die unethical

Stillwaggon. AIDS and the Ecology of Poverty.
- 40 million infected worldwide, 90% in developing countries, 30 million in sub-saharan Africa. 20 million already died. 15 million AIDS orphans and 12 million in sub-saharan Africa.

Transmission of HIV

- Effects gay men, drug injectors, female partners of bisexual men, infants of infected mothers

- 90-100% of people who have blood transfusions, needle sharers by drug users.

- Vertical transmission, Mother to child

- Anal intercourse

- Men with women sex is a very low chance of getting it

Epidemiology of HIV

- HIV infection influenced by same factors as other infectious diseases:
Poor nutrition, parasitic diseases, poor general health, little access to healthcare or breakdown of public health, economic disadvantage

- 2 big factors in sub-saharan Africa are
Parasitic infections

- The most important determinant of susceptibility to disease is nutrition because of its effect on protective barriers and on immune system response

- Parasitic infections produce a chronic immune response to foreign bodies leading the immune system to exhaustion

- Poverty leads to these two factors.

Ecology of Disease Transmission

- More than half of early childhood deaths are from malnutrition and its relation to infectious disease

- Nutritional and parasitic problems lead to physical and mental disability and cause unproductive labour, poverty and impairment

- Microbes and pathogens make the people sick and then it spreads through the whole population

- HIV is thought to come from SIV simian immunodeficiency virus in monkeys that come to humans from hunting or butchering that exchanged blood.

- Infectious disease reflects complex interactions between the infectious agent, the host and the environment.

Limitations of Global AIDS Policy

- Policies are written knowing that AIDS effects poor countries because poverty effects disease transmission but nothing is done to change poverty

- Prevention surrounds the individual’s sexual and behavioural tendencies and not the social and biological context of disease emergence

- The stereotypes of sexual practices and behaviours in Africa limits the amount of help that is given to them. This is part of the reason why AIDS is misunderstood. Long term policies turned into a permanent crisis

- It is said that the deaths from AIDS causes disruptions on the social and economic networks. Young people have to take care of their parents and leave school and get jobs so investment in human capital shrinks.

- AIDS is an endogenous variable in future growth, AIDS was itself endogenously determined because in order to stop AIDS it requires attacking the underlying causes such as poverty, malnutrition, parasite infection, war, economic disruption and rapid urbanization.

Appendix: Sex Everywhere

- HIV numbers higher in places where unprotected sex with prostitutes are. In countries where people have fewer sexual partners there is less.

- Behaviour doesn’t explain difference in rates of HIV between different populations

- Knowledge of safe sex methods doesn’t change people’s behaviour to be safer.

- People have sex everywhere, some have a lot and some people don’t.

- Differences in sexual behaviour can’t explain differences in HIV rates between countries.

Natrass. The fight for Antiretrovirals.
- President Mbeki was the former president of South Africa and he claimed HIV did not lead to AIDS and that ARV's killed people. HIV science is flawed and corrupt by the pharmaceutical industry

- He was titled an AIDS denialist

- Topic is important because SA has the largest AIDS population and it shows the implications of when world leaders reject science

- Mbeki says azt has toxic effects and uses biased evidence from corrupt researchers to prove his points. This researcher tried to defend a man in court who gave HIV to someone and she said it did not exist.

- Treatment for AIDS is a 3 drug cocktail called HAART that disrupts the replication cycle of HIV in 3 areas because AZT was not an effective monotherapy and was expensive.

- Mbeki may have certain points correct. He claims a lot about oppression and poverty causing AIDS, pharmaceuticals just want to use this to steal money from SA. Poverty can weaken your immune system. Mbeki payed too much attention to the socio-economic side and none tot he biomedical side.

- Trials in Thailand showed AZT lowered mother-to-child transmission of the disease but Mbeki still denied it

- Western cape province strayed from south africa and implemented their own treatments for AIDS and it is estimated that if it was implemented sooner it would have saved many lives across the country

- The health minister tried blocking grants for these provinces

- Mbeki was forced to give in because of doctors and TAC, so HAART was provided in the public sectors though inefficiently

- TAC took legal action against the health minister after she resisted ARVs and delayed registration for Nevirapine for MTCTP. The judge ruled in favour of TAC. The health minister wanted an appeal and said she was worried about its toxicity and it wasn't approved by the FDA.

TAC made a civil disobedience campaign against the government because they would not sign their national AIDS treatment plan. Mandela opposed the government and Mbeki resented him. The health minister pulled the race card and said white people were leading this.

- In 2003 the cabinet revolted against Mbeki and announced they would proceed with HAART

- Disk jockey who had HIV looked to alternative treatments and not ARVs because the government promoted it. This led to many deaths.

- Mbeki refused to go through with ARVs and MTCTP because he said the country didn't have enough money and it would make it poorer. But in fact it saved money because with less infants being born with AIDS then you don't have to treat them as well.

UNAIDS. Sub-Saharan Africa AIDS epidemic update Regional Summary
South Africa

- Most affected region, one third (32%) of new cases and AIDS deaths. More women than men getting the disease in their late teens to mid 30's.

- HIV prevalence increases for people who have multiple sexual partners.

- South Africa has the most AIDS and most in Kwazulu Natal region

- Zimbabwe 1/4 people have AIDS

- AIDS awareness and knowledge is not associated with safer behaviour

- Few people understand that having multiple sex partners can increase their risk because many believe HIV is transmitted supernaturally or by a mosquito

- In Mauritius non-sterile injecting equipment is the most important factor in HIV infection

- TB is a major cause of death from people living with AIDS. HIV responsible for high TB numbers. LAck of access to HIV counselling and testing for TB stops HIV treatment and care. Better coordination is needed.

- In east africa their behavioural change has led to a decrease in AIDS cases. Uganda first country in sub-saharan africa to register a drop in adult national HIV prevalence

- Male circumcision reduces heterosexual HIV transmission in men. Race, religion, ethnicity, etc play a role in determining it. Highest in west africa.

- Majority of men who have sex with men ahve sex with woman aswell and spreads the infection.

- Injecting drugs will give you AIDS quickly

- In west Africa unprotected paid sex remains central to HIV transmission

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